Surgical Instrumentation 2nd Ed

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WCN 02-200-202
SURGICAL
INSTRUMENTATION
Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202
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SURGICAL SECOND
EDITION
INSTRUMENTATION
Nancymarie Phillips
RN, PhD, BA, BSN, MEd, RNFA, CNOR(E)
Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States
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CONTENTS
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii CHAPTER 3 CATEGORIES OF SURGICAL

INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . 23
CHAPTER 1 HISTORY OF SURGICAL Clamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 1 Basic Hemostatic Clamps . . . . . . . . . . . . . . . . . . . . 24
Historic Surgical Instrumentation . . . . . . . . . . . . . . . . 1 Grasping Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Ritual and Magic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Ring-Handled Grasping Forceps . . . . . . . . . . . . . . 39
Non-Ring-Handled Grasping Forceps . . . . . . . . . . 41
CHAPTER 2 ANATOMY OF SURGICAL Dissection Instrumentation . . . . . . . . . . . . . . . . . . . . . 48
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 5 Sharp Dissection Instrumentation . . . . . . . . . . . . . 48
Evolution of Modern Surgical Instrumentation . . . . . 5 Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anatomy of a Surgical Instrument . . . . . . . . . . . . . . . . 6 Manual Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Handle Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Probes and Dilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Joint Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Measurement and Expansion . . . . . . . . . . . . . . . . . 62
Tip and Jaw Styles: Sharp Dissection . . . . . . . . . . . 11 Evacuation and Instillation Instrumentation . . . . . . 66
Tip and Jaw Styles: Clamping, Occluding, and Evacuation Instrumentation . . . . . . . . . . . . . . . . . . 66
Grasping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Injection and Irrigation Devices . . . . . . . . . . . . . . . 68
Tip Styles: Blunt Dissection . . . . . . . . . . . . . . . . . . . 15 Retraction and Exposure . . . . . . . . . . . . . . . . . . . . . . . 68
Categories of Surgical Instruments . . . . . . . . . . . . . . . 16 Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
How Surgical Instruments Are Named . . . . . . . . . . . 17 Approximation and Closure Instrumentation . . . . . 77
Materials Used in the Manufacture of Surgical Suturing Instrumentation . . . . . . . . . . . . . . . . . . . . 77
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Anesthesia Intubation Instruments . . . . . . . . . . . . . . 83
Metallics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHAPTER 4 CONSIDERATIONS FOR
Steel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Copper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
INSTRUMENT SET ASSEMBLY . . . . . . . . . . . . 86
Titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Instrument Containers and Trays . . . . . . . . . . . . . . . . 89
Silver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Perforated Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Surface Finishes of Metallic Surgical Instruments . . 19 Closed Rigid Containers . . . . . . . . . . . . . . . . . . . . . 90
Inspection and Quality Control of Metallic Specialty Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . 19 Assembly of Instrument Sets . . . . . . . . . . . . . . . . . . . . 91
Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Determining Instrument Set Contents . . . . . . . . . 91
Clamps, Needle Holders, and Graspers . . . . . . . . . 20 Counts and Accountability . . . . . . . . . . . . . . . . . . . 92
Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Overview of Processing Options . . . . . . . . . . . . . . . . . 93
Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CHAPTER 5 SOFT TISSUE FOUNDATION
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Cleaning and Lubrication . . . . . . . . . . . . . . . . . . . . 21 SETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Ultrasonic Cleansing . . . . . . . . . . . . . . . . . . . . . . . . 21 Short Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
v
vi Contents
Excisional Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER 10 BASIC BONE AND JOINT

Medium Foundation Set . . . . . . . . . . . . . . . . . . . . . . . 109 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 244
Soft Tissue Dissection . . . . . . . . . . . . . . . . . . . . . . 109
Plates and Screws: Fracture Fixation
Long Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Laparotomy Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Drills and Power Equipment . . . . . . . . . . . . . . . . . . . . . . 250
Extra-Long “Add-On” Set . . . . . . . . . . . . . . . . . . . 135
Bone Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
CHAPTER 6 PLASTIC SURGERY Small Bone Instruments . . . . . . . . . . . . . . . . . . . . .254
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 136 Large Bone Instruments . . . . . . . . . . . . . . . . . . . . . 254
Basic Plastic Surgery Instrumentation . . . . . . . . . . . 136
CHAPTER 11 HEAD AND NECK
Basic Plastic Surgery P rocedures . . . . . . . . . . . . . . . . 164
Rhytidectomy-Browlift . . . . . . . . . . . . . . . . . . . . . 164
PROCEDURE INSTRUMENTATION . . . . . . . 285
Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Ear and Mastoid Instrumentation . . . . . . . . . . . . . . . 285
Surface and Subsurface P rocedures . . . . . . . . . . . . . 164 Ear Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . 286
Debridement and Excisional Procedures . . . . . . 164 Mastoid Instrumentation . . . . . . . . . . . . . . . . . . . . 293
Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Nose and Throat Instrumentation . . . . . . . . . . . . . . 297
Breast Augmentation-Reduction Procedures . . . 165 Intranasal and Pharyngeal Instrumentation . . . . 298
Anterior Neck Instrumentation . . . . . . . . . . . . . . . . . 315
CHAPTER 7 GENERAL SURGERY Thyroidectomy and Neck Dissection
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 166 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . 315
General Surgery Major Laparotomy Tray . . . . . . . . 166 Tracheostomy-Tracheotomy
Gastrointestinal Instrumentation for Open Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . 317
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Cholecystectomy Add-Ons . . . . . . . . . . . . . . . . . . 180 CHAPTER 12 NEUROSURGERY
Liver and Stomach Add-Ons . . . . . . . . . . . . . . . . .182 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 319
Lower Gastrointestinal Instrumentation for Basic Neurosurgical Instrumentation . . . . . . . . . . . . 319
Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 184 Cranial Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Bowel Resection Add-Ons . . . . . . . . . . . . . . . . . . . 184 Spinal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .340
Rectal-Anal Instruments . . . . . . . . . . . . . . . . . . . . . . 189
Hemorrhoidectomy and Rectal Excision . . . . . . 189 CHAPTER 13 CARDIOTHORACIC AND
VASCULAR INSTRUMENTATION . . . . . . . . . 342
CHAPTER 8 GYNECOLOGIC
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 195 Basic Cardiothoracic and Vascular
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Basic Gynecologic Instrumentation . . . . . . . . . . . . . 196 Basic Cardiothoracic and Vascular Procedures . . . 375
Basic Gynecologic Procedures . . . . . . . . . . . . . . . . . . 227
Abdominal Hysterectomy . . . . . . . . . . . . . . . . . . . 227 CHAPTER 14 MICROSURGERY
Vaginal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . 227 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 376
Vaginal-Perineal Procedures . . . . . . . . . . . . . . . . . . . 227
Dilation and Curettage . . . . . . . . . . . . . . . . . . . . . . 227 Basic Microsurgery Instrumentation . . . . . . . . . . . . 376
Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . . 228
CHAPTER 15 ENDOSCOPIC
CHAPTER 9 UROLOGIC INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 395
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 229 Essential Components of Endoscopic
Open Urology Instrumentation . . . . . . . . . . . . . . . . . 229 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Nephrectomy, Cystectomy, and Percutaneous Endoscopy Procedures . . . . . . . . . 396
Prostatectomy Instrumentation . . . . . . . . . . . . 230 Nonpuncture Endoscopy . . . . . . . . . . . . . . . . . . . . 396
Testicular Instrumentation . . . . . . . . . . . . . . . . . . 238 Access and Creation of the Working Space . . . . . . . 396
Uroplasty Instrumentation . . . . . . . . . . . . . . . . . . 240 Illumination and Viewing within the Working
Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Contents vii
Manipulation within the Working Space . . . . . . . . . 397 CHAPTER 16 DECONTAMINATION

Irrigation and Evacuation within and from the AND STERILIZATION . . . . . . . . . . . . . . . . . . . 413
Working Space . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Closure within the W orking Space . . . . . . . . . . . . . . 397
Instructions for Use (IFUs) . . . . . . . . . . . . . . . . . . 414
Specialty Instrumentation . . . . . . . . . . . . . . . . . . . . . 397
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .414
Essential Endoscopic Instrumentation . . . . . . . . . . . 398
Inspection/Packaging . . . . . . . . . . . . . . . . . . . . . . . . . 416
Basic Endoscopic Procedures . . . . . . . . . . . . . . . . . . 409
Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Disinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Robotic-Assisted Percutaneous
Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Sterile Storage and Packaging . . . . . . . . . . . . . . . . . . 419
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Microbiological Concerns . . . . . . . . . . . . . . . . . . . 421
Neuroendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . 422
Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412
Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Upper Airway Endoscopy . . . . . . . . . . . . . . . . . . . 412
Urologic Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . 412
PREFACE
This text, Surgical Instrumentation, Second Edition, is instrumentation and provides background infor-
designed for perioperative personnel in all surgical mation about the philosophy and contributions
disciplines. Surgeons, nurses, technologists, and techni- of different cultures to the discipline of surgery.
cians will find the design and collections in this book ●● Anatomy and Physiology of Surgical
informative and user friendly. Books about surgical Instrumentation. The materials and characteris-
instrumentation have been in print for more than tics of surgical instruments are explored, as well
100 years. However, none have offered comprehensive as the design from handle to tip.
collections of instruments used with foundation sets ●● Categories of Surgical Instrumentation. Surgical
for multiple specialties. They feature individual instru-
instruments are designed for specific functions
ments without providing guidance for establishing or
and are grouped into functional categories that
streamlining the set creation process.
define the purpose for each instrument.
Specific groupings make it easier to learn the
THE DEVELOPMENT OF THIS TEXT instruments.
The four foundation sets described in this text are ●● Considerations for Instrument Set Assembly.
designed to be base units for use during procedures Trays and containers for packaging instruments
that meet the needed instrument weight, length, gauge, are described in this chapter. Accountability is
shape, and material necessary for a safe, efficient surgi- a team effort that begins with the construction
cal procedure. The additional instrument groupings, and assembly of each set.
such as those specific to a particular organ or region of ●● Soft Tissue Foundation Sets. The foundation sets
the body, can be established as “add-on” sets to be used are designed to meet specific needs for a proce-
in combination with the appropriate foundation set. dure at a basic level by grouping instruments by
Every perioperative nurse or surgical technologist category and function.
who scrubs has encountered sets with instruments that ●● Plastic Surgery Instrumentation. Instruments spe-
have not been used for many years, yet the items con-
cific to the type of plastic surgery procedure are
tinue to be packed into the tray for no apparent reason.
described in combination with foundation sets.
This book may serve as a guide for establishing stan-
dardized instrument sets that will facilitate the count
●● General Surgery Instrumentation. Functional in-
process and ease the burden of inventory control. struments that are added to foundation sets for
general surgery are described by organ system
and body location.
ORGANIZATION OF THE TEXT ●● Gynecologic Instrumentation. Specialty instru-
This text is divided into 16 chapters. Images of the sur- mentation specific to the needs for surgery of
gical instrumentation are displayed in table form with the female reproductive tract is described.
descriptions and sizes listed. ●● Urologic Instrumentation. Instrumentation spe-
●● History of Surgical Instrumentation. The first cific to genitourinary procedures of the urethra
chapter describes the history of surgical and kidney is included in this chapter.
viii
Preface ix
●● Basic Bone and Joint Instrumentation. Many of the lungs, heart, and vascular system is
specialties utilize instrumentation to debulk, described.
dissect, or repair bony tissue throughout the ●● Microsurgery Instrumentation. Microsurgery is
body. The bone instruments are used in combi- usually performed on soft tissues. These sets
nation with soft tissue foundation sets accord- can be used in combination with foundation
ing to the location on the body. sets or as stand-alone sets.
●● Head and Neck Procedure Instrumentation. ●● Endoscopic Instrumentation. The application
Upper airway and otorhinolaryngology pro- of endoscopic techniques to multiple specialties
cedures require specialty instrumentation de- is described. Percutaneous and natural orifice
signed for narrow passages and the soft tissues endoscopy is described in functional terms.
of the anterior neck and throat. ●● Decontamination and Sterilization. A critical
●● Neurosurgery Instrumentation. Procedures of component in a complete understanding of
the brain and spinal cord use a unique blend of surgical instrumentation is understanding
soft tissue sets, compact tissue sets, and micro- decontamination and sterilization of the
surgical sets. Instrumentation for procedures of instruments. This new chapter includes infor-
the cranium and spine is described. mation on cleaning (manual and mechanical),
●● Cardiothoracic and Vascular Instrumentation. inspection, disinfection, sterilization, and
Instrumentation used for surgical procedures packaging.
ABOUT THE AUTHOR
Nancymarie Phillips, RN, PhD, BA, BSN, MEd, RNFA, CNOR(E). Dr. Phillips is the Professor Emeritus for
Perioperative Education at Lakeland Community College in Kirtland, Ohio. Her programs included Perioperative
Nursing, Registered Nurse First Assisting, and Surgical Technology. She has authored numerous articles and texts
about perioperative patient care. She was the 2006 recipient of the AORN Perioperative Clinical Education Award,
the 2006 Lakeland Community College Teaching Excellence Award, and was a nominee for the 2006 Ohio Magazine
Excellence in Education Award.
Dr. Phillips has been a perioperative nurse since 1975. In addition, she has worked as a scrub nurse, circulator,
first assistant, consultant, author, and educator. She can be reached at nancymphillips@aol.com. Her RNFA education
website is www.nvo.com/delphipro.
ACKNOWLEDGEMENTS
We thank Denell Lewalk, MLS, and Jennifer Gerres, Joseph Charleman, CST, CSFA, CRCST, LPN
DPM, for their assistance in this massive undertaking. Chapter 7: General Surgery Instrumentation
The author and Cengage Learning wish to extend
Chapter 10: Basic Bone and Joint Instrumentation
a deep gratitude to Berkeley College School of Health
Studies, Woodland Park, NJ campus for providing their Chapter 16: Decontamination and Sterilization
lab and instruments for a photoshoot. Special thanks to
Joseph Charleman for his assistance with the arrange-
Margaret Rodriguez, CST, CSFA, FAST, BS
ments, preparation, and logistics of this photoshoot. We
Chapter 2: Anatomy and Physiology of Surgical
would also like to acknowledge the following individu-
Instrumentation
als for their assistance with the photoshoot:
Chapter 4: Considerations for Instrument Set
Mike Gallatelli, photographer Assembly
Metroland Photo Chapter 5: Soft Tissue Foundation Sets
www.metrolandphoto.com Chapter 9: Urologic Instrumentation
Chapter 11: Head and Neck Procedure
Annadelia De La Cruz, AAS, BA
Instrumentation
Administrative Assistant
Surgical Technology & Surgical Processing
Department REVIEWERS
Mayra Y. Cabrera, AAS, CST Rob Blackston CST, CSFA
Clinical Coordinator Program Director of Surgical Technology
Surgical Technology & Surgical Processing North Idaho College
Department Coeur d’Alene, ID
Robert Torres, BA, CRCST, CHL David Braun, CST, CRCST

Clinical Site Monitor Program Director/Instructor School of
Surgical Technology & Surgical Processing Surgical Technology
Department Western Suffolk BOCES
Northport, NY
CONTRIBUTORS Julia Hinkle, RN, MHS, CNOR

The author and publisher would like to acknowledge Professor/Program Chair
the following professionals for contributing to the con- Ivy Tech Community College
tent of this book: Evansville, IN
xi
xii Acknowledgements
Rosemary Nagler Mecklin Soules, CST, AAS

Assistant Principal Health Careers/Clinical Education Surgical Technology Program Director
Coordinator of Surgical Technology Meridian Community College
Western Suffolk BOCES Meridian, MS
Northport, NY
Stefanie Vaughn, CST
Alisia Pooley, CST Program Director of Surgical Technology
Surgical Technology Instructor Angelina College
Mohawk Valley Community College Lufkin, TX
Rome, NY
Mary Seely, CST, AS

Surgical Technology Program Director
Monroe Community College
Rochester, NY
ABOUT THE INSTRUMENTS
The instruments appearing in this book have been gra- Scanlan International
ciously provided by the following manufacturers: www.scanlaninternational.com
One Scanlan Plaza
CareFusion Saint Paul, Minnesota 55107
Becton, Dickinson and Company International: 651-298-0997
1 Becton Drive U.S. & Canada: 800-328-9458
Franklin Lakes, NJ 07417-1880 Fax: 651-298-0018
Phone: 201-847-6800 Email: info@scanlangroup.com
Cook Medical, Inc. Sklar Instruments

www.cookmedical.com www.sklarcorp.com
P.O. Box 489, 750 Daniels Way 889 South Matlack Street
Bloomington, IN 47402-0489, USA West Chester, PA 19382
812-339-2235 Phone: 610-756-7863
Email: surgi@sklarcorp.com
Integra LifeSciences Corporation
www.integralife.com Sontec Instruments
JARIT Surgical Instruments www.sontecinstruments.com
Padgett Surgical Instruments 7428 South Tucson Way
R&B Surgical Instruments Centennial CO 80112
Ruggles Surgical Instruments 800-821-7496
311 Enterprise Drive
Plainsboro, NJ 08536 Teleflex Medical
Phone: 609-275-0500 http://www.teleflex.com
3015 Carrington Mill Boulevard
Intuitive Surgical, Inc. Morrisville, NC 27560
www.intuitivesurgical.com 919-544-8000
1020 Kifer Road
Sunnyvale, CA 94086-5304
Phone: 408-523-2100
xiii
CHAPTER 1
HISTORY OF SURGICAL
INSTRUMENTATION
OBJECTIVES CHAPTER OUTLINE

After reading this chapter the learner should be able to: Historic Surgical Instrumentation
1. Describe several historic findings that indicate ancient humans used surgical Ritual and Magic
instruments.
2. Discuss the countries that contributed ideas to the surgical armamentarium.
3. List several materials that comprised early surgical instruments.
INTRODUCTION
Since the beginning of time, man has sought to appease the gods and
remedy the failings of the human body with the medical and surgical
arts. Each culture has historically approached medicine and surgery
in a different way and has lent a societal touch to the evolution of
surgical practice.
HISTORIC SURGICAL INSTRUMENTATION

Forms of early surgical practice encompassed tending injuries and wounds
associated with animal encounters or battles. Some Neolithic tribes were
known to have practiced amputation for serious injury, tumors, or infec-
tion. Relics of surgical instruments, such as sharpened flints and natural
substances like shells, have been found wherever civilizations have been
uncovered. Scientists have speculated dates ranging from 10,000 bc for early
incisions to 2500 bc for suturing with horsehair or animal tendons.
Hindus developed the earliest known organized practice of surgery
(shastrakarma), which is one of the eight branches of Ayurveda (Indian
medicine). Shushruta (circa 800 bc), a medical practitioner from Benares,
India, wrote the Samhita. In this text he described the need for cleanli-
ness and precision in surgical treatment. His writings were captioned
under seven topics: esya (exploration), ahrya (extraction), chedya (excision),
lekhya (scarification), vedhya (puncturing), vsraya (evacuation), and sivya
(suturing). He based his methods of surgery on his studies of anatomy us-
ing dead bodies. Shushruta developed 121 separate surgical instruments of
natural materials, such as bone, ivory, mussel shell, and stone. He also advo-
cated the use of hypnosis and wine as anesthetics.
1
2 Surgical Instrumentation
RITUAL AND MAGIC the internal anatomy sacred. Archeologists discovered

papyri that described medical care during this period.
Prehistoric man performed documented incisional In 1862, American Edwin Smith purchased a 22-page
procedures as early as 6000 bc. Scientists speculate papyrus, dating from 1500 bc that contained many
that some procedures, such as opening holes into the treatments performed during ancient times. It was
skull (known as trepanation), were performed for ritu- later deciphered by James Henry Breasted. German
alistic or magic reasons. Significant numbers of skulls Egyptologist George Ebers purchased a similar papy-
have been found that indicate the patients lived for rus in 1872 that consisted of 110 pages that dated back
many years after the procedure, as new bone growth to the First Dynasty in 3000 bc. A later papyrus was
was identified around the cut edges of the bony holes. written as a guide for midwives and those who cared
Figure 1-1 depicts trepanation instruments used for for female patients. These papyri contained medi-
opening skull bone. cal and surgical references intermingled with magical
The ancient Egyptians did not feature cutting as a spells for protection against supernatural forces.
primary medical treatment. Egyptian temple and tomb Cataract surgery, known as couching in many an-
art indicates that most of the anatomic study involved cient lands, was a common procedure between 1345
the embalming of bodies for burial. The religious and 1200 bc. This surgery was performed by using a
sects were guardians of physical knowledge and held rodlike tool with a blunt end to tap the eye, causing
the lens to shift away from the pupil. This allowed light
to enter. Later methods of performing this procedure
included inserting a needle into the eye to dislodge
the natural lens (Figure 1-2).
Courtesy of the National Library of Medicine
Courtesy of the National Library of Medicine
Figure 1-1 Ancient trepanation instruments. Figure 1-2 Instruments used historically for cataract surgery.
Chapter 1 History of Surgical Instrumentation 3
Mesopotamian society (circa 3500 bc) exercised necessity to displace cataracts. Surgery was considered
generalized laws and rules governing conduct. They manual labor, and the ancient Roman physicians con-
had a concept of comparative worth concerning human tributed very little to surgical knowledge. In fact, artists
life and believed in medical training before commenc- frequently had a greater knowledge of the human body
ing practice. The physicians in Mesopotamia identified than physicians because they studied corpses during
specific procedures, named each drug used in medical postmortem dissection.
care, and kept records of medical and surgical activities Arabian surgeons established a school for brain
by carving cuneiform figures into clay tablets. Over surgery in Islam in 800 ad. Other surgical procedures
20,000 such tablets have been discovered. were also performed, such as couching. However,
Ancient Babylonians (modern-day Iraq) were led little was known of human anatomy because human
by the great King Hammurabi (1795–1750 bc). He dissection was banned by the Koran. During this era,
established the first known major metropolis and set Andalusia (Moorish Spain) was part of the Islamic
forth the law that bears his name. The law was clear Empire. A famous skilled Moorish surgeon of the
with regard to medical treatment. A surgeon who suc- time, El Zahrawi (940–1013 ad), wrote an encyclo-
cessfully treated his nobleman patient would be paid pedia of 30 volumes referred to as the At-Tasrif to
10 shekels for his labor. If he treated a slave, he was paid record methods of medical and surgical treatment.
2 shekels, and for treatment of a freeman, he would He taught his students to treat each patient as an
be paid 5 shekels. If the nobleman or freeman patient individual and to practice within ethical limits. His
died, the surgeon could lose a hand. If a slave died, the writings guided the development of most surgical text-
surgeon had to repay the cost of the slave to his master. books in European universities between the 12th and
The law was carved in black diorite stone that stood 17th centuries ad. Many of the surgical instruments
8 feet tall and was designed like a monument for dis- used during that period were designed by El Zahrawi
play in a public location in the city until it was taken by himself, who personally drew the 200 illustrations for
warring tribes as a trophy. It was discovered in Persia his texts. He is also credited with being the first to use
in 1901. The entire code of Hammurabi has been trans- ligatures for hemostasis in surgery. The history and
lated into English and is available online. images of El Zahrawi and other Muslim physicians
Greek civilization gave rise to more organized are available online at http://www.muslimheritage
written texts on medicine and health. The Greeks en- .com/surgery.
couraged a scholarly approach and established formal The Chinese practiced acupuncture and acu-
schools. Most of the surgery performed dealt with war pressure for at least 2000 years of recorded history.
wounds and orthopedic injury. The Greeks used palm The central belief of these practices is that there is a
bark and wood bound by moist clay and linen strips mind–body–spirit connection to health and wellness
like splints to stabilize broken bones. Hippocrates associated with the ch’i, or life force. The main focus
(460–377 bc) used instruments of hardened iron, cop- of health and wellness was not based in surgical pro-
per, bronze, and brass. His surgical armamentarium cedures, but in a pharmacopoeia of 1800 medicinal
consisted of more than 200 types of surgical instru- herbs, biologic materials, and chemicals.
ments. Although physicians were trained in medical The ancient Aztec civilization left little written
and surgical treatments, the main focus of healthcare history, but significant evidence of successful surgery
dealt with diet and exercise. has been unearthed in archeological explorations.
The early Romans had knowledge of steel. The an- They had a strong knowledge of human anatomy
cient ruins of Pompeii (circa 310 bc to 79 ad) revealed because their culture practiced human dissection
an instrument manufacturer’s place of business with on their enemies. They felt that they captured the
preserved bundles of surgical tools made of several essence of the life force if they cut the beating heart
metals wrapped in protective fabric. Homes of physi- from the chest of their captives. Blood sacrifice was
cians revealed beautifully carved boxes for instrument a daily event. The main feature of their surgical ar-
storage. Most of the surgical practice was borrowed mamentarium was sharp dissection of bone and soft
from other cultures. Couching was performed as a tissues.
SUMMARY knowledge base concerning human anatomy and

physiology led physicians to create new tools for
Throughout history, physicians have devised and
exploration and treatment of body regions never
modified available materials for use in surgical pro-
surgically treated before. With each successive era,
cedures. As scientists contributed new knowledge
the sophistication of surgical instrumentation has
of metals and eventually synthetics, such as plastics,
improved significantly.
instrumentation became more functional, incor-
porating the principles of physics. The increasing
REFERENCES Phillips, N. M. (2016). Berry and Kohn’s operating room

technique (13th ed.). St. Louis: Mosby-Elsevier.
Ahmed, M. (2008). Muslim scientists and scholars. Rutkow, I. M., & Burns, S. B. (1998). American
Retrieved from www.ummah.net/history/scholars. surgery: An illustrated history. Philadelphia:
Haeger, K. (1988). The illustrated history of surgery. Norman Publishing.
New York: Bell.
CHAPTER 2
ANATOMY
OF SURGICAL
INSTRUMENTATION
After reading this chapter the learner should be able to: Evolution of Modern Surgical
1. Discuss the evolution of ancient surgical instruments into designs in Instrumentation
current use. Anatomy of a Surgical
2. Describe the ergonomics of instrument design. Instrument
3. List the three essential design components of every surgical instrument. Handle Styles
4. List the common metals used in modern surgical instrumentation. Joint Styles
Tip and Jaw Styles: Sharp
Dissection
Tip and Jaw Styles: Clamping,
Occluding, and Grasping
INTRODUCTION Tip Styles: Blunt Dissection
Surgical instrumentation is one of the essential elements of a safe Categories of Surgical
and efficient operating room. Even in the most skilled hands of a Instruments
surgeon, the instruments must be in good condition and function How Surgical Instruments Are
Named
as intended to prevent potential tissue damage. Surgical procedures
Materials Used in the
require the use of a variety of instruments of different sizes, shapes,
Manufacture of Surgical
and chemical compositions in order to achieve a safe and opti- Instrumentation
mal outcome for the patient. This chapter explores the broad range Metallics
of unique design specifications of surgical instrumentation used to Steel
perform invasive procedures on all types of tissues and anatomic Copper
structures. Titanium
Silver
Surface Finishes of Metallic
Surgical Instruments
Inspection and Quality Control of
EVOLUTION OF MODERN SURGICAL Metallic Surgical Instruments
INSTRUMENTATION Scissors
Clamps, Needle Holders, and
As discussed in Chapter 1, civilization has evolved and so, too, have sur-
Graspers
gical instruments and procedures. Conversely, human anatomy has not
Forceps
changed significantly over the centuries; however, the practice of surgical
Retractors
intervention has become increasingly complex in its goal to treat disease
Maintenance
while minimizing tissue trauma, pain, and recovery time for patients.
Cleaning and Lubrication
Ultrasonic Cleansing
5
Despite these changes, much of our basic modern ●● The functional or connecting joint mecha-
instrumentation has been modeled after long-standing nism that allows the instrument sides to stay
styles with modifications for contemporary surgical together in order to perform its task
procedures. ●● The tips and jaws are the working ends that
come into contact with the patient’s tissues
ANATOMY OF A SURGICAL and may be sharp, blunt, smooth, toothed, ser-
rated, crushing, or noncrushing, also known as
INSTRUMENT
atraumatic.
Basic design specifications are generally standardized
Keeping these components in mind, the design pos-
according to the required function of the instrument.
sibilities are nearly limitless. Surgical instruments
Modifications in size, shape, and design are made to
can be as simple as a flat sheet of metal or a single
accommodate the variety of human anatomic structures.
rod, or as complex as having up to 15 to 20 parts and
Instruments can be classified by their use and function,
pieces. Newer energized instrumentation can make
which then determine the unique designs and shapes. A
contact with the patient’s tissues through electrical
simple form of instrument anatomy is depicted by the
current, radio frequencies, or collimated laser light
small mosquito hemostat shown in Figure 2-1. It has
waves.
all the standard design components, such as jaws, box
locks, shanks, and handles. The essential standardized
design components include the following: Handle Styles
●● The handle or other form of hand grip held by Handles are designed to optimize the operator’s func-
the surgical practitioner tional grip and dexterity. The working parts of an
Tip
Jaws
Box Lock
Shanks
Ratchet
© Cengage®.
Finger Rings
Figure 2-1 Basic anatomy of a surgical instrument (Halsted mosquito clamp).
Chapter 2 Anatomy of Surgical Instrumentation 7
instrument’s jaws determine the style of the handle. on delicate tissues (Figure 2-3). Ratchets are used to
Controlled and precise actions such as cutting, dissect- lock and keep constant pressure from both sides of the
ing, and clamping require steady and secure manipu- instrument to occlude flow, provide traction, or hold
lation as provided by ring handles and compression structures together (Figure 2-4). Pistol grip handles
grips (Figure 2-2). Compression handles are pressure provide additional leverage for instruments with longer
sensitive for precision closing power on heavy or firm shafts used in narrow anatomic spaces or small inci-
tissues such as bone, cartilage, or fascia. Spring handles sions such as in open nasal or spinal procedures and
are preferred for microsurgery because activation of in laparoscopic instruments, which must be inserted
the jaws requires only minute motion to effect action through percutaneous trocar cannulas (Figure 2-5).
A. Ring handles
B. Grooved
handle
A: Courtesy of Sklar Instruments. B: Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ. C: © 2019 Cengage®.
C. Grooved
handle with
horn
Figure 2-2 Ring handles and compression handle grips.
A. Double-leaf spring
B. D
ouble-leaf locking
spring
C. Cam ratchet
A–B: © 2019 Cengage®. Photo by Margaret Rodriguez. C–D: Courtesy of Sklar Instruments. E: © 2019 Cengage®.
D. Bar and locking nut
E. Bar ratchet
Figure 2-3 Spring handles and locking handle grips.
A. Ratchet lock D. Single spring
B. Thumb screw E. Double spring
A, C: Courtesy of Sklar Instruments. B, D–E: © 2019 Cengage®. F: Courtesy of CareFusion, a divison of Becton, Dickinson and Co.
C. Twist screw
F. Double spring with ball and socket joint
Figure 2-4 Locking and opposition handle system.
A. S
tyle 1 pituitary or
Takahashi
B. Style 2 Kerrison
C. Style 3 Kerrison
A, C–D: Courtesy of CareFusion, a divison of Becton, Dickinson and Co. B: © 2019 Cengage®.
D. Style 4 Kerrison
Figure 2-5 Rongeurs handles.
Joint Styles tissue or other materials placed between the open jaws
The type and style of a joint facilitate the closing preci- of the scissors. Double-action joints use the principles
sion of the jaws and tips of an instrument. Three styles of pivots and levers to increase the closing pressure and
are most commonly used (Figure 2-6). Grasping and enable the jaws to grasp, cut, and debulk firm tissues.
clamping instruments with finger rings usually have box
lock joints. Hemostats and ringed tissue forceps have a
unique design of one side passing through the hollowed- Tip and Jaw Styles: Sharp Dissection
out center of the opposing side to create a box lock Sharp dissection is used to precisely cut and sepa-
between the jaw portion and the shanks. Overlapping rate tissue planes and divide tissue attachments. The
joint styles are common in sharp dissection instruments distal end or instrument tip styles of scissors may
such as scissors. The two sharp, flat blades are held be sharp or dull, curved, straight, or angled. Cutting
together with a screw, and the scissoring action slices graspers known as rongeurs or biters have two sides
A. Box lock
B. Scissor or lap joint
A–B: Courtesy of Sklar Instruments. C: © 2019 Cengage®. Photo by Margaret Rodriguez.
C. Double-action joint
Figure 2-6 Joint types.
that close, entrapping tissue in between hollowed Tip and Jaw Styles: Clamping,
depressions referred to as cups or in linear channeled
Occluding, and Grasping
grooves. Examples of these instruments may be found
Clamping jaws and grasping tips are used to hold tis-
in upcoming specialty chapters. Incisions are sharply
sue or items such as sutures or retraction material
made with a variety of scalpel handles and varying
(e.g., umbilical tapes, Silastic vessel loops, Penrose
shapes of disposable blades or other types of nondis-
drains) (Figure 2-10). The jaws of clamping instruments
posable knives (Figures 2-7, 2-8, and 2-9).
A. Straight
B. Slightly curved
C. Strongly curved
D. Forward angle
A, G: Courtesy of Sklar Instruments. B: Courtesy of Scanlan International. C–F: © 2019 Cengage®. Photo by Margaret Rodriguez.
E. Lateral angle
F. C
urved microsurgical spring
handled
G. Angled with tip guard
Figure 2-7 Sharp dissection tip styles: curvatures and angles.

A. Blunt–blunt
B. Blunt–tenotomy
C. Sharp–blunt angled
D. Sharp–sharp
A, C–E: © 2019 Cengage®. Photo by Margaret Rodriguez. B: © 2019 Cengage®.
E. Sharp–tenotomy
Figure 2-8 Sharp dissection tip styles.
are designed to mechanically occlude the lumens of

vessels, ducts, intestinal tracts, and other structures.
Clamps, commonly called hemostats, are primarily used
to provide hemostasis, or the stoppage of blood flow.
Noncrushing styles of clamps are used to temporarily
© 2019 Cengage®. Photo by Margaret Rodriguez.

occlude structures with lumens, such as the bowel for
surgical repair or excision. Grasping tips are used to
hold tissue for manipulation, traction, or excision. Some
grasping tips have teeth for a more secure attachment to
the tissue. Most of these have serrations over the surface
of the instrument’s jaws. There are styles of jaw serrations
designed for specific use with soft tissue, bone, metal
needles, and blades and include horizontal, longitudinal,
Figure 2-9 Variations of scissors. atraumatic, and cross-hatched patterns (Figure 2-11).
A. Kocher clamp D. Lahey/Gemini/right angle longitudinal
E. Crile hemostat
A: © 2019 Cengage®. B–G: © 2019 Cengage®. Photo by Margaret Rodriguez.
B. Right angle/Mixter and Adson/Schnidt
F. Kelly hemostat
C. Rochester Pean G. Doyen noncrushing intestinal clamp
Figure 2-10 Hemostatic clamps: jaw and tip variations.
C. Cross-hatched (diamond jaw) needle holder with tungsten

carbide insert
D. Micro “alligator” grasping forceps
A. Curved Allis and straight Judd-Allis
E. Foerster straight and curved sponge forceps
A–B, D–F: © 2019 Cengage®. Photo by Margaret Rodriguez. C: Courtesy of Sklar Instruments.
B. Allis-Adair and straight Allis F. Regular and large Babcock tissue forceps
Figure 2-11 Grasping: tip variations
Tip Styles: Blunt Dissection plastics. Other forms of blunt dissection include sepa-
Blunt dissection is used to separate tissue planes with- rating tissue layers such as peritoneal attachments of
out creating an incision (Figure 2-12). Examples include the bladder flap to the anterior surface of the uterus,
the scraping or peeling back of periosteum from bones separating adhesions, and freeing up nerves from the
in the specialties of neurosurgery, orthopedics, and thyroid or in the axillary region to name a few.
A. Pillar retractor/dissector
B. Freer elevator
C. Micro-ring curette
D. Boies nasal fracture elevator
E. #5 Penfield elevator
A–B: © 2019 Cengage®. C: Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ. D–E: © 2019 Cengage®. Photo by Margaret Rodriguez.
Figure 2-12 Blunt dissection: tip variations
CATEGORIES OF SURGICAL tenaculum. Graspers can have locking or

spring compression handles. The tips can have
INSTRUMENTS single or multiple teeth or be fine or blunt. The
Surgical instrumentation consists of many materials, jaws can be smooth or serrated for firm hold-
styles, weights, sizes, and shapes. All categories of ing of tissue.
instruments can be found in sets for open or minimally ●● Dissection instrumentation: Used to bluntly
invasive surgery (MIS), also known as endoscopic pro- separate or sharply incise soft tissues, cartilage,
cedures. The common element is that each instrument or bone. Handles can be ring, spring, or pistol
has a specific function and should be used only for that style. Scalpels and tissue elevation tools have
purpose. Failure to use the instrument for its intended sharply pointed or rounded tips on a flattened,
purpose can cause injury to tissue secondary to dam- rodlike single hand grip. The sharpened jaws of
age to the instrument’s function. Instrumentation cate- scissors can be straight, curved, or angled. The
gories as arranged for this text are described as follows: tips of scissors may come to a sharp point or
be relatively blunt and rounded. Unique shapes
●● Clamps: Used for closing circumferentially
may be seen in microsurgical, vascular, or rhi-
around an anatomic part either in a crush-
noplasty instrumentation.
ing or noncrushing manner for hemostasis
or occlusion. Standard clamps usually have ●● Dissecting instruments designed to excise soft
locking handles, but some forms of micro- tissue or bone have a variety of handle shapes,
instrumentation require the operator to main- including ring, spring, or pistol grip as with
tain grasping pressure to hold tissue. The jaws pituitary and Kerrison rongeurs. Scraping
can be smooth or have serrations (teeth). instruments include periosteal elevators such as
Cobb or Key, as well as Penfield and freer ele-
●● Grasping and holding forceps: Used to tem-
vators. Malleable looped endometrial curettes
porarily secure an anatomic part while it is
are also used to scrape and remove fibroids
manipulated as appropriate. Grasping and
from the inner lining of the uterus.
holding instruments may be of a tweezer-type,
which requires manual compression of both ●● Probes, cannulas, and dilators: Used to sharply
sides, or they may be ringed and ratcheted or bluntly expand, tunnel, examine, or create
instruments such as Allis, Babcock, or sponge an anatomic passage through which injec-
forceps, which are often mistakenly referred to tion, tissue sampling, or decompression can
as clamps, however, are not designed to pro- take place.
vide hemostasis or occlude the flow of tubular ●● Templates and measuring instrumentation: Used
structures. Graspers are also used to extract to mark, calculate, and assess anatomic tis-
stones as with Randall stone forceps or provide sues and landmarks for removal, positioning,
traction such as the Schroeder-Braun uterine implantation, or excision. Depth gauges, rulers,
calipers, trials, and sizers are included in this MATERIALS USED IN THE
category.
MANUFACTURE OF SURGICAL
●● Retraction and exposure instruments: Used to
provide a clear visual field at the surgical site INSTRUMENTATION
by displacing and securing tissues and organs. Materials used in the manufacture of surgical instru-
Retractors may be handheld single- or double- ments include metals, metal alloys, plastics, silicone,
ended instruments. Self-retaining retrac- natural latex rubber, and other synthetics. These materi-
tors may be simple ratcheted designs or be als can be used alone or in combination. Care is taken
extremely complex with interchangeable parts when working with a patient who may be allergic to one
that may require separate sterile table setup or more of these materials. Implantable devices repre-
and careful accounting to prevent retained sent a higher risk of potential serious immune response
items. All retractors must be placed carefully to than the surgical instruments used to perform a specific
prevent tissue damage or potential practitioner procedure. These factors should be addressed in the
injury. operative care plan by the patient’s physician. The metals
●● Approximation and closure instrumentation: that present a risk of sensitivity include the following:
Used to align and secure edges of soft and ●● Nickel (most commonly associated with
compact tissues for healing. Some approxima- sensitivity)
tion devices employ fixation implants such as ●● Beryllium
sutures, staples, clips, wires, screws, and plates.
●● Cobalt
●● Miscellaneous instrumentation: Instruments
typically not used directly on a patient’s tissues;
●● Chromium
however, they are used in conjunction with And rarely:
other instruments. Examples include mallets,
●● Tantalum
plate benders, tamps, and impactors.
●● Titanium
●● Vanadium
HOW SURGICAL INSTRUMENTS
ARE NAMED Metallics
A surgical instrument is commonly named for a per- The most common types of modern metals used in the
son, its appearance, its function, or even by a nick- manufacture of surgical instruments in the 20th and
name. Names of many instruments can be associated 21st centuries include steel, copper, nickel, titanium,
with specific surgical specialties and may be named and silver. Combination alloy metals, such as Vitallium
after pioneers in that field. Examples include: (combined cobalt, chromium, and molybdenum), have
●● Heaney—gynecological been used in dental and orthopedic implants since the
1930s. Occasionally, items such as patient positioning
●● DeBakey and Cooley—cardiovascular
devices are sometimes made of malleable lead or alu-
●● Cushing—neurosurgical minum. With the exception of titanium, all metals have
●● Kocher—gastrointestinal some magnetic properties and cannot be used in the
●● Lahey—thyroid presence of magnetic resonance imaging (MRI).
●● Castroviejo—ophthalmological The most common types of metals used for surgi-
cal instrumentation in surgery are described in the
There is a degree of geographic or regional preference following sections.
for the types and even names of surgical instruments
used. Surgeons may call an instrument by its correct
name or use a nickname that was used in the area where Steel
he or she trained, but then find the same instrument is Alloy composition of steel may be iron or carbon
called by a different name in other parts of the country. based. Most of the instrumentation used in surgery
is stainless steel, which is a carbon-based material. ●● Forceps: Used to grasp and hold various types
Additional components include carbon, silicon, man- of tissues
ganese, phosphorus, sulfur, and chromium. Stainless ●● Dilators: Used to sequentially expand a lumen
steel was given its name for resisting stains when or opening
placed in a vinegar solution. This “stainless” property is
caused by passivation of the chromium that forms the 300 Series Stainless Steel
surface layer. It is not actually totally stainless; however, Instruments that require slight to moderate malleabil-
it is resistant to corrosion and rust formation. Stainless ity are composed of 300 series stainless steel. This type
steel is sold in bar stock lots referred to as “forgings” of steel is also corrosion resistant. Instruments that are
graded by its composition. The forgings are exposed to made of 300 series stainless steel include:
heat and placed into molds for casting. A large weight
is pounded on the mold to cause the metal to take the
●● Suction cannulas: Used for removal of fluids
desired shape and hardness. Several grades are manu- and substances from the surgical field
factured throughout the world. German-made surgical ●● Probes: Used for exploration of depth or direc-
instruments are commonly preferred, although many tion of anatomic areas and blunt dissection or
other countries produce forgings suitable for surgical separation of tissue planes
instruments. Steel is further refined into the chemical ●● Retractors: Malleable (bendable or shapeable)
constituents of austenite and martensite by exposure for displacement or repositioning of tissues to
to heat. enhance visualization at the surgical site
●● Surgical wire: Used for stabilization of fractures
400 Series Stainless Steel
●● Surgical steel suture: Used for tissue approxi-
Heat treating and passivation are processes used for the
mation and wound closure
manufacture of instruments requiring a dissection or
debulking edge to maintain the necessary sharpness to
cut both soft and compact or bony tissues. Passivation Copper
is the terminal process of submerging instruments in
Few surgical instruments are made of copper. Those
a nitric acid bath, which removes any traces of foreign
copper instruments in use today are plated with nickel
particles and creates a coating of chromium oxide to
to minimize staining and corrosion. Copper is some-
resist corrosion. Instruments made of this grade of
times preferred for malleable uterine curettes and vas-
steel do not readily bend or flex while in use. Other
cular suction cannulas. Newer styles of instrumentation
instruments that require this level of hardness are used
are made of malleable 300 grade stainless steel to avoid
for secure grasping and holding. Examples of instru-
the use of plated instruments in surgery. The plating
ments made of 400 series stainless steel include:
wears off with time, exposing the bare copper surface.
●● Scissors: Used to dissect fine and heavy soft
tissues and suture materials
Titanium
●● Chisels, osteotomes, and rongeurs: Used for
Certain specialty surgical instruments and implants
debulking and dissecting bone or other com-
may be made of lightweight, nonmagnetizing tita-
pact tissue
nium. These instruments are corrosion resistant and
●● Curettes and rasps: Used to remove, shape, or very strong. However, purchase of and repairs to these
smooth dense tissue instruments are costly. Microsurgical instruments, ves-
●● Clamps and hemostats: Crushing and non- sel occluding clips, staples, replacement joints, screws,
crushing for mechanical hemostasis, occlusion and bone plates are commonly made of titanium
of lumens, and stabilizing tissue because it is inert and lightweight. This metal has been
●● Needle holders: Used for tissue approximation known to science since 1791, but received more scru-
by grasping suture needles attached to strands tiny after 1910 as a specialty metal for surgical appli-
of suture material to allow for passage through cation. Titanium is named for the Titans from Greek
tissue layers mythology, known for their strength.
Silver ●● Chrome plating: Chrome electrically bonded

The malleability, stability, and strength of silver make over brass or carbon steel; used in floor-grade
it a good material for metallic tracheostomy tubes and instrumentation; not suitable for surgery as the
delicate probes, such as those used in the lacrimal plating can chip off. Do not place these types of
ducts of the eye. instruments in an ultrasonic cleaner.
●● Ceramic or plastic coating: Provides insulation
during procedures that utilize electrosurgery.
SURFACE FINISHES OF METALLIC
SURGICAL INSTRUMENTS INSPECTION AND QUALITY
Consideration is given to the surface finish of a surgi- CONTROL OF METALLIC
cal instrument as part of its overall selection criteria.
The surface finish selection is based on several factors.
SURGICAL INSTRUMENTS
Basic surface finishes available in surgical instruments Care of the metallic instrument used in surgery consists
are as follows: of proper handling and usage, cleaning and process-
ing, and packaging and storage. All newly purchased
●● Polished: Shiny, high gloss, highly reflective
instrumentation should be cleaned, lubricated, and
like a mirror. This finish resists corrosion due
processed before sterilization and patient use. Stainless
to its density; however, it may be marred or
steel instrumentation will pit and stain over time when
damaged by poor instrument care. The reflec-
combined with certain elements. Table 2-1 shows the
tivity may also allow for light to bounce off the
types of stains and their probable sources. Chloride
instrument and obscure the surgeon’s visualiza-
ions found in iodine, blood, and saline cause corrosion
tion of the field.
and pitting. A pencil eraser can be used to determine
●● Matte or satin: Dull finish, low reflectivity; whether the mark is rust or a surface stain. If the mark
however, it is slightly less resistant to corrosion rubs off with the eraser, it is a stain. If the discoloration
due to the sand-blasting technique used during is removed, revealing a different color mark beneath, it
the manufacturing process. is rust. Rusty instruments pose a hazard to patients and
●● Ebonized: Blackened or dull surface. Not should be removed from service and replaced.
reflective at all, so appropriate for use in laser Each pitted and roughened area represents a weak-
cases, especially in narrow, deep passages such ened area that can harbor and shield microorgan-
as the vagina or nasal passages (Figure 2-13). isms from effective decontamination and sterilization.
Common points of pitting are near the box locks and
other hinge points. Pits can lead to fractures in the
joints, causing instrument breakage during use. Misuse
of instrumentation includes using an instrument for an
unintended purpose, such as using a fine needle holder
for a heavy needle or bone cutters to cut wire.
Each instrument should be inspected for stress
cracks at the joints, gaps along closed jaws, tight open-
ing and closing action, sharpness of cutting surfaces,
and generalized appearance prior to placement in pro-

cessed trays and again prior to use in the operating
room (Figure 2-14).
Scissors
Most manufacturers have recommended test materi-
als such as latex sheets or gauze pads for use in test-
ing the cutting edges of scissors during tray assembly.
Figure 2-13 Ebonized nasal specula. The scissors should work smoothly, without snagging
TABLE 2-1 Stains on surgical instrumentation
© 2019 Cengage®. Photo by Margaret

Stain Color Causative Agent
Rust color or Dried blood is autoclaved on the instrument.
dark orange Discoloration appears like rust. It can also be
from soaking in tap water.
Rodriguez.
Brown High pH (>7.0: alkaline) detergent or
chlorhexidine solution can cause this type
of stain. It can also be from soaking in tap Figure 2-14 Bone cutter blades damaged from cutting
water. Chromium deposits can be a cause. Kirschner wires.
Polyphosphate detergent can cause copper
components in the sterilizer to deposit on the
instruments in an electrolytic action. into each other smoothly. The closed jaws should not
show any light passage when closed and held in front
Dark brown This can be caused by an improperly function-
ing sterilizer. Low pH (<7.0: acidic) detergent of a lamp except in noncrushing (atraumatic) vascular
or baked-on blood can cause this type of stain. and intestinal clamps where light may still be visible.
The box locks should engage smoothly without tight-
Blue, blackish Instruments of dissimilar metals cause reverse
plating. Chlorides such as blood and saline ness. The hinge should not wobble or feel loose. The
can be causes. ratchets should click smoothly and hold securely. The
instrument should be closed to the first ratchet, and
Gray This is caused by liquid stain remover used in
when lightly tapped against the table edge, it should
excess.
not spring open. Needle holders can also be tested in
Blue-gray This occurs from chemical disinfectant used the operating room by loading a suture needle in the
in disproportionate concentrations. Use only jaw and trying to move the needle. If it does not hold
distilled water for dilutions.
the needle securely, the needle may be too heavy for the
Black This is caused by ammonia exposure. needle holder, or the jaw of the needle holder is sprung
Ammonia is found in many hospital cleansing and should not be used as the needle may shift posi-
agents used in surface disinfection. It is not
tion during placement into tissue, potentially causing
intended for instrumentation.
damage to adjacent structures. Another needle holder
Multicolor- Overheating in the autoclave causes this should be used and the questionable one tagged for
rainbow coloration. further inspection and repair or replacement.
© 2019 Cengage®.
Light and This is usually caused by water droplets on

dark speckles poorly rinsed and dried instruments.
Forceps
Tweezer-type tissue forceps should be tested by grasp-
ing the forceps between the thumb and forefinger,
the cut surface. The cut should be clean and straight. compressing the two sides, and opening and clos-
Tips should be completely intact and configured as ing them slowly to examine the approximation of
originally designed, either sharp or blunt, and have no the tips. The teeth should align without scraping the
burrs or chips. The screw in the hinge should be snug sides of the opposing side of the forceps. Tissue for-
and not allow the two halves to wobble as they are ceps without teeth should maintain alignment of both
opened and closed. Dissecting forceps are tested in the sides upon closure. Grasping and holding instruments
same manner. The jaws or cups of the forceps should such as perforating towel clips and tenacula should be
produce a clean bite from the test material. There inspected for blunting or presence of barbs of the sharp
should be no shredding or tearing from a jagged edge. tips. If present, they should be repaired or replaced.
Clamps, Needle Holders, and Graspers Retractors

The tips of clamps should meet without slippage when Handheld retractor blades should hold their shape,
closed over a sheet of paper. Teeth at the tip should nest yet have slight “give” to protect the patient’s organs.
Retractors that attach to frames should have secure prevent drying and caking of bioburden on instrument
attaching screws and ratchets. The retractor should surfaces.
be placed into the holder and given a few tugs to test Water-soluble lubricants should be used for stiff-
how well it holds the desired position. The edges of the feeling instruments following the mechanical decon-
retractor blades should be smooth and not have any tamination process. Water-soluble “milk baths” are
sharp or rough areas. used because oil and water do not mix, and oil-based
lubricants create a barrier over the instrument surface
and do not permit steam or chemical gas penetration
MAINTENANCE during the sterilization cycle.
Basic care of surgical instrumentation involves proper
use and cleaning. Initial decontamination begins at Ultrasonic Cleansing
the point of use in the operating room and involves Ultrasonic cleaners are fluid chambers that utilize
wiping off blood and tissue from instruments, as well sound waves to create a process of cavitation to dis-
as not soaking instruments in sterile saline irrigat- lodge tiny retained tissue from serrations or crevices of
ing solution. Metallic instruments should also not be instruments as the bubbles created implode. All visible
immersed in chemical sterilant solution such as glu- debris and biologic matter, referred to as bioburden,
taraldehyde (Cidex) for more than 20 minutes, as the should be cleaned from instrumentation before it is
instrument surface can be damaged. Tungsten carbide placed in the ultrasonic cleaner. Only approved clean-
inserts found in the jaws of some needle holders may ing solutions are used in these machines. Instruments
dissolve when immersed in benzyl ammonium chlo- should be completely open and/or disassembled before
ride. Sodium hypochlorite (bleach) should never be being placed in the ultrasonic cleaner, and the unit
used to disinfect instrumentation. It will cause pitting should not be overloaded.
of the instrument surface finish. Not all instruments are compatible with ultrasonic
cleaning. Complex powered equipment such as drills,
saws, and wire drivers may be permanently damaged
Cleaning and Lubrication by submerging them in the cleaning fluid. Placing
Instruments should be cleaned with a neutral pH deter- dissimilar metals together in the ultrasonic machine
gent (7.0) and rinsed thoroughly with distilled water. can cause an electrolytic reaction that can damage the
Blood and body substances should not be allowed instrumentation. At the completion of the cycle, the
to dry on the surfaces. Enzymatic sprays or foams instrumentation is removed, rinsed thoroughly, and
may be used on grossly contaminated instruments air dried. The cleaning solution is changed regularly or
prior to transportation to the decontamination area to whenever it becomes visibly soiled.
SUMMARY investment for any surgical facility. More importantly,

Surgical instrumentation has many intricate com- the potential for patient harm from improperly func-
ponents that work together for tissue manipulation tioning or sterilized instrumentation should be fore-
and alteration. The individual characteristics of the front in the minds of the surgical and processing
instrumentation are important to the surgical team as personnel entrusted with their care. Instrument man-
they perform the surgical procedure on various tissues ufacturers will continue to innovate and design the
within the patient’s body. The purchasing of quality best tools of the trade and respond to the ever-changing
surgical instrumentation represents a major capital technological advances in surgical patient care.
REFERENCES Junge, T. (2002, April). Heavy metals: Metallurgy

primer. Surgical Technologist, 34(4), 22–29.
Association of Surgical Technologists. (2018). Surgical Ryan, M. P., et al. (2002, February). Why stainless steel
Technology for the Surgical Technologist (5th ed.). corrodes. Nature, 415(6873), 770–774.
Clifton Park, NY: Cengage Learning. Taylor, M., & Campbell, C. (1999, August). Back to
Burstein, G. T., Hutchings, I. M., & Sasaki, K. (2000, basics: Introduction to instruments. British Journal
October). Electrochemically induced annealing of of Theatre Nursing, 9(8), 369–371.
stainless steel surfaces. Nature, 407(6806), 885–887. Vrancich, A. (2003, March). Instrumental care. Materials
Hallab, N., Merritt, K., & Jacobs, J. J. (2001, March). Management in Health Care, 12(3), 22–25.
Metal sensitivity in patients with orthopaedic
implants. The Journal of Bone and Joint Surgery,
83A(3), 428–436.
CHAPTER 3
CATEGORIES
OF SURGICAL
INSTRUMENTATION
Clamps
After reading this chapter the learner should be able to:
Basic Hemostatic Clamps
1. List the categories of instrumentation. Clamp Serrations the Full Length of Jaw
2. Describe how each category applies to the function of the instrument. Clamp Serrations Half the Length of the Jaw
Clamp Serrations the Full Length of the Jaw
3. Discuss the differences between instruments in each category. Serrations Along Variable Lengths of Jaw
Heavyweight to Intermediate-Weight Clamps
(Curved/Straight)
Variable Serrations Along Length or Tip of Jaw
INTRODUCTION Noncrushing Jaws
Clamps for Occlusion of Tubes
The basic surgical instruments used in the most common proce- Towel and Drape Clamps
dures are explored here in more depth. In subsequent chapters the Grasping Forceps
Ring-Handled Grasping Forceps
instruments will be sorted into functional sets by surgical specialties Perforating Grasping Forceps
and additional specialty instruments will be added. The purpose for Nonperforating Grasping Forceps
Non-Ring-Handled Grasping Forceps
individualizing the instruments by categories in this chapter is to Dissection Instrumentation
familiarize the reader with similarities and subtle differences that are Sharp Dissection Instrumentation
commonly confused. Many of the instruments described here are com- Scalpels and Knives
Scissors
mon to multiple types of surgical procedures and not to one specific Biopsy Forceps
specialty. Manual Compact Tissue Dissection: Bone Saws
Debulking
As each specialty chapter develops throughout this text, addi- Manual Debulking
tional specific instruments will be introduced as appropriate to assist Sharp to Blunt Manual Debulking Curettes
Elevators and Strippers: Blunt Debulking
with the creation of functional instrument sets for related procedures. Instruments
Illustrations and graphics have been obtained from multiple instru- Probes and Dilators
Measurement and Expansion
ment manufacturers in order to utilize the most commonly encoun- Sounds and Probes
tered variations. Some instrument names may vary by company; Manual Graduated Dilators
Mechanized Dilators
however, each instrument is described by as many names as known in Measuring Devices
table format with the accompanying figure number. Special features Evacuation and Instillation Instrumentation
and characteristics are listed as necessary to augment the learner’s Evacuation Instrumentation
Suction Tips
knowledge baseline. Injection and Irrigation Devices
Syringes
Retraction and Exposure
Retractors
CLAMPS Handheld Retractors
Self-Retaining Retractors
Bed-Mounted Self-Retaining Retractors
Clamps are used to securely provide hemostasis, hold a segment of tis- Approximation and Closure Instrumentation
sue or surgical device, or occlude a lumen. Most specialties use similar Suturing Instrumentation
clamps in varying weights. Most clamps are made from stainless steel for Needle Holders
Ligature Carrier
durability and strength; however, some specialties use certain materials; Anesthesia Intubation Instruments
23
for example, titanium is used in microsurgery for its hemostatic clamps are described and depicted accord-
nonmagnetic property, especially in the presence of ing to size and weight. Other specialty hemostatic
magnetic resonance imaging (MRI). The last section in clamps will be described in later specialty chapters.
this grouping contains clamps used for tubing that are
not intended for use on a patient’s tissues. Mosquito Styles
This clamp is known for its fine tip and short jaw style.
Although these are common to plastic and vascular
Basic Hemostatic Clamps procedures, they are found in general sets for use on
Basic hemostatic clamps are designed to stop bleed- small structures, such as suture markers (tags) and
ing by an occlusive motion of the jaws. The basic vessel loops. Each set is grouped by a common design.
CLAMP SERRATIONS THE FULL LENGTH OF JAW
Halsted mosquito clamp

Size: 5.00
FIGURE 3-1
Characteristics: Straight or curved with short jaw;
serrated full length of jaw
Uses: Hemostasis; holding (tagging) suture ends
Courtesy of Sklar Instruments.
Hartman mosquito clamp

Size: 3.50
serrations full length of jaw; shorter and heavier
FIGURE 3-2
than Halsted
Jacobson mosquito clamp

Size: 5.00
FIGURE 3-3
lighter weight and more delicate than Halsted;

Uses: Hemostasis; commonly used in plastic
surgery
Chapter 3 Categories of Surgical Instrumentation 25
Standard Hemostatic Clamps serration patterns. These features sometimes dic-

This style of hemostatic clamp is common to tate how the clamp will be used. Consider the fact
almost every service. Many of these styles are used that a fully serrated jaw will have more traction than
and referred to interchangeably. There are dis- a half-serrated jaw when applied to a pedicle of
tinct differences, particularly in tip, weight, and tissue.
CLAMP SERRATIONS HALF THE LENGTH OF THE JAW
Kelly clamp
Size: 5.50
Characteristics: Curved or straight;
jaw is one-third of shank; horizon-
tal serrations halfway down the
jaw
Uses: Hemostasis
FIGURE 3-4
Notes: Clamp, tag, snap, hemostat,
stat
Rankin clamp
Size: 6.250
Characteristics: Curved or straight; jaw is
one-third of shank; lighter weight than Kelly
FIGURE 3-5
Uses: Hemostasis
CLAMP SERRATIONS THE FULL LENGTH OF THE JAW
Crile clamp
Size: 5.500; 6.250
Characteristics: Horizontal
serrations full length of jaw;
curved or straight; jaw is
one-half length of shank
Uses: Hemostasis; holding
FIGURE 3-6
suture ends
Notes: Clamp, tag, snap,
hemostat; available in delicate
weight for pediatrics
Lahey clamp
Size: 5.500
curved or straight; jaw slightly
shorter than Crile clamp
FIGURE 3-7
Uses: Hemostasis; holding
suture ends
Notes: Hemostat—this is
not the same as the Lahey
toothed traction forceps. Also
known as Spencer-Wells
forceps
continues
CLAMP SERRATIONS THE FULL LENGTH OF THE JAW continued
Jones clamp
Size: 5.50
Characteristics: Horizontal serrations full
FIGURE 3-8
length of jaw; curved or straight; jaw slightly
shorter than Lahey clamp
Uses: Hemostasis; holding suture ends
Notes: Hemostat
Pean clamp
Size: 6.750, 9.00; 10.00
Characteristics: Longitudinal serrations full
length of jaw; curved only
FIGURE 3-9
Uses: Clamping larger segments of tissue for
hemostasis
Notes: May be pronounced as “peen” or as
“peon”
Rochester Pean clamp

Size: 5.500; 6.250; 7.250; 8.00; 9.00; 10.250;
12.00
FIGURE 3-10
length of jaw; curved or straight; heavy-style
instrument; jaw is proportionate to shanks
hemostasis
Notes: Do not confuse this with a basic Pean
as noted earlier; serrations are different;
shorter styles: sometimes referred to as hemostat or Kelly;
longer styles: sometimes referred to as a long or extra-long Kelly Courtesy of Sklar Instruments.
continues
CLAMP SERRATIONS THE FULL LENGTH OF THE JAW continued
Rochester
Carmalt clamp
Size: 6.250; 8.00
Characteristics: Longitudinal
serrations from box locks to
0.250 distance from tip; tip is
FIGURE 3-11
cross-serrated for traction;
curved or straight
Uses: Clamping larger segments
of tissue for hemostasis
Notes: Commonly used to
grasp tough tissue, drains, or
heavy material
Angled Hemostatic Clamps hold fuller and tougher bands of tissue, particularly along
These hemostatic clamps are heavier and stronger than the edges of highly vascular organs. The serrations and
most of the standard hemostats. These are designed to traction ability vary according to the use of the clamp.
SERRATIONS ALONG VARIABLE LENGTHS OF JAW
Wertheim
pedicle clamp
Size: 9.750
Characteristics: Heavy, right-
angle clamp with longitudinal
serrations the distal half of jaw
to angle of flexure; jaw mea-
FIGURE 3-12
sures 20
Uses: Grasp lower angle of
vaginal cuff during abdominal
hysterectomy
continues
SERRATIONS ALONG VARIABLE LENGTHS OF JAW continued
Moynihan
clamp
Size: 7.00
Characteristics: Intermediate
weight with longitudinal ser-
rations along the full length of
the short, slightly right-angled
FIGURE 3-13
jaw
Uses: Grasp tissue along gall-
bladder attachments and liver
bed; used as a passer for
suture around a stalk of tissue
Notes: Commonly used for circum-
ferential blunt dissection of tubu-
lar structures; can be used for
passing suture around or through
meticulous vascular beds of tis-
sue such as mesentery. Similar to
Adson tonsil clamp Courtesy of Sklar Instruments.
Mixter horizontal
clamp
Size: 6.250
weight, long jaw with horizon-
tal serrations the full length
of jaw; curved in a mild right
angle or a true right angle
FIGURE 3-14
Notes: Similar function to other
Mixter clamps with variations in
direction of serrations
© 2019 Cengage®.
continues
Mixter longitudinal clamp
FIGURE 3-15
Size: 8.50
Characteristics: Intermediate weight, long jaw with longitudinal ser-
rations three-fourths the length of the jaw; cross-serrated tips.
Available in delicate weight
Uses: Grasp tissue along gallbladder attachments and liver bed
Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Gemini Mixter clamp

Size: 5.50; 7.00; 8.00; 9.00; 11.00
Characteristics: Delicate
weight with horizontal serra-
tions the full length of the jaw;
the jaw is one-third the length
of the shanks
FIGURE 3-16
© 2019 Cengage®.
Schnidt clamp
Size: 7.50
Characteristics: Intermediate-
weight clamp with horizontal
serrations halfway along the
jaw; the jaw is one-quarter the
length of the shanks; curved.
FIGURE 3-17
Similar to Adson tonsil clamp

Uses: Commonly used for ton-
sils; used for passing suture
around or under tissue
Notes: Referred to as tonsil
clamp
continues
Adson clamp
Size: 7.250
length of the shanks; curved
FIGURE 3-18
or straight
Uses: Commonly used for ton-
sils; used for passing suture
around or under tissue
clamp; very useful as a passer
for suture
Hemostatic Clamps with a Tooth or Teeth at Tip

These clamps are commonly used for higher levels of traction and enclosing the distal aspect of tissue within the
confines of the clamp with a tooth. It clearly delineates the distal tip for dissection.
HEAVYWEIGHT TO INTERMEDIATE-WEIGHT CLAMPS (CURVED/STRAIGHT)
Kocher clamp
Size: 5.500
curved or straight tip; heavy
style-instrument; jaw is pro-
portionate to shanks 1 3 2
FIGURE 3-19
tooth at tip
Uses: Firm grasp of tissue; can
be used for hemostasis of
a pedicle; good for holding
fascia
Notes: Name is sometimes used
interchangeably with Oschner,
although it is a heavier instru-
ment; the teeth/tooth at the tip of
the jaw help to enclose the tissue
within the confines of the jaws
© 2019 Cengage®.
continues
HEAVYWEIGHT TO INTERMEDIATE-WEIGHT CLAMPS (CURVED/STRAIGHT) continued
Oschner clamp
Size: 5.500
Characteristics: Horizontal serrations full length of jaw; curved
FIGURE 3-20
or straight; lighter weight than Kocher; jaw is proportionate to
shanks 1 3 2 tooth at tip
Uses: Firm grasp of lesser amounts of tissue;
can be used for hemostasis of a pedicle
Notes: Name is sometimes used interchangeably
with Kocher, although it is a lighter instrument
Rochester Oschner clamp

Size: 6.250; 7.250; 8.00; 9.00; 10.00
FIGURE 3-21
length of jaw; curved or straight tip; heavy
style-instrument; jaw is proportionate to
shanks 1 3 2 tooth at tip
Uses: Firm grasp of tissue; can be used for
hemostasis of a pedicle
Notes: Name is sometimes used interchange-
ably with Oschner, although it is a heavier
instrument Courtesy of Sklar Instruments.
Phaneuf clamp
Size: 8.250
Characteristics: Longitudinal
serrations the full length of the
length of the shanks; straight
FIGURE 3-22
or angled jaw; jaw is short;
shanks are longer in propor-
tion 1 3 2 tooth at the tip
Uses: Firm grasp of shorter,
thicker pedicles of tissue; can
be used for hemostasis of the
uterine artery
Notes: Distinguished from other 1 3 2 toothed
clamp by shortness of the jaw; commonly
used for the uterine artery
continues
HEAVYWEIGHT TO INTERMEDIATE-WEIGHT CLAMPS (CURVED/STRAIGHT) continued
Allen clamp
Size: 6.00
weight; jaw is straight with
longitudinal serrations
1 3 2 teeth at the tip
FIGURE 3-23
be used for hemostasis of a
fine tissue pedicle
Notes: Resembles a 1 3 2
toothed Kocher clamp, but
lighter weight
Edge Hemostasis and Grasping Clamps along variable aspects of the jaw or tip to pro-
These clamps have locking ratchets for secure grip- vide a nonslip surface. These clamps can be found
ping. Traction is commonly placed on these styles in many types of basic instrument sets in multiple
of clamps. Most have an open area and serrations numbers.
VARIABLE SERRATIONS ALONG LENGTH OR TIP OF JAW
Pennington
clamp
Size: 6.250; 8.00
Characteristics: Ringed handles
with open, triangular, serrated
grasping edges; shanks and
FIGURE 3-24
jaws are straight
Uses: Used for grasping and
stabilizing large cut edges
of tissue intended for
approximation
Notes: Commonly used in
cesarean section to grasp the
incised edges of the uterus; pro-
vides hemostasis of the uterine
vessels imbedded in the myo-
metrium; used by body piercing
personnel to stabilize cutaneous tissue for perforation Courtesy of Sklar Instruments.
continues
VARIABLE SERRATIONS ALONG LENGTH OR TIP OF JAW continued
Lovelace
clamp
Size: 7.00, 8.00
Characteristics: Ringed
handles with open, triangu-
lar, serrated grasping edges;
shanks are curved in at the
box locks; angled or straight.
FIGURE 3-25
The jaws measure 10; interme-
diate weight
stabilizing mobile structures
such as the gallbladder
Notes: Firmly grasps structures
with moderate traction
© 2019 Cengage®.
Foerster sponge forceps

Size: 7.00; 9.50
Characteristics: Ringed han-
dles with open, oval, serrated
or smooth grasping edges;
shanks are straight or mildly
curved at the box locks; inter-
mediate weight
stabilizing mobile structures;
FIGURE 3-26
can be used to grasp cut
edges of the uterus for hemo-
stasis. Folded radiopaque
sponges can be positioned
in the jaws to create sponge
sticks
with moderate traction; com-
monly used for sponge forceps
and prepping; also known as
ring forceps; curved forceps are
commonly used in amniotic and
placental removal from the endometrial
cavity during childbirth © 2019 Cengage®.
continues
VARIABLE SERRATIONS ALONG LENGTH OR TIP OF JAW continued
Mastin muscle clamp

Size: 7.00
Characteristics: Shanks are curved to one side
with four fitted pins along the length of the
FIGURE 3-27
jaw. One side of the jaw is serrated and the
other side of the jaw is smooth. Intermediate
weight
Uses: Holds muscle tissue under traction with-
out crushing the fibers
Notes: Commonly used in open neck proce-
dures and muscle biopsies
NONCRUSHING JAWS
Bainbridge clamp
Size: 6.00; 7.250
FIGURE 3-28
Characteristics: Intermediate to lightweight noncrushing clamp;
longitudinal serrations along the full length of the jaw with cross-
hatching at the tip; jaws are curved or straight, tapering to a
blunt tip
Uses: Used for occluding a lumen of an organ such as
bowel without crushing the tissue
Notes: Commonly used in intestinal or thyroid procedures Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Doyen clamp
Size: 6.50, 9.00
FIGURE 3-29
Characteristics: Jaws are curved or straight and longer than the
shanks; the jaws are slightly malleable and longitudinally ser-
rated; noncrushing
Uses: Grasps the body of a larger organ such as a lung without
crushing
Notes: Provides mild atraumatic traction Courtesy of Sklar Instruments.
Kocher intestinal clamp

Size: 10.50
FIGURE 3-30
Characteristics: Jaws are two-thirds the length of the

shanks with longitudinal serrations; the jaws have mild
flexibility and can be curved or straight
Uses: Used to grasp pedicles without crushing
Notes: Differs from Kocher clamp because it is atraumatic
(toothless) and longer; occludes lumens of bowel without
tissue destruction; closely resembles a Doyen clamp Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Tube Occluding and Securing Clamps of these are smooth, without coarse serrations, so
The clamps in this section are named for the facil- clamped or secured tubing is not damaged in the hold-
ity that requested or suggested a specific design. All ing process. These are not used on the patient’s tissues.
CLAMPS FOR OCCLUSION OF TUBES
Tube occluding clamp

Size: 6.50
Characteristics: Smooth curved jaws; intermediate to
FIGURE 3-31
heavy weight for firm control
Uses: Used to occlude moderate thickness of tubing
Notes: Applies even occlusive pressure without dam-
aging the tubing; resembles a short curved Pean;
not interchangeable with a curved Pean because
there are no serrations
Tube occluding clamp with guard

Size: 6.00
Characteristics: Smooth straight jaws; heavy
weight
FIGURE 3-32
Uses: Used to occlude moderate to heavy tubing
such as chest tubes
Notes: Applies even occlusive pressure without
damaging the tubing
Towel and Drape Clamps are nonperforating. The perforating towel clamps can
Towel and drape clamps are found on many types of be used to secure solid tumors during dissection.
sets. Some surgeons do not use these because they The clamps provide a secure hold as the tumor is
may impair the integrity of the drape. If placed on manipulated.
a drape they should be placed only once to prevent The most common types of towel clamps are
contamination of the sterile field. Care is taken not to described here. Some specialty drape clamps will be
grasp the patient’s skin through the drape when apply- described in the specialty chapters. Many facilities refer
ing this clamp. Some varieties penetrate and others to these clamps as “towel clips.”
TOWEL AND DRAPE CLAMPS
Jones towel
clamp
Size: 3.50
Characteristics: Tips are
curved inward. Penetrates
the drape and secures with a
springlike cross-action
FIGURE 3-33
Uses: Used to secure towels
over the surgical site
Notes: Works with a spring
action. Once a penetrating tip
has been positioned, it cannot
be removed and replaced without
contamination
Hoff towel clamp

Size: 40, 6.250
Characteristics: Nonpiercing,
flat serrated tips. Ratchets,
ring-handled
Uses: Secures drapes
Courtesy of Sklar Instruments. FIGURE 3-34
continues
TOWEL AND DRAPE CLAMPS continued
Backhaus towel clamp

Size: 3.50; 5.250
Characteristics: Penetrates the drape and locks with ratchets
FIGURE 3-35
Uses: Used to secure towels over the surgical site
Notes: The short style is usually found on plastic trays, head and neck
sets, or peripheral vascular sets for securing circumferential towels; this
is the most common type of perforating towel clamp; sometimes used
to grasp fibrous tissue during excision of large solid masses. Once a
penetrating tip has been positioned, it cannot be removed and replaced
without contamination Courtesy of Sklar Instruments.
Lorna towel clamp

Size: 3.50; 5.250
Characteristics: Nonperforating
towel clamp with ratchets.
Curved tips
FIGURE 3-36
Notes: The tips resemble
an Allis clamp; sometimes
referred to as “Edna” towel
clips
Roeder towel clamp

Size: 5.250
Characteristics: Penetrates the
drape and locks with ratchets
FIGURE 3-37
Notes: This style has ball stops

at half the length of the curved
jaw; this prevents the rotation
of the jaws of the clamp from
the unsterile undersurface to
the sterile surface. Once a
penetrating tip has been posi-
tioned, it cannot be removed and
replaced without contamination
continues
TOWEL AND DRAPE CLAMPS continued
Peers towel
clamp
Size: 5.250
Characteristics: Nonperforating
towel clamp with ring handles
and ratchets
FIGURE 3-38
Notes: The tip resembles an
Allis clamp, but has a double
row of tiny blunt teeth that
interdigitate
GRASPING FORCEPS
The purpose of this instrument type is to grasp or hold tissues or thick structures.
Ring-Handled Grasping Forceps

Perforating Grasping Forceps
These graspers have toothed structures at the tip of the jaw for a firm, piercing grip that uses opposing prongs
without crushing the structures.
PERFORATING GRASPING FORCEPS
Billroth tumor
forceps
Size: 10.750
Characteristics: Ring-handled
grasper with 4 3 4 sharp,
opposing tips that pen-
FIGURE 3-39
etrate, pierce, and hold tis-

sue; straight; intermediate to
heavy weight. Shanks curved
inwards. Locks with ratchets
Uses: Used to grasp large
fibroid tumors
Notes: Strong perforating clamp
continues
PERFORATING GRASPING FORCEPS continued
Lahey traction
forceps
Size: 6.250; 8.00
grasper with 3 3 3 sharp teeth
in opposing jaws; intermediate
FIGURE 3-40
weight with locking ratchets
Uses: Used to grasp fibrous
tissue
Notes: Commonly used in gen-
eral surgery to grasp fibrous
breast or thyroid tissue
Nonperforating Grasping Forceps

These graspers use serrations at the tip of the jaw or a circumferential design to securely hold tissue causing minimal
trauma.
NONPERFORATING GRASPING FORCEPS
Allis forceps
Size: 5.00; 5.50; 6.00; 7.250;
10.00
graspers with atraumatic teeth
4 3 5 or 5 3 6 along the
edge of the tip of the jaw; the
FIGURE 3-41
jaw can be straight or angled;

intermediate weight
Uses: Holding tissue edges
Notes: One of the most com-
monly used instruments in the
surgical setup; longer Allis for-
ceps are used in general surgery;
angled Allis forceps are used in
hemorrhoid ligation for occlusion
banding
continues
NONPERFORATING GRASPING FORCEPS continued
Allis Adair
forceps
Size: 6.50
9 3 10 along the edge of the
FIGURE 3-42
tip of the jaw; straight
Uses: Holding wide tissue edges
Notes: Tip of jaw is very wide;
commonly used in place of
Pratt T clamp for grasping
edges under traction
Babcock forceps
Size: 6.250; 8.250; 9.50
forceps with circumferential
jaws with horizontal serrations
across the edge of the tip of
the jaw; intermediate weight
to lightweight; atraumatic
FIGURE 3-43
Uses: Used to hold delicate tis-
sues and tubular structures
Notes: Has a soft touch and
feels mildly malleable
Non-Ring-Handled Grasping Forceps Non-Ring-Handled Grasping Forceps

These forceps are commonly referred to as “pick-ups.” without and with Teeth
They resemble tweezers. This set of forceps is not all- Surgeons will frequently refer to nontoothed varieties
inclusive and is limited to the types most frequently as “thumb forceps” or “smooth pick-ups” even though
found in basic instrument sets. they have fine serrations or grasping surfaces at the tip.
Handle styles will vary according to the location of the grasping tissue above the dermal layer to pre-
tissue and surgeon’s preference. The shanks of several vent perforating the epidermal layer and “but-
of the bayonet styles and intermediate-weight forceps ton holing” the skin, which can leave permanent
have a stop peg to prevent overcompensated grasping scars.
of tissue that can cause crushing of the fibers. Additional non-ring-handled grasping forceps
Forceps with teeth have a tip with an inter- without and with teeth will be described in the appro-
digitating projection. Care is taken to prevent priate specialty chapters.
NON-RING-HANDLED GRASPING FORCEPS
Dressing
forceps
Size: 50 to 120
Characteristics: Serrated tips
for traction. Medium-weight
FIGURE 3-44
tissue
Uses: Can be used to manipu-
late tissue or dressing material
Notes: Commonly found in pairs
in a set. Sometimes referred
to as thumb forceps
Tissue forceps
Size: 50 to 120
Characteristics: Serrated
1 3 2 tips with teeth for trac-
tion. Medium-weight tissue
FIGURE 3-45
Uses: Can be used to manipu-
late tissue
to as rat tooth or mouse tooth
forceps
continues
NON-RING-HANDLED GRASPING FORCEPS continued
Adson forceps
Size: 4.750
FIGURE 3-46
Characteristics: Delicate tip with wide thumb grasp area; straight or curved tip forceps.
Can be smooth, serrated, or 1 3 2 toothed tip
Uses: Grasp fine tissue edges
Notes: Several types with and without teeth used for tissue
approximation; extra-fine teeth are available
Courtesy of Scanlan International.
Brown-Adson forceps
Size: 4.750
Characteristics: Delicate, lon-
gitudinally 8 3 8 toothed tips
with wide thumb grasp area
FIGURE 3-47
Notes: Commonly used in plas-
tic surgery
Brown forceps
Size: 6.00; 8.00; 10.00
weight forceps with narrow
ridged handles; the tips have
FIGURE 3-48
longitudinal 8 3 8 teeth
Uses: Used on moderate tis-
sue as opposed to delicate or
heavy tissue
Notes: The handles are nar-
row and firmer compared to
Brown-Adson forceps; useful
for manipulation of tissue with
a layer of subcutaneous fat
attached. Intermediate weight Courtesy of Sklar Instruments.
continues
Broli-Adson forceps
FIGURE 3-49
Size: 6.00
Characteristics: Flat wide handle with longer narrow tip.
Resemble standard Adson forceps. Straight or curved
serrated tip. Available with 1 3 2 teeth
Uses: Delicate tissue in deeper plane Courtesy of Scanlan International.
McIndoe forceps
FIGURE 3-50
Size: 60; 6.250
Characteristics: Straight serrated forceps with serrated
thumb grip. Available with fine 1 3 2 teeth. Stop peg
Uses: Moderate tissue Courtesy of Scanlan International.
Cooley forceps
Size: 6.00; 8.00
to fine-weight forceps with
longitudinal teeth and match-
FIGURE 3-51
ing grooves; the straight tips
narrow toward the distal
grooved end and interdigitate
Uses: Used for vascular and
general surgery procedures
Notes: Atraumatic forceps with
2-mm-wide tips. Similar to
DeBakey forceps, but with a
reverse jaw configuration Courtesy of Sklar Instruments.
DeBakey forceps
Size: 6.00; 7.750; 8.00; 9.00
Characteristics: Intermediate-weight forceps with longi- FIGURE 3-52
tudinal fine teeth and matching grooves
Uses: Used for most vascular and general surgery
procedures
Notes: Atraumatic forceps; the favorite tool of many surgeons; the straight tips
narrow toward the distal end and interdigitate. Also known as cartilage forceps Courtesy of Scanlan International.
continues
Comparison of Cooley and

DeBakey Jaw Types
Characteristics: Approximation versus interdigitation
Uses: Found on clamps, forceps, and many styles of
graspers
Notes: Cross-section of DeBakey and Cooley jaw
FIGURE 3-53
types. These jaw types can be found on forceps
A.
and clamps
A. DeBakey jaw
B. Cooley jaw
B.
A, B: © 2019 Cengage®.
Gerald forceps
Size: 7.00
Characteristics: Lightweight to
intermediate-weight forceps
with fine serrations at the tip;
FIGURE 3-54
the tips are very narrow; the
shanks have a stop peg to
prevent overcompensated
grasping of tissue
Uses: Used on very delicate
tissue
Notes: Frequently used during
dissection
Cushing forceps
Size: 7.00; 7.250
Characteristics: Lightweight to intermediate-weight
FIGURE 3-55
forceps with fine serrations at the tip; the proximal end

is beveled for use as a blunt dissector; the handle is
longitudinally grooved to fit the bulk of the thumb and
pad of the index finger
Uses: Used on very delicate tissue
Notes: Frequently used during dissection; handles can be
straight or bayonet style; the handle grooves can vary Courtesy of Scanlan International.
continues
Kelly forceps
Size: 9.00
FIGURE 3-56
Characteristics: Intermediate-weight forceps with
1 3 2, 2 3 3, or 3 3 4 teeth; the shanks have a stop
peg to prevent overcompensated grasping of tissue;
the handle style is Gutch
Uses: Used to grasp fascia
Notes: Frequently used in hernia procedures for grasping fascial edges Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Singley forceps
Size: 9.00
weight forceps with circular
fenestrated tips; the serra-
FIGURE 3-57
tions run horizontally across
the fenestration; the shanks
have a stop peg to prevent
overcompensated grasping of
tissue
Uses: Used to grasp delicate
tissue
Notes: Sometimes referred to as
ring-tip pick-ups
Semken forceps
Size: 5.00; 6.00
Characteristics: Lightweight
forceps with fine serrations
at the tip; straight forceps;
FIGURE 3-58
straight or curved tips
Uses: Gentle tissue handling
Notes: Commonly used on fine
membranes and single-layer
tissues near the surface; can
be used for dressing changes
and are sometimes referred to
as dressing forceps
continues
Russian
forceps
Size: 6.00; 8.00; 9.00; 10.00
to heavyweight forceps with
FIGURE 3-59
circular, fitted, groovelike ser-
rations at the tips
Uses: Atraumatic grip for fine to
moderately thick tissue
Notes: Sometimes referred to as
Mayo Russians
Bonney forceps
Size: 7.00
Characteristics: Heavy forceps
with 1 3 2 or 2 3 3 teeth and
serrated tips
FIGURE 3-60
Uses: Used for heavier tissue
and fascia
Notes: The handles are cross-
serrated for a firmer grip
Ferris Smith forceps

Size: 7.00
Characteristics: Heavyweight
forceps with wide platform
handles with cross-hatched
FIGURE 3-61
grooves for a firm grip; the

teeth are 1 3 2 or 2 3 3 over
serrated tips
Uses: Used for firm or fibrous
tissue
colorectal surgery for grasping
the perineal fascia during abdom-
inal perineal resection
continues
Jansen forceps
Size: 6.50
FIGURE 3-62
Characteristics: Intermediate-weight bayonet forceps with
serrations at the tip; the shanks have a stop peg to pre-
vent overcompensated grasping of tissue
Uses: Used on medium-weight tissue
Notes: Commonly used during nasal procedures or for a small area that requires
the surgeon’s hand to be out of the line of vision; useful for nasal packing Courtesy of Sklar Instruments.
Wilde forceps
Size: 6.50
80-degree angled forceps
with serrated tips
FIGURE 3-63
Uses: Used in nasal procedures
Notes: Useful for inserting nasal
packing
DISSECTION INSTRUMENTATION instrumentation. Damaged or broken instruments can

cause serious injury during the dissection process.
Instrumentation used in dissection can be sharp or
blunt. Sharp dissection is performed by incising ana-
tomic planes, nonanatomic planes, or scars from for- Sharp Dissection Instrumentation
mer surgery or by transecting specific tissue layers. Sharp dissection instruments commonly have a bladed
Blunt dissection is performed by placing an instru- edge. This means that the working component is
ment between the anatomic planes or tissue layers to machined or honed to a fine edge without chips or
cause separation of the fibers. In many instances, the burrs to slice through tissue without interruption.
best blunt dissection tool is the surgeon’s forefinger Primary sharp dissection instruments include single-
wrapped in a single layer of Raytec or a Foerster sponge blade knives. Secondary sharp dissection instruments
forceps clamped around a rolled sponge. Regardless of commonly have two blades that work in opposition to
the method employed, the end result is a division of cut tissue, such as scissors or ring-handled punches.
layers. In some cases portions of the tissue are inten-
tionally removed to create space or are prepared as a Scalpels and Knives
specimen and sent for pathologic examination. Scalpels and knives are single-handled instruments that
Considerations for dissection include provision for are designed to attach to a disposable blade. Through
hemostasis and prevention of peripheral damage of adja- history scalpels and the knife edge were permanently
cent structures. In certain disease states such as tumors or attached and required frequent sharpening. Disposable
necrosis, identification of anatomic layers is extremely dif- blades are more efficient and provide a fresh, sterile,
ficult. This can be complicated by the use of poor-quality sharp edge for each individual patient.
SCALPELS AND KNIVES
Scalpel #3
Size: #3
FIGURE 3-64
Characteristics: Nickel plated, ridged grip for thumb
and forefinger; handle is marked in centimeters and
millimeters for use in measurement of tissue
Uses: Sharp dissection
Notes: Blade assembly fits size 10 series disposable blades (10-11-12-15) © 2019 Cengage®.
Scalpel #3L
FIGURE 3-65
Size: #3L
Characteristics: Nickel plated, ridged grip for thumb and forefinger; handle is longer for use in deep tissue
Notes: Blade assembly fits size 10 series disposable blades (10-11-12-15) (straight tip) (angled tip) Courtesy of Sklar Instruments.
Scalpel #4
FIGURE 3-66
Size: #4
Characteristics: Nickel plated, ridged grip for thumb and
forefinger; handle is marked in centimeters and millimeters for use in measurement of tissue
Notes: Blade assembly fits size 20 series disposable blades (20-21-22-23-25) © 2019 Cengage®.
Scalpel #4L
FIGURE 3-67
Size: #4L
Characteristics: Nickel plated, ridged grip for thumb and forefinger; handle is longer for use in deep tissue
Notes: Blade assembly fits size 20 series disposable blades (20-21-22-23-25) (straight only) Courtesy of Sklar Instruments.
Scalpel #7
FIGURE 3-68
Size: #7
Characteristics: Nickel plated, ridged grip for
thumb and forefinger; shank is thin for fine incision management
Notes: Blade assembly fits size 10 series disposable blades (10-11-12-15) © 2019 Cengage®.
FIGURE 3-69
Scalpel #9
Size: #9
Characteristics: Nickel plated, ridged grip for thumb
and forefinger; shank is thin and short for fine incision management
Notes: Blade assembly fits size 10 series disposable blades (10-11-12-15) Courtesy of Sklar Instruments.
continues
SCALPELS AND KNIVES continued
Beaver handle
Size: 3.750
FIGURE 3-70
Characteristics: Stainless steel with rounded handle;
used for delicate tissue dissection
Notes: Slotted blade assembly accepts fine disposable
mini-blades referred to as beaver blades; flat end of blade
fits into slot, and handle chuck is turned like a screw motion
until blade is held secure; also called miniature blade handle © 2019 Cengage®.
Scalpel blades
Characteristics: Standard blade assortment for
scalpel handles A.
Notes: Each blade is individually wrapped in
perforation-resistant foil; blades are disposable
(see handle description for size matching with B.
blade)
A. #10 blade
B. #11 blade
FIGURE 3-71
C. #12 blade
D. #15 blade
E. #20 blade C.
D.
E.
A-E: © 2019 Cengage®.
Scissors abscess sacs for incision and drainage. Some surgeons

Scissors use opposing blades for sharp dissection. use this blunt-method maneuver with round-tipped
Scissors can also be used for blunt dissection by insert- scissors. In deep tissues, this maneuver serves as a
ing the closed tips into a tissue plane, then gently method for blind palpation during dissection as an
opening the blades widely to spread the fibers. This extension of the surgeon’s fingers.
procedure is referred to as Hilton’s maneuver and is Most standard scissors are primarily intended for
commonly used in areas densely packed with vessels right-handed use; however, many manufacturers offer
and nerves. This procedure is also useful for opening left-handed styles of scissors and other ring-handled
instruments by special order. Left-handed scissors may Many combinations of handle and blade styles
be packaged into specialty sets labeled with a particular and tip configurations are available. Some manufac-
surgeon’s name for easy identification. turers offer an option of electrosurgical current as a
This section covers the most basic styles of scissors mode of function. Scissors with electrosurgical capa-
that are commonly found in basic instrument sets for bilities cannot be sharpened and must be used with all
general, neurologic, minor soft tissue, and vascular the safeguards associated with protecting the patient
surgery. Additional specialty scissors will be added and team from stray current and accumulation of
within each specialty chapter. energy.
SCISSORS
Standard
operating
scissors
Size: 4.50; 5.00; 5.50; 6.00; 6.50
Characteristics: Operating
scissors; sharp-blunt tips can
be straight or curved
FIGURE 3-72
Uses: Trim suture ends at the
working end of the instrument
table
Notes: Also referred to as nurse
scissors or suture scissors;
used on the back table by the
scrub person; not commonly
handed up to the main field
Mixter scissors
Size: 6.250
Characteristics: Jaws are half
the length of the shanks;
intermediate-weight metal;
can be straight or curved. FIGURE 3-73
Blunt/blunt tips
Uses: Dissection of moderate-
weight tissue
Notes: Used in dissection of
intermediate-depth tissue
continues
SCISSORS continued
Mayo scissors
Size: 6.250
Characteristics: Heavy operat-
ing scissors with blunt-blunt
tips. Can be straight or curved
Notes: Found in most instru-
FIGURE 3-74
ment sets in both curved
and straight styles; curved
are used on patient tissue;
straight are used to cut suture
Metzenbaum scissors
Size: 5.50; 7.00; 8.00; 9.00; 11.00; 14.50
FIGURE 3-75
Characteristics: Fine, lightweight scissors with blunt-
blunt tips; jaws are half the length of the shanks; avail-
able in curved and straight styles
Uses: Dissection of fine tissue
Notes: Found on most instrument sets; the most commonly
used style is curved. Should not be used to cut suture Courtesy of Scanlan International.
Harrington scissors
Size: 11.50
scissors with blunt-blunt tips;
jaws are one-fourth the length
of the shanks
FIGURE 3-76
Uses: Dissection of intermediate
to fine tissue
continues
SCISSORS continued
Jorgenson
scissors
Size: 9.00
Characteristics: Sharp angle to
jaw; blunt-blunt tips
Uses: Dissection of moderate to
heavy tissue
Notes: Some gynecologic sur-
FIGURE 3-77
geons use these scissors for
separating the uterine cervix
from the vaginal cuff
© 2019 Cengage®.
Thorek scissors
Size: 7.250; 10.00
Characteristics: Sharp curve to
jaw; blunt-blunt tips
Uses: Dissection of intermediate
tissue
Notes: Some gynecologic sur-
FIGURE 3-78
geons use these scissors for
separating the uterine cervix
from the vaginal cuff
© 2019 Cengage®.
continues
SCISSORS continued
Stevens tenotomy
scissors
Size: 4.50
Characteristics: Jaws are
wedge shaped and can be
curved or straight; tips are
sharp-sharp; ring-handles are
FIGURE 3-79
standard. Micro styles have
spring handles
Uses: Incision into narrow
spaces; jaw shape allows
scissors to spread and visual-
ize the channel as it is cut
© 2019 Cengage®.
Martin scissors
FIGURE 3-80
Size: 8.00
Characteristics: Tip is wedge shaped; the curved
blades have fine serrations for traction
Uses: Used for cutting cartilage
Notes: The wedge-shaped tip is used for blunt entry into a cartilaginous area; the serrations
provide a secure cutting surface after dissection of the planes Courtesy of Sklar Instruments.
Potts-Smith scissors
Size: 7.00; 7.50
Characteristics: Jaw is one-
quarter the length of the
shanks and right angled to the
specified degree; sharp-sharp
FIGURE 3-81
tips; 25, 45, or 60 degrees

Uses: Used to open and trim
blood vessel edges
Notes: Available in two blade
lengths: 20 mm intermedi-
ate weight or 13 mm delicate
weight
continues
SCISSORS continued
Strully scissors
FIGURE 3-82
Size: 8.00
Characteristics: Jaws are slightly curved and measure one-fifth the
length of the shanks; the tips have a ball tip to prevent perforation;
intermediate-weight instrument
Uses: Curvilinear dissection of delicate tissue
Notes: Commonly used in vascular and neurosurgery Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Iris scissors
Size: 3.750; 4.00; 4.50
Characteristics: Fine scissors with sharp-sharp tips; jaws
are straight or curved and one-third to one-half the length
FIGURE 3-83
of the shanks; the ring handles are standard or flattened
into a ribbon style for a wider stabilizing grip. Available in
right-angle jaw
Uses: Dissection of delicate tissue
Notes: Standard ring handles; gold handle has carbon
blade inserts
© 2019 Cengage®.
Lister bandage
scissors
Size: 5.50; 7.250
Characteristics: Angled blunt-
blunt scissors. Lower blade
FIGURE 3-84
has a protective wedge tip to
protect underlying tissue when
in use
Uses: Cuts heavy dressing
material and can be used to
remove circumferential dress-
ings without harming the
patient’s skin. Is sometimes used
to extend the lower uterine seg-
ment incision during cesarean
section. Can be used to cut the
umbilical cord Courtesy of Sklar Instruments.
continues
SCISSORS continued
Utility scissors
Size: 6.50; 7.50
Characteristics: Durable lightweight metal; the jaws are
right angles; the upper blade is blunt; the lower ser-
FIGURE 3-85
rated blade is slightly longer with a wedge-probe tip; ring
handles are heat-stable plastic and have a larger thumb
handle for wide stabilization
Uses: Used to cut thick dressing material. Not used on
tissue
Notes: Not used for patient tissue; some manufacturers
coat the blades with fluoride to prevent adhesive tape
buildup; handles can be plastic color coded. Autoclavable Courtesy of Sklar Instruments.
Wire-cutting scissors
Size: 4.250; 4.750
Characteristics: Blades are
one-fourth the length of the
shanks and jaws have one
serrated blade at a 45-degree
FIGURE 3-86
angle; available in angled
styles; tips are blunt-blunt
Uses: Used only for cutting wire
suture or intermediate pins
Spencer stitch scissors

Size: 3.50
Characteristics: Blades avail-
able in curved or straight
styles. One blade has a hook
that slides under the stitch
FIGURE 3-87
before cutting
Uses: Used for removing sutures
from the patient
Biopsy Forceps
Biopsy forceps sharply dissect tissue for pathologic Incisional biopsies are performed with biopsy forceps
examination and are not commonly found on stan- by biting into the tissue that is being studied. The sam-
dard instrument sets. They are added as needed. The ple is not all-inclusive of the entire diseased segment.
sharpness of the cutting edges outlines the margins to Many of these biopsy forceps were designed for use on
be studied by the pathologist. Use of dull instruments the uterus, but can be used for other tissues as needed.
causes tissue distortion and crushing that can cause Keep in mind that after the biopsy is taken, there is a
the diagnostic process to be delayed or inaccurate. need for appropriate hemostasis.
BIOPSY FORCEPS
Gaylor uterine
biopsy forceps
Size: 9.00
Characteristics: Ring handle
with box lock joint; locking.
Tips have round cutting jaw;
FIGURE 3-88
curved shanks and tips
Uses: Procurement of a sharply
dissected tissue specimen
Notes: Primarily used in gyne-
cologic procedures; after
procurement of tissue sample,
care is taken to extract the
specimen using a small needle
without damaging the tissue
specimen
Instrument: Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Tip Close-up: Courtesy of Sklar Instruments.
Tischler cervical punch

biopsy forceps
Size: 9.750
Characteristics: Oval cutting
surface with a cup-style jaw;
cup interdigitates with lower
jaw for cleaner cut on tougher
FIGURE 3-89
tissue; ring-style handle; no
ratchets; 6 3 3 3 1.5 mm
specimen
Uses: Procurement of a sharply
Notes: Primarily used in gyneco-
logic procedures; after procure-
ment of tissue sample, care is
taken to extract the specimen
without damaging the tissue
specimen
MANUAL COMPACT TISSUE DISSECTION: BONE SAWS
Satterlee bone saw
FIGURE 3-90
Size: Handle 120; blade width 3.00
Characteristics: Pistol-style handle of stainless steel; single
screw-bolt; disposable blade is preferred. Most styles have a fixed saw blade
Uses: Used for larger bone transection Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Gigli wire saw with guide and two handles

Size: 12.00; 20.00; 30.00 wire
Characteristics: Two opposing handles, either loop or
T-shaped, that attach to a disposable length of twisted
wire; the length of wire is placed beneath the surface
FIGURE 3-91
to be cut, and each end is attached to a hook on A. B.
the edge of the handles
Uses: Used to cut through bone in a rapid hand-opposi-
tion sawing motion
A. Gigli wire saw
B. T-shaped handles (2)
C. Loop handles (2)
C. D.
D. Bailey saw wire guide A, D: Courtesy of CareFusion, a division of Becton, Dickinson and Co.
B, C: © 2019 Cengage®.
DEBULKING hypertrophy is potentially serious if the process causes

obstruction or interference with the normal body pro-
The process of debulking is performed to reduce cesses. Benign tissues can be carefully dissected as
hypertrophic (enlarged) areas of abnormal tissue or to hemostasis is maintained. Malignancy has the poten-
decrease the bulk of necrotic material for the promo- tial for spreading to other areas of the body, causing
tion of healing by reepithelialization. Hypertrophic multiple disturbances to organ systems in general.
overgrowth of tissue or neoplasm can happen to any Malignant tissues cannot be readily debulked, or cut
type of cell—ranging from soft tissue to compact bone. away, because this is thought to cause spreading or
Debulking as a form of dissection does not include seeding throughout the body. In palliative proce-
the careful separation of tissue layers by cutting linear dures, however, the main consideration is to minimize
incisions through defined planes. Debulking involves obstructions and restore as much function as possible
scraping or tearing away tissue from the surface to an in an effort to provide comfort to the patient.
underlying level demonstrated to be as clear of disease
as possible. It is not always a precise measurement
and does not clearly delineate tissue planes as identi- Manual Debulking
fied during dissection. Debulking can be performed Sharp to blunt manual debulking instrumentation is
manually or by a mechanized device. Common manual characterized by a sharp cutting surface, opposing
debulking instruments will be described in this sec- cutting/grasping surfaces, or a series of abrasive serra-
tion. Specialized mechanical debulking devices will be tions that can be used for soft or compact tissue. Blunt
described in the appropriate specialty chapters. debulking instrumentation generally has a rounded
Some hypertrophy is benign, and some is the edge or a grooved configuration that permits the sur-
result of malignancy. Each type of overgrowth has the geon to peel away layers of soft tissue and muscle.
potential to cause impairment or even death. Benign These are commonly wrapped separately to prevent
dulled edges caused by repeated processing by steam between manufacturers and are represented here as
sterilization. appropriate. Smaller measurement numbers on the
NOTE: Curettes and debulking instruments have handle indicate a smaller, more delicate working sur-
working surfaces that are measured either numeri- face. Sizes listed in the chart are the way they will be
cally or in millimeters. Measurement methods differ seen on the handle.
SHARP TO BLUNT MANUAL DEBULKING CURETTES
Fox dermal curette
FIGURE 3-92
Size: Handle 5.50; curette size 1 mm to 6 mm
Characteristics: Thin, probe-style handle with circular open ring
tip on one end with one cutting edge
Uses: Used to scrape away small surfaces of soft tissue Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Sims uterine curettes

Size: Handle 11.00; tip size 00 to
01 to 6
Characteristics: Hoop-shaped,
oval, sharp debulking surface
FIGURE 3-93
on a long malleable shank;
sharp on one side, blunt on
the other
Uses: Used inside the uterus to
remove endometrial tissue
Thomas blunt uterine

curettes
Size: Handle 11.00;
tip size 1 to 6
oval, blunt debulking FIGURE 3-94
surface on a long malleable
shank
Uses: Used inside the uterus to
remove endometrial tissue.
Blunt for use on friable post-
partum uterine tissues
ELEVATORS AND STRIPPERS: BLUNT DEBULKING INSTRUMENTS
Freer elevator
FIGURE 3-95
Size: 7.00
Characteristics: Double-ended shank with 5-mm-wide
sharp and blunt ends; central finger grip is cross-
serrated for a secure grasp; slight curve to tips
Uses: Used to peel soft tissue layers from fibrous or compact layers © 2019 Cengage®.
Penfield dissectors
FIGURE 3-96
Size: 7.250; 7.50; 7.750; 8.750; 11.50
Characteristics: Lightweight double-ended shank; two
styles; blunt-blunt double-ended elevator; blunt elevator/
stripper end with wax impactor on the other end
Uses: Used to strip muscle and periosteum from bone
© 2019 Cengage®.
Notes: The tamp end is used to pack bleeding bone with wax
Langenbeck periosteal elevator
FIGURE 3-97
Size: 7.250
Characteristics: Short, single-ended shank with a wide (17 mm) or
narrow (7 mm) blunt-angled tip; handle is wide and flattened
Notes: Narrow tip; wide tip
Cushing periosteal elevator
FIGURE 3-98
Size: 6.00
Characteristics: Short, single-ended shank with a blunt-angled tip;
handle is wide and flattened
Notes: Sometimes called “little joker” © 2019 Cengage®.
Sedillot elevator FIGURE 3-99
Size: 7.250
Characteristics: Single-ended elevator with wide
ribbed handle
Uses: Used to strip muscle and periosteum from bone Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Pierce elevator
FIGURE 3-100
Size: 8.50
Characteristics: Double-ended shank with right- and left-angled
ends; central finger grip is cross-serrated for a secure grasp
Uses: Used to peel soft tissue layers from fibrous or compact layers Courtesy of CareFusion, a division of Becton, Dickinson and Co.
continues
ELEVATORS AND STRIPPERS: BLUNT DEBULKING INSTRUMENTS continued
Cobb elevator
Size: 9.50; 110
Characteristics: Rounded
smooth tip is 1.250 wide.
Handle is straight and hex-
FIGURE 3-101
agonal in design
Uses: To peel periosteum from
bone
© 2019 Cengage®.
Woodson elevator
FIGURE 3-102
Size: 100
Characteristics: Double-ended. One end is 1/80 semi-sharp blade;
opposite end is a spatula with a depth of 1/20
Uses: Separates soft tissue from compact surface. Can be used as
sharp or blunt dissection. Spatula can be used to apply bone wax Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Key periosteal elevator
FIGURE 3-103
Size: 6.750
Characteristics: Heavy hexagonal handle with 1/80 wide
single curved end. Straight edge of tip is slightly beveled
Uses: Used to strip muscle and periosteum from bone © 2019 Cengage®.
Adson periosteal elevator
FIGURE 3-104
Size: 6.50
Characteristics: Medium-weight, longitudinally grooved handle
with a curved-blunt or sharp wedged tip
Uses: Used to strip muscle and periosteum from bone Courtesy of CareFusion, a division of Becton, Dickinson and Co.
PROBES AND DILATORS instruments can be used to “sound” a wound. Some

Probes and dilators are used to expand and explore a instruments used as sounds are rodlike. Other instru-
natural or created opening in the body. Most of these ments that can be used as sounds are the tips of clamps
instruments are blunt; however, some have knives or scissors. Specially designed instruments may have
incorporated in the tips. The term sound refers to other working elements or graduated surfaces that
the act of blindly, but gently, inserting an instrument serve to intentionally enlarge the opening and the
into an opening to feel how deep it is. Many types of length/depth of the passage.
Measurement and Expansion
SOUNDS AND PROBES
Grooved director
Size: 6.50
FIGURE 3-105
Characteristics: Tiny, probing stainless-steel guide used
to create a trough for sliding a probe into a trabecu-
lated opening; the director has a groove down the cen-
ter that runs the full length with a slotted flange finger
grip
Uses: Used to sound a duct, sinus, or fistula Courtesy of Sklar Instruments.
Grooved director with

ball tip
Size: 6.50
Characteristics: Tiny, probing
stainless-steel guide used
FIGURE 3-106
to create a trough for sliding
a probe into a trabeculated
opening; the director has a
groove down the center that
runs the full length with a
ball-tipped end and a slotted
flange finger grip
Uses: Used to sound a duct, sinus,
or fistula
Barr fistula probe

Size: 11.50
Characteristics: One size;
sterling silver probe; double-
ended or with eyed tip for FIGURE 3-107
passing suture or Seton drain;
narrow rounded finger-grip
handle; slightly malleable
Uses: Used to sound a duct,
sinus, or fistula
continues
SOUNDS AND PROBES continued
Williams lacrimal probe

Size: 5.00; sizes 4/0–3/0, 2/0–0, 1–2, 3–4, 5–6, 7–8
FIGURE 3-108
Characteristics: Sterling silver, double-ended, ball-tipped (two
sizes each probe); center of probe shank has flat finger hold
(referred to as a tongue tie) with slot and size markings
Uses: Used to sound a duct, sinus, or fistula
Bowman lacrimal
probe
Size: 5.50; sizes 4/0–3/0, 2/0–0,
1–2, 3–4, 5–6, 7–8
Characteristics: Sterling silver,
double-ended (two sizes each
probe); center of probe shank
has flat finger hold with slot
and size markings
FIGURE 3-109
Uses: Used to sound a duct,
sinus, or fistula
Van Buren urethral sounds

Size: 11.00; 8-40 Fr.
FIGURE 3-110
Characteristics: Curved, blunt tip; stainless-steel shaft
with flat smooth finger grip with size etchings
Uses: Used to dilate the male urethra
Notes: Curvature is safe for dilation at the level of the
prostatic urethra. Alternative use includes as a tunneling
probe under the skin Courtesy of Sklar Instruments.
continues
SOUNDS AND PROBES continued
Dittel urethral sounds
FIGURE 3-111
Size: 11.50
Characteristics: Straight, blunt tip; stainless-steel shaft
with flat, smooth finger grip with size etchings
Uses: Used to dilate the female urethra
Notes: The straight tip is useful and safe for dilation of the female urethra.
Alternative use includes as a tunneling probe under the skin Courtesy of Sklar Instruments.
Sims uterine sound
FIGURE 3-112
Size: 13.00
Characteristics: Probe-style malleable shaft with measure-
ments marked in centimeters or inches; slightly curved
ball tip; finger grip is flat and corrugated for traction; silver plated
Uses: Used to sound the depth of the uterine cavity.
Alternative use includes as a tunneling probe under the skin © 2019 Cengage®.
MANUAL GRADUATED DILATORS
Bakes common duct dilators

Size: 8.750
Characteristics: Single-ended, bullet-tipped probe with
short, cylindrical handle; shaft is malleable
FIGURE 3-113
Uses: Used to sound a duct or tubular structure
Notes: The tip resembles a bullet shape on the end of a
slender shaft
Pratt uterine dilators

Size: 11.50; sizes 13 to 15 Fr.
Characteristics: Curved, double-ended, blunt-tipped,
probe-style dilators; each end is progressively larger;
FIGURE 3-114
solid and nonflexible; stainless steel

Uses: Commonly used to dilate the uterine cervix.
Alternative use includes as a tunneling probe under
the skin
MECHANIZED DILATORS
Otis graduated urethrotome
FIGURE 3-115
Size: 11.750; working element length approximately 90
Characteristics: Straight dilation assembly with two
cutting blades for releasing urethral strictures
Uses: Enlarges the urethral opening Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Trousseau tracheal dilator

Size: 5.50
FIGURE 3-116
Characteristics: Double-pronged mechanical dilator with slightly
angled, rounded tips. Matte finish
Uses: Enlarges tracheotomy opening for insertion of tracheostomy
tube
LaBorde tracheal
dilator
Size: 5.50
Characteristics: Three-prong
mechanical dilator with ring
handles. Right-angle rounded
tips. Satin finish
Uses: Enlarges tracheotomy
FIGURE 3-117
opening for insertion of tra-
cheostomy tube
© 2019 Cengage®.
MEASURING DEVICES
Castroviejo caliper
Size: 7.00
FIGURE 3-118
Characteristics: Combined measuring and marking device; grad-
uated in 0 to 20 mm. Straight precision tips for accuracy. Screw
hold to maintain position of measurement. Satin finish to reduce
glare
Uses: Used to measure diameters and widths
Tessier caliper
Size: 10.250
FIGURE 3-119
Characteristics: Linear measuring graduated in 0 to 20 millimeters
Uses: Commonly used in ear/nose/throat (ENT)
Ring handle caliper
FIGURE 3-120
Size: 110
Characteristics: Long ring handle design for deeper measurements in the
0- to 65-millimeter range. Measuring bar locks and corresponds to the
tips of the jaws. Low-glare finish
Uses: Measures deep surfaces Courtesy of Scanlan International.
EVACUATION AND INSTILLATION INSTRUMENTATION

Removal of blood and body fluids from the surgical site promotes clear visualization of the surgical field.
Evacuation Instrumentation
SUCTION TIPS
Yankauer suction tube with removable tip

Size: 120
Characteristics: Long angled tube with removable
FIGURE 3-121
screw tip; hand grip is ridged; stainless steel; some are

chrome-plated
Uses: Suction fluids and substances; good for oropharyn-
geal suctioning
Notes: Disposable models are preferred; reusable Yankauer tips have
a screw tip that must be removed for cleaning and processing; the
screw tip is a counted item; sometimes known as tonsil suction Courtesy of Sklar Instruments.
continues
SUCTION TIPS continued
Poole suction tube
FIGURE 3-122
Size: 120
Characteristics: Medium-length, stainless-steel tube
with screw-on perforated cover to prevent suction lesions of viscera during intraabdominal suctioning; cover guard is
used to perform deep suctioning during irrigation. Disposable styles are preferred. Outside diameter is 32 Fr.
Uses: Primarily used in intracavitary suctioning
Notes: Cover is removable for fine-tip suctioning Courtesy of Sklar Instruments.
Frazier suction tube

Size: 7.50; sizes 6 to 12 Fr.
FIGURE 3-123
Characteristics: Used for fine-tip suction during intricate
surgical procedures; suction is activated by covering
the hole in the finger grip with the thumb; has a clot-
clearing stylet
Uses: Commonly used in ENT and plastic surgical procedures
Notes: Available in disposable models; reusable styles must be processed with stylet removed.
Disposable styles are preferred Courtesy of Sklar Instruments.
Adson suction tube

Size: 6.00; 8.00; sizes 11 to 15 Fr.
FIGURE 3-124
Characteristics: Slightly curved tip. Used for fine-tip
suction during intricate surgical procedures; suction is
activated by covering the hole in the finger grip with
the thumb; smaller than Frazier suction tips; has a clot-
clearing stylet
Uses: Commonly used in small surgical areas
Notes: Reusable stylets must be processed with stylet removed. Disposable styles are preferred Courtesy of Sklar Instruments.
Baron suction tube
FIGURE 3-125
Size: 3.00; sizes 3, 5, 7 Fr.
Characteristics: Tip is angled at the thumb control. Used for fine-tip suction during intricate surgical procedures;
suction is activated by covering the hole in the finger grip with the thumb; smaller than Frazier suction tips;
has a clot-clearing stylet
Uses: Commonly used in small surgical areas
Notes: Reusable styles must be processed with stylet removed. Disposable styles are preferred Courtesy of Sklar Instruments.
Buie suction tube

FIGURE 3-126
Size: 16.00
Characteristics: No stylet; stainless-steel suction tip;
available with or without a thumb-controlled suction.
Angled slightly at the tubing connection point
Uses: Commonly used in rigid endoscopic procedures
of the upper and the lower gastrointestinal tract Courtesy of Sklar Instruments.
Injection and Irrigation Devices
SYRINGES
Syringe tip styles

Characteristics: This Luer-lock tip style interdigitates with a con- A.
necting instrument; connects tightly with needle hubs and other
devices used for injection; this tip style is useful for connections
FIGURE 3-127
with graduated connecting devices such as ureteral catheters
Uses: Used for instillation, injection, and aspiration
A. Three-ring syringe
B.
B. Luer lock syringe
C. Slip-tip syringe
C.
A: Courtesy of Joe Fortunato.

B, C: © 2019 Cengage®.
Toomey syringe
FIGURE 3-128
Characteristics: Toomey syringe has plunger for instilling
and aspirating irrigating fluids; it is graduated on the side
to allow monitoring of fluid amounts. The tip is conical to fit
into various sizes of tubing. Disposable styles are preferred
Uses: Used for instillation and aspiration
Notes: Often used in urology for bladder irrigation. Capacity of 30 mL Courtesy of CareFusion, a division of Becton, Dickinson and Co.
RETRACTION AND EXPOSURE Retractors

Retractors are used to stabilize and displace anatomic Handheld Retractors
structures in a surgical field in order to provide visual Handheld retractors do not require the application of
exposure. Two basic styles of retractors are commonly over tight pulling to provide a clear visual field. They
used in surgery: (1) manual handheld and (2) self- are dynamically designed to be held comfortably with
retaining, free-mounted, or bed-mounted. Handheld one hand in a natural position. Some larger manual
retractors are held by the first assistant. Self-retaining retractors, when repeatedly held in a prolonged pose,
retractors work on the principle of countertraction can contribute to repetitive stress injury with resultant
secured with a locking mechanism. Use of any retrac- carpal tunnel syndrome.
tor requires knowledge and skill associated with ana-
tomic structures and should only be placed and held
by adequately trained personnel.
HANDHELD RETRACTORS
Malleable ribbon retractor
FIGURE 3-129
Size: 13.00; width 3/40 to 2.00
Characteristics: Flat piece of chromium-plated copper
that is easily shaped to the desired retraction form
Uses: Used to secure and protect viscera during abdominal procedures. Narrower and shorter ribbon retractors can be
used in other areas of the body. Also known as Zalkind ribbon retractors
Notes: Size denotes width of blade Courtesy of Sklar Instruments.
Lahey retractor
FIGURE 3-130
Size: 7.750
Characteristics: Intermediate weight; solid, narrow,
right-angled blade; solid closed handle
Uses: Commonly used in neck or intermediate tissue depth procedures
Notes: Single-ended Courtesy of Sklar Instruments.
Green retractor
FIGURE 3-131
Size: 8.50
Characteristics: Intermediate weight; fenestrated, narrow, right-angled blade with rounded edge; open loop handle
Cushing vein retractor
FIGURE 3-132
Size: 9.50
Characteristics: Intermediate weight; closed, right-angled, 18-mm blade with curved lip; open straight handle
Langenbeck retractor
FIGURE 3-133
Size: 9.00
Characteristics: Right-angle retractor with curved lip;
flat solid hand grip; blade length can vary
Uses: Used for layers closer to the surface
Richardson retractor
FIGURE 3-134
Size: 9.50
Characteristics: Right-angle retractor; blade width can
vary; handle can be open loop style or hollow closed
(shown); both have finger ridges for a secure, ergonomic grip
Uses: Used for several layers of the body wall
Notes: Single-ended; similar to Kelly retractor, but has a shorter blade; common blade size 2.00 3 3/40 Courtesy of Sklar Instruments.
continues
HANDHELD RETRACTORS continued
Kelly retractor
FIGURE 3-135
Size: 9.500; 9.750; 10.00
Characteristics: Right-angle retractor; blade length can
vary and is longer than Richardson; handle can be
open loop style or hollow closed (shown); both have
finger ridges for a secure ergonomic grip
Uses: Used for several layers, including deep body wall Courtesy of Sklar Instruments.
Deaver retractor
Size: 12.00; sizes 1.00, 1.50, 2.00, 3.00, 4.00
FIGURE 3-136
Characteristics: Flat, semi-firm, large, curved blade
with S curve at hand grip for traction; size is denoted
for width of blade; slightly flexible; hollow grip handle
available
Uses: Used for several layers, including deep body wall
Notes: Pediatric Deaver blade is measured in increments of 1/80 up to 7/80; when used to retract an organ,
a moist laparotomy sponge should be placed between the retractor blade and the structure Courtesy of Sklar Instruments.
Harrington retractor
Size: 12.00
FIGURE 3-137
Characteristics: Flat, large, curved blade with hollow
hand grip for traction; size is denoted for width of
blade; slightly flexible; heart-shaped viscera protector
at the tip to prevent perforation
Uses: Used to retract the liver
Notes: Commonly called “sweetheart” or “valentine” retractor Courtesy of Sklar Instruments.
Sauerbruch retractor
FIGURE 3-138
Size: 9.00
Characteristics: Intermediate weight; closed, narrow, right-
angled blade with curved lip; ridged cylindrical handle
Uses: Commonly used in neck or intermediate-tissue-depth
procedures Courtesy of CareFusion, a division of Becton, Dickinson and Co.
De Lee retractor
Size: 9.50
FIGURE 3-139
Characteristics: Right-angled retractor with

2.750 3 2.00 blade; scooped-out blade surface
provides additional lateral wall retraction; hollow grip
handle. Available in right, left, or central blade scoop
Uses: Used for several layers, including narrow incisions
into body wall
Notes: Used often in obstetrics to retract the bladder
flap during cesarean section Courtesy of Sklar Instruments.
continues
Doyen retractor
FIGURE 3-140
Size: 9.750
Characteristics: Right-angled retractor with solid
thumb hook and smooth hand grip; blade is long and
rounded like a saddle with a 2.00 blunt edge
or bladder Courtesy of Sklar Instruments.
Mayo abdominal retractor
FIGURE 3-141
Size: 10.00
Characteristics: Curved retractor with solid ergonomic
finger grip handle; blade is 2.750 wide and curved
under with blunt edges
Uses: Used for body wall Courtesy of Sklar Instruments.
Little retractor
FIGURE 3-142
Size: 7.250
Characteristics: Intermediate weight; solid, 0.50 curved
blade with ridged handle. Smooth rounded tip
Uses: Commonly used in neck or intermediate-tissue-depth procedures
Murphy retractor
FIGURE 3-143
Size: 7.50
Characteristics: Single-ended, prong-tipped; stainless
steel; two to six prongs; sharp and blunt prong styles;
Egyptian ankh–shaped handle with thumb hooks and
finger ring for secure grasp
Uses: Used for layers closer to the surface © 2019 Cengage®.
Israel rake retractor

FIGURE 3-144
Size: 9.00
Characteristics: Right-angled blunt rake style with four
to six prongs; open handle; not flexible
Uses: Used for layers closer to the surface © 2019 Cengage®.
Volkman retractor
FIGURE 3-145
Size: 4.50; 8.00; 8.50; 9.00

steel; one to six prongs; sharp and blunt prong styles
Notes: Open or closed handle styles Courtesy of Sklar Instruments.
continues
Weinberg retractor
Size: 4.00 wide by 6.00 long
FIGURE 3-146
Characteristics: Smooth handle with hand hook at base. Extra-long scooped blade for
deep exposure
Uses: Commonly found in deep pelvic sets
Notes: Also known as Joe’s hoe or vagotomy retractor
Meyerding retractor
Size: 7.00
Characteristics: Single-ended
retractor available with right
angle, smooth rounded blade,
or rake-style tip. Finger loop
FIGURE 3-147
at the end of the handle
Uses: For more superficial tissue
Ragnell retractor
FIGURE 3-148
Size: 5.50
Characteristics: Double-ended, right-angle retractor; flat
spine; one end is slightly larger than the other. Blades face
opposing directions
Notes: The ends angle in opposite directions and can be used as finger holds during retraction Courtesy of Sklar Instruments.
Senn retractor
Size: 6.250
FIGURE 3-149
Characteristics: Double-ended, right-angle retractor;

flat spine; one end is squared with a smooth blunt lip,
and the other end has one to three prongs like a rake
Notes: The ends angle in opposite directions; pronged end can be
blunt or sharp; sometimes confused with the Mathieu retractor Courtesy of Sklar Instruments.
continues
Crile retractor
Size: 4.50
FIGURE 3-150
flat spine; one end is slightly larger than the other
Notes: The ends point in opposite directions; hence the
working end is in the tissue, the opposite end serves as the finger grip.
Available in tiny pediatric sizes up to large blades for deep procedures in the adult Courtesy of Sklar Instruments.
Mathieu retractor
Size: 6.250
FIGURE 3-151
flat spine; one end is squared and the other end has
prongs like a rake
Notes: The ends angle in the same direction; pronged end
can be blunt or sharp; sometimes confused with the Senn retractor Courtesy of Sklar Instruments.
Army-Navy retractor
Size: 8.250
FIGURE 3-152
open area down the spine of the hand grip. One end
is larger than the other. Both blades angle in same
direction
Notes: Commonly used in pairs Courtesy of Sklar Instruments.
Goelet retractor
FIGURE 3-153
Size: 7.50
Characteristics: Double-ended retractor with rounded,
curved, saddle-shaped blades that face in the same
direction
Uses: Retracts superficial tissue Courtesy of Sklar Instruments.
Eastman retractor
Size: 9.50
FIGURE 3-154
Characteristics: Double-ended, right-angle retrac-

tor; ridged area around the spine of the hand grip.
Squared blades with rounded edges face the same
direction
Notes: One end is slightly larger than the other and resembles a double-ended Richardson retractor Courtesy of Sklar Instruments.
Self-Retaining Retractors damaged. A locking or stabilizing mechanism is built

Self-retaining retractors provide exposure without caus- into each style. Some use screws, and some use a
ing physical strain on the surgical team. Care is taken ratchet system. Each self-retaining retractor has a pri-
when placing the components of the retractor because mary frame that locks to hold tissues in position. Some
inadvertent structures could become entrapped and styles have detachable blades, hooks, rakes, or traction.
SELF-RETAINING RETRACTORS
Jansen retractor
Size: 4.50
FIGURE 3-155
Characteristics: Screw mechanism causes retraction
arms to spread tissues; rake tips (3 3 3 or 4 3 4
prongs) hold tissue in position
Uses: Small incisions near the surface
Alm retractor
FIGURE 3-156
Size: 4.00
arms to spread tissues; rake tips (4 3 4 prongs) hold
tissue in position
Uses: Small incisions
Notes: Commonly used in podiatry or hand procedures Courtesy of Sklar Instruments.
Gelpi retractor
Size: 4.50, 6.50, 7.00
Characteristics: Double sharp prongs with ratchet lock;
FIGURE 3-157
arms are slightly curved; with or without ball stops
Uses: Used for hernias and other soft tissue incisions
Notes: Commonly found in general and orthopedic
surgery
continues
SELF-RETAINING RETRACTORS continued
Weitlaner retractor
Size: 4.00; 5.50; 6.50; 8.00; 9.50
Characteristics: Double-armed blades with ratchet
FIGURE 3-158
lock; tips have sharp or blunt 4 3 3 rake prongs that
interdigitate when closed
Uses: Used for small deep incisions
Notes: Straight arms separate and secure the tissue;
more than one can be used at opposing ends of the
incision; used by almost every surgical service
Beckman retractor
Size: 6.750 to 12.50
Characteristics: Double-armed
blades with ratchet lock; tips
are mounted on hinged arms
and have sharp 3 3 4 rake
prongs
FIGURE 3-159
Uses: Used for small deep inci-
sions where the handles can
flex downward out of the field
© 2019 Cengage®.
Glassman visceral retainer

Size: Available in adult and pediatric sizes
Characteristics: Sterile, flexible, synthetic pad that overlies
organs during closure. Radiopaque with ring that remains out- FIGURE 3-160
side of body until retainer is removed
Uses: Protects organs from injury during closure. Prevents inci-
dental stitching through bowel
continues
Balfour retractor
Size: 7.00; 10.00
Characteristics: Adjustable lateral side wall solid or open retractor
blades that traverse a stainless-steel bar into a locking position;
a curved Mayo-style bladder blade attaches with a wing nut;
incision and body wall are supported on three sides. Blades are
FIGURE 3-161
interchangeable as solid, fenestrated, short, or deep.
Uses: Used for abdominal incisions where exposure of 7.00 to 10.00
is needed.
Notes: Bladder blade can be used alone as a retractor during
cesarean sections; observe for wing nut and screws during the
counting procedure; this retractor disassembles for cleaning and
processing.
Bed-Mounted Self-Retaining Retractors Care is taken not to permit the supporting post to rest
Bed-mounted retractors are attached to the side rail of against the patient’s tissues. Pressure against the arm,
the operating bed frame at the level of the mattress. A for example, could cause a permanent brachial palsy.
long side-mount supporting post with a securing bolt Once the supporting post is mounted, a large
is aligned with the railing and tightened. The post is frame is attached that encircles the incision. Retractor
part of the sterile apparatus and remains sterile above blades are slid onto the frame with the blade inserted
the level of the patient’s body. The screw mechanism into the incision. As the blades are tightened onto the
and the securing bolt are manipulated by the circulator frame and directed laterally, exposure of the surgical
as the supporting post is attached to the operating bed site is provided without causing strain on the team.
rail. This lower segment is considered unsterile after the Bed-mounted retractors are commonly packaged
attaching procedure. The upper end of the post remains in two or more processing trays because of excessive
sterile for assembly of the primary retractor system. weight and number of components.
BED-MOUNTED SELF-RETAINING RETRACTORS
Strong T-bar IMA retractor

Characteristics: Single bar attaches to operating room table with rake-style retrac-
tors attached to adjustable T-bar; assorted blades are used to provide exposure
FIGURE 3-162
Uses: Cardiac
Notes: Used in cardiac procedures to retract the sternum and dissect the internal
mammary artery
Pilling branded instrumentation courtesy of Teleflex Medical.
continues
BED-MOUNTED SELF-RETAINING RETRACTORS continued
Bookwalter abdominal
retractor
FIGURE 3-163
Characteristics: Attaches to the operating room
table side rails and eliminates the need for a second
assistant; large ring has extensions, which secure
to the frame
Uses: All major abdominal procedures
Notes: Multiple retractor blades available, which attach
to the ring Pilling branded instrumentation courtesy of Teleflex Medical.
Wishbone retractor
Characteristics: Upright single supporting post with split two-piece wish-
bone frame from which retractor blades are secured
FIGURE 3-164
Notes: Multiple retractor blades available, including Deaver, fence blades,
hoes, Kelly, malleable, Mayo blades, and Richardson
© 2019 Cengage®.
Gomez retractor
Characteristics: Upright four corner supporting posts with longitudinal bars for securing
FIGURE 3-165
retractor blades
Uses: Specifically designed for bariatric surgery
Notes: Multiple types of retractor blades available
APPROXIMATION AND CLOSURE will remain serviceable for many uses. Using a needle
holder to load a scalpel blade onto a handle can cause
INSTRUMENTATION the jaws to misalign and should be avoided, particu-
larly if the jaws are lined with diamond dust or special
Suturing Instrumentation metal. Replacement can be costly. Needle holders are
The superficial closure of the surgical site is the outer- not designed for torque. A damaged needle holder may
most manifestation of the surgical procedure that the fail to hold a needle in position at a critical time during
patient can visualize. Use of the correct suture in the the surgical procedure, harming the patient and creat-
correct needle holder promotes a satisfactory appearing ire in the surgeon. A Kelly or short Pean is more
ance. Proper care of the instrument assures that it suited to this task and is less costly to repair.
Needle holders are sometimes referred to as needle Handle styles range from ring to spring configura-
drivers. The majority of the needles used with a needle tions. The jaws are short and can be smooth, finely
holder have a curve. Straight needles, with the excep- cross-serrated, notched, or inset with diamond dust or
tion of some ocular and endoscopic styles, are used carbide.
without a driver.
NEEDLE HOLDERS
Derf needle
holder
Size: 4.750
Characteristics: Ring handles
with short, linear, serrated
jaws with a central notch;
delicate weight. Shorter jaws
FIGURE 3-166
than Webster and Halsey
Uses: Used for plastic closure
Webster needle holder

Size: 5.250
with a variety of jaws: cross-
serrated, smooth, or diamond
dust inset; delicate weight
FIGURE 3-167
Notes: Similar to Halsey needle

holder
continues
NEEDLE HOLDERS continued
Halsey needle
holder
Size: 5.250
with cross-serrated or smooth
jaws; lightweight
FIGURE 3-168
Baumgartner needle
holder
Size: 5.250
Characteristic: Heavier cross-
serrated jaws for firmer hold
on larger needles
Uses: For closure where a
FIGURE 3-169
heavier, shorter needle holder
is needed
continues
Olsen-Hegar
needle holder
Size: 5.50; 6.00
with cross-serrated jaws; scis-
sors built in at the box locks
FIGURE 3-170
Uses: Used for intermediate-
weight suture
Notes: Commonly used by
plastic surgeons when placing
multiple individual stitches
Crile-Wood needle
holder
Size: 6.00; 7.00
with narrow, intermediate-
weight jaws; cross-serrated
with narrow central notch
FIGURE 3-171
Uses: Used for lightweight to
intermediate-weight suture
continues
Sternal wire
needle holder
Size: 7.00
Characteristics: Short, snub-
nosed jaws with cross-
serrations for holding wire
FIGURE 3-172
suture
Uses: Commonly used in car-
diothoracic surgery
Mayo-Hegar needle
holder
Size: 6.250; 7.00; 8.00, 120
with heavy jaws; cross-
serrated with central notch
FIGURE 3-173
weight to heavyweight suture.
Commonly found in most sets
Sarot needle holder

Size: 5.00; 7.00; 10.250
FIGURE 3-174
Characteristics: Ring handles with medially curved

shanks; fine jaws with cross-serrations; central notch
Uses: Used for lightweight to intermediate-weight suture
Notes: Commonly used in vascular surgery
continues
Heaney needle
holder
Size: 8.50; 100
Characteristics: Ring han-
dles with medially curved
FIGURE 3-175
shanks; curved jaws with
cross-serrations
Uses: Used for lightweight to
intermediate weight suture
gynecologic and genitourinary
surgery; the curved tip per-
mits improved visualization for
intravaginal suturing
Ryder needle holder

Size: 5.00; 6.00; 7.00; 8.00; 9.00;
10.250
with narrow flat jaws; cross-
serrations in jaw
Uses: Used for lightweight
FIGURE 3-176
suture
Notes: Commonly used in vas-
cular, neurological, and plastic
surgery
LIGATURE CARRIER
Deschamps
ligature
carrier
Size: 8.00
Characteristics: Shaft with
medium-weight handle on one
FIGURE 3-177
end and curved eyed needle
tip; available in right and
left curvature and sharp or
blunt tip
Uses: Circumferential suturing
with a free suture. Also known
as aneurysm needle
ANESTHESIA INTUBATION
controlling the tip of the endotracheal tube and the
INSTRUMENTS tongue. These are decontaminated and terminally ster-
The anesthesia provider uses specially designed for- ilized after each use. They are maintained in the anes-
ceps to manage difficult oral or nasal intubation by thesia cart.
ANESTHESIA INTUBATION INSTRUMENTS
Collin tongue forceps

Size: 6.750
FIGURE 3-178
Characteristics: Ring-handled grasper with fenestrated,
round, serrated jaws. Ratchet locks. Shanks curved
inward for nonobstructed observation of tongue
Uses: Used in oral procedures to secure the tongue.
Anesthesia personnel can use this instrument to assist
with intubation
continues
ANESTHESIA INTUBATION INSTRUMENTS continued
Magill forceps
Size: 7.00; 9.00
Characteristics: Long-angled grasping for-
ceps with serrated, oval, fenestrated tips. No
FIGURE 3-179
ratchets
Uses: Used by anesthesia provider to position
nasal and oral tubes in the oropharyngeal
cavity
Young tongue forceps

Size: 6.50
FIGURE 3-180
Characteristics: Fenestrated grasping forceps
with padded gripper inserts to apply traction
to the tongue. Shanks are curved laterally for
better vision. Care is taken to avoid use in
latex-sensitive patient. Locks with ratchets
Uses: Used by oral surgeon or anesthesia pro-
vider to secure the tongue
Bite block
Size: Adult and child
Characteristics: Wedge shape, firm silicone
rubber holder that prevents the angle of the
jaw from closing without undue force
FIGURE 3-181
Uses: Holds the jaw open during a surgical
procedure
SUMMARY standardized sets that can be used for many differ-

ent services. In the subsequent chapters of this text,
Surgical instrumentation takes many forms and
more specialized instruments will be introduced
has many functions. Assembling sets of the appro-
and assembled into functional sets that meet the
priate instrumentation for the planned surgical
needs associated with the performance of particular
procedure requires knowledge of the case and the
surgeries.
preferences of the surgeon. Most facilities have
CHAPTER 4
CONSIDERATIONS
FOR INSTRUMENT
SET ASSEMBLY
CHAPTER OUTLINE OBJECTIVES
Instrument Containers and Trays After reading this chapter the learner should be able to:
Perforated Trays 1. Discuss the selection of instrument packaging material.
Closed Rigid Containers 2. Demonstrate the process for opening a closed container of instruments.
Specialty Trays 3. Demonstrate the process for opening a wrapped set of instruments.
Assembly of Instrument Sets
Determining Instrument
Set Contents
Counts and Accountability
Overview of Processing Options
INTRODUCTION
Each surgical procedure requires a collection of instruments for the
safe, efficient, and effective performance of the intended operation.
Sets are constructed based on the instruments most commonly used
by the facility’s surgical staff for similar types of operative procedures.
For example, a routine laparotomy tray would be used for surgical pro-
cedures involving the intraperitoneal organs, as the name would imply.
Additionally, a laparotomy tray might be used for a modified radical
mastectomy with axillary dissection because the sizes and variety of
instruments are similar. A tray designed for use in orthopedic proce-
dures involving the hand, foot, or other small bones may be given a
name such as hand tray, small bone, or minor ortho tray. Despite the
tray’s name, it would contain instruments appropriate to any of those
similar types of surgical procedures. Advanced planning in set con-
struction can permit the set to be used for a wide variety of surgeon’s
needs with the addition of a few individually wrapped instruments
when necessary. Selecting the proper set of instruments is based on a
range of factors, including the following:
1. The resources available to the facility and volume of procedures
performed
2. The nature and frequency of scheduling of the planned type of
procedure
3. The potential for additional or unanticipated procedures that arise
during the originally scheduled surgical intervention
86
Chapter 4 Considerations for Instrument Set Assembly 87
e. Mouth gags—Davis, McIvor, Jennings,

4. The anatomic area to be operated and posi- Dingman, or others
tioning of the patient 3. Visualization and a clear working area:
5. The instrumentation preferences of the sur- a. Containment and protection of adjacent struc-
geon or specialty team tures—use of surgical sponges or sheeting for
6. Patient-specific considerations (e.g., size of packing or walling off nonoperative structures,
body habitus, depth of tissue layers, anatomic maintenance of tissue integrity with moistened
variability, concurrent comorbidity) sponges or plastic bowel bag
7. The type of anesthesia and route of adminis- b. Use of minimally invasive or robotic access
tration for the procedure ports and endoscopic devices for enhanced sur-
8. Specialty instrumentation with multiple gical site visualization and guided imagery
components, sizing trials, guided imagery 4. Hemostasis and occlusion:
attachments, robotics/minimally invasive, or a. Clamping—use of hemostats/clamps to
powered equipment mechanically stop bleeding and ligate vascular
structures
The following nine general characteristics determine b. Occlusion—use of noncrushing instruments
instrument set selection, regardless of the procedure for temporary occlusion of vascular, intestinal,
being performed. The essentials of procedural instru- ductal structures, or tubing
ment planning include, but are not limited to, the 5. Manipulation of tissue:
following: a. Use of finger-controlled, tweezer-type tissue
1. A method for entering the patient’s body and forceps—instruments designed to temporar-
access to the surgical site: ily grasp and hold tissue during dissection or
a. Sharp dissection—incision through the skin or suturing/stapling
mucous membranes b. Use of self-retaining, ratcheted tissue forceps—
b. Blunt dissection and/or dilation—separation of instruments designed to gently hold or firmly
layers between planes penetrate tissue or organs to allow for traction
and relocation to provide access to deeper areas
c. Natural orifice—oral, aural, nasal, anal, ure-
or structures during dissection or suturing/
thral, or vaginal entrance
stapling
d. Tissue penetration, separation, coagulation, or
6. Tissue dissection:
vaporization with surgical energies, including
laser, ultrasound, x-ray, electricity, or radio a. Biopsy—a small tissue specimen is procured for
frequency laboratory analysis and identification; may be
through percutaneous needle access with ultra-
2. Retraction and exposure:
sound imaging assistance
a. Manual or handheld retractors—Richardson,
b. Surgical removal:
Senn, or other manual retractor
1) Excisional—target tissue is completely
b. Self-retaining retractors—Balfour, O’Sullivan-
removed
O’Connor, Scott retractor and stays
2) Incisional—sample or portion of target
c. Complex table attachment retractors—
tissue is removed
Bookwalter or others
7. Evacuation of blood, body fluids, or tissue
d. Specula for entry into natural body
specimens:
orifices—Graves vaginal speculum, Auvard
weighted vaginal speculum, Pratt rectal specu- a. Suctioning—fluids, including blood, irrigation,
lum, Sims rectal speculum, and others exudate, or pus, are removed from the surgical
site by negative pressure with suction tips and manner. The packaging method and materials must
tubing permit all of the instrument surfaces to remain in contact
b. Irrigation and aspiration—typically, small with the sterilization process (steam, gas, or gas plasma)
amounts of therapeutic solution are instilled for the period of time recommended by the steril-
and then removed by negative pressure with izer manufacturer. The arrangement of the instruments
needle and syringe or suction tips, traps, and involves sorting and stringing the ringed instruments
tubing in an open position on specialized racks to accomplish
c. Ultrasonic fragmentation and aspiration—high- thorough sterilization. The racks, sometimes referred
frequency sound is used to break tissues apart to as “stringers,” are designed to slip through the ring
by cavitation, and they are removed by negative handles and hold the instruments open. The process
pressure into specimen collection devices for placing the instruments on the racks is referred to
as “stringing the instruments.” Various types and sizes
d. Debridement—debulking (reduction in size or
of stringers are available to accommodate the quantity
mass) of necrotic, infected, or hypertrophic
of ringed instruments needed in a set (Figure 4-1). Any
tissue or tumor
instrument that goes through the sterilization process
8. Prevention of retained foreign items: in a closed position is considered unsterile because
a. Instruments—all instruments and parts that the sterilant (steam, gas, or liquid chemical) is unable
can be disassembled used during the procedure to contact all surfaces. If one instrument within a
must be removed and accounted for prior to processed tray is unsterile, the rest of the instruments
wound closure; additionally, clamps/hemostats have to be considered unsterile. The resulting cross-
are typically strung in even numbers to facili- contamination occurs during handling of sterile items
tate the instrument count process with contaminated gloves following contact with the
9. Tissue approximation: unsterile or unexposed/unsterile instrument surfaces,
a. Suturing—wound closure, reapproximation of including the closed box locks and ratchets.
incised tissue layers, ligation of bleeding vessels, Placement of instruments in the perforated or
or anastomosis of tubular structures mesh-bottom basket must be organized and pro-
vide separation and protection of the more deli-
b. Stapling—devices may be linear, curved, or
cate instruments from larger, heavier items. Large,
circular and may be used for primary or sec-
self-retaining or handheld retractors are grouped
ondary approximation of incised edges with
together by type and placed on the bottom of the
nonmagnetizing metallic or absorbable staples;
basket. The string of ringed instruments is placed on
most devices are single-use
The majority of surgical procedures are performed by

entering the patient’s body through the skin and require
the use of the same or similar instruments, regardless
of the subsequent procedural steps that follow. After
entering the superficial layers, additional instruments
are used to perform the main part of the procedure
according to the tissue type and techniques used to
achieve the end result. Standardization of instrument

sets is an efficient and cost-effective way to plan for
needed resources. This includes selecting instruments
from each category appropriate for each surgical proce-
dure in a consistent manner.
When creating a new set of instruments, consid-
eration is given to assembling and packaging the set
in a way that permits sterile processing and subsequent
instrument removal in a systematic and organized Figure 4-1 Instruments on stringer.
top of the heavier items. Smaller, loose items such of an interwoven metallic mesh. The tray must be
as scalpel handles may be placed into a small paper durable and stable for the type of sterilization method
bag or foam pouch compatible with the sterilization chosen. The perforations permit the sterilant to pen-
method to be used. etrate throughout the inner basket to all surfaces of the
Peel packages may also be used for this purpose; instruments within it.
however, they must not be sealed when placed into the The standard stainless-steel perforated tray is a
larger sterilization tray. Sealing of peel packs placed standalone, open-top pan fashioned into a sturdy square
inside of a wrapped tray or rigid container would impede or rectangle configuration for ease of stacking and storage
or prevent penetration of the sterilant (e.g., steam or (Figure 4-2). The racks of instruments fit evenly within
gas), leaving the items inside the peel pack unsterile. the edges or sides of the tray. Other types of standalone
Sealed peel packages should be sterilized individually trays have perforated hinged lids (Figure 4-3). Specialty
and separately, not as part of larger prepared trays. trays used for delicate or microsurgical instruments may
Special protective tip guards are available to pre-
vent tips and points of sharp, delicate, or microsurgi-
cal instruments from being blunted or broken. The
tip guards also protect against potential perforation of

the gloved hands of the surgical technologist or other
scrub person during the initial back table setup. These
tip guards must be compatible with the sterilization
process used and not prevent penetration of the steril-
ant from reaching every surface of every item covered
by them.
INSTRUMENT CONTAINERS
AND TRAYS
After the individual instruments are strung on stringers, Figure 4-2 Stainless-steel sterilization tray without lid.
the loaded stringers are placed in a tray with other loose
instruments, such as scalpel handles and retractors. In
general, instruments are placed in mesh-bottom or per-
forated baskets with the heavier items on the bottom of
the basket and the lighter or more delicate instruments
on top. An internal chemical indicator/integrator strip
is placed near the center of the tray, which is the hard-
est area for the sterilant to reach. The internal chemi-
cal indicator/integrator changes color following the
sterilization cycle to provide visual verification that the
entire tray was exposed to the sterilizing agent. Several
types of surgical instrument trays are commercially
available and are described in the following sections.
Perforated Trays
The most common type of tray is the perforated tray.
It can be made of stainless steel, aluminum, or high-
impact plastic. The entire tray has small one-eighth-
inch, evenly spaced openings or holes over the entire
surface of the bottom and the sides, or it can be made Figure 4-3 Sterilization tray with lid.
have a series of pegs or silicone strips or mats with finger- methods. The tape should be peeled off the woven fab-
like projections that hold instruments apart to prevent ric wrappers during opening and discarded. Tapes used
damage or dulling of sharp edges or tips. These special to close nonwoven paper wrappers should be broken or
trays do not require the instruments to be strung on racks torn without peeling. Failing to remove all tape from
(Figure 4-4). woven fabric wrappers leaves adhesive residue and may
Standalone trays are wrapped in double-thickness cause problems with the laundering process. Peeling
wrappers made from nonwoven, compressed cellulose tape from nonwoven wrappers violates the integrity of
(paper), nonwoven polypropylene (Tyvek), or woven the package, risking contamination of the contents dur-
linen (cloth) or muslin. Wrappers commonly used are ing the unwrapping process.
made from two single-thickness sheets that are fused Outer packaging materials (wrappers or peel packs)
together. When single-thickness, nonfused wrappers should be visually checked before opening for signs of
are used, they must be wrapped twice (sequentially) in wetness or previously dried wet spots, punctures, and/
order to provide the double-thickness barrier required or tears, which would deem the package unsterile.
to maintain package integrity and sterility. Most facili-
ties have standardized their policies to use nonwoven
cellulose or polypropylene wrappers because they are Closed Rigid Containers
disposable and more durable than woven cloth variet- Mesh baskets and high-impact plastic trays are not
ies. Some manufacturers have recycling programs that standalone trays. They are nested into a rigid alumi-
reprocess used disposable nonwoven wrappers. num or composite plastic boxlike structure with a
Nondisposable woven cloth wrappers (also referred locking lid referred to as a closed container. The lid
to as linen, fabric, or muslin) must be laundered and has a gasket seal that creates the tight closure neces-
monitored closely for holes that need patching. Woven sary to maintain sterility after processing and locks
wrappers have a limited number of uses, and each use with a tamper-evident device. In closed containers
must be tracked by stamped-on marks that indicate with nested baskets, the lid and/or bottom of the closed
how many times they have been processed. container have perforations that act as vents. These
All cloth or paper-wrapped items are sealed with perforations allow for the access into and dissipation/
chemical indicator tape that changes color following outflow of the steam or gas from the interior of the
exposure to steam, gas, or gas plasma sterilization tray. Disposable nonwoven paper filters allow for pen-
etration of the steam or gas, but must cover the vent
holes completely to prevent contamination of outside
air or dust (Figure 4-5). In many facilities, the filters
from the top and bottom of the container are checked
for holes prior to delivering the internal instrument
basket to the sterile field. These filters may also
provide an additional chemical indicator/integrator
area for visual assurance of exposure to the appro-
priate sterilizing agent. If the internal filter is damp
upon opening, the contents of the closed container
must be considered contaminated because the filter
has become saturated. This process causes a capillary

action (also called wicking) that permits passive dif-
fusion of microorganisms through the filter barrier.
In rare cases of processing by the immediate-use (for-
merly called flash) method, special closed containers
or open containers wrapped in a single-thickness
wrapper are used for sterilization of one-of-a-kind
instruments, which must be returned to the sterile
Figure 4-4 Hinged covered specialty tray with silicone strips. field as quickly as possible. Moisture in these contain-
tined trays can be released for use. The large number of

instrumentation systems available for surgeons’ prefer-
ences often makes purchase of all possible options cost
prohibitive for hospitals; therefore, “loaner” trays have
become an appropriate alternative.
Pneumatic, electric, or battery-powered instru-
ments such as saws, reamers, perforators, and wire

or screw drivers may have manufacturer containers
designed to keep the items secure and prevent shift-
ing of items to prevent damage and facilitate assembly
on the sterile field. These trays are often perforated
containers that are wrapped with appropriate wrapper
materials in the sterile processing department.
Microsurgical instrumentation preparation requires
use of specialized trays, which may have silicone mats
Figure 4-5 Aesculap SterilContainer. with fingerlike projections or prongs that hold the
extremely delicate and fragile instruments securely
and prevent them from shifting position or knocking
ers is considered to be sterile condensate and does not together with other instruments. The wrapped, per-
indicate contamination of the set because it has not forated metal trays may have a briefcase-like appear-
been placed into a storage area. ance with a handle, locking mechanism, and hinged
protective lid that can be removed from the tray base.
Specialty Trays Microsurgical instruments are extremely costly and
Surgical specialty trays such as those for orthope- easily damaged if not handled, processed, and packaged
dic total joint procedures or microsurgical eye cases appropriately.
require uniquely designed trays that protect the instru-
ments and organize complex sets into stackable sec- ASSEMBLY OF INSTRUMENT SETS
tions. Some orthopedic trays have outlined silhouettes
Standardized instrument sets are a collection of instru-
of instruments to facilitate their identification and
ments that are used for related surgical procedures.
placement. The stackable form of tray or container
Each time a particular set is assembled, the specific
design also helps prevent damage of more delicate or
numbers of each instrument needed must be known.
sharp-tipped instruments from heavier bone instru-
Instrument sets are assembled in the central sterile
ments such as heavy mallets included in the same set.
processing department and sterilized for use in surgical
Instruments with sharp edges such as osteotomes,
procedures.
chisels, or curettes may be placed in foam pocket pro-
tectors to prevent dulling, nicking, or chipping of the
sharpened surfaces. These types of instrument damage Determining Instrument Set Contents
can potentially contribute to tissue damage from jag- Knowledge of the procedure to be performed and
ged instrument edges. the anatomy of the organ system involved is impor-
A common practice with total joint replacement tant when determining what should be included in an
instrumentation is to have industry representatives, instrument set. The best way to be sure all instrumenta-
commonly referred to as “ortho reps,” bring in instru- tion needs are met is to follow an organized system of
ment sets to the sterile processing department a day or categorization. Categories to consider when creating a
more before a scheduled procedure so that trays can be useful set of instruments are listed in Table 4-1.
sterilized with biological indicators that demonstrate Key elements to include in every set will depend
sterility prior to implantation in a patient. These bio- on its intended use. Most sets will have several types
logical indicators must be incubated for 24 hours and of sharp dissection instruments such as scissors and
demonstrate no growth of bacteria before the quaran- scalpel handles, hemostats or clamps, tissue forceps
TABLE 4-1 Categories of instruments to consider ment that leaves the sterile field during use contains
when creating an instrument set bioburden and could cause cross-contamination of
inanimate surfaces or individuals without the protec-
Hemostats and clamping
tion of gloves. Not all contamination is visible to the
Grasping and tissue forceps naked eye.
Sharp dissection Accountability can be accomplished in several
ways. The most common method employs an inventory
Excisional and debulking
sheet provided with each sterile set that lists and veri-
Probing and dilation fies the items packaged in the processing department
Suction, aspiration, and instillation by name and number. The processing personnel count
the instruments and document the total numbers on a
Retraction and exposure count sheet when wrapping and processing the set for
© 2019 Cengage®.
Suture approximation and wound closure use in the operating room. These preliminary counts
are recorded on an inventory count sheet that is then
Specialty devices
used by the surgical technologist or other scrub person
and circulating nurse to establish a baseline preopera-
tive instrument count when the set is opened for a pro-
cedure. The same count sheet is used at the end of the
or graspers, handheld or self-retaining retractors, suc-
case for the closing counts. To facilitate the instrument
tion tips, and closure tools such as needle holders or
count process between the surgical technologist and the
wire twisters. Not all sets will have probes, dilators, or
circulating nurse, the ringed instruments placed onto
debulking equipment unless they are necessary for the
a stringer during tray assembly should be ordered in a
intended procedure.
manner that eliminates confusion and the potential for
oversight of specific instruments. An example is to keep
Counts and Accountability all instruments of the same type, regardless of length,
Each set will have facility-standardized quantities together as shown in Figure 4-1. In that image, short
of specific instruments. Counting the instruments and long Rochester-Peans and short and long straight
is made easier when the items are packed in even Kochers are grouped together. In some facilities, the
numbers. The surgical team, particularly the surgical policy is that all of the ringed instruments are ordered
technologist or other scrub person and the circulat- in a manner from shortest to longest. Instrument types
ing nurse, is responsible for performing a baseline are listed on a count sheet more than once to account
instrument count and a closing instrument count. for each different length (short, medium, long, extra-
Additional counts are required if a cavity within a long) of a particular type of instrument. Regardless of
cavity is closed. This accountability is important for preferred model of string preparation, careful attention
patient and team safety, inventory control, and infec- must be paid to prevent the possibility of an instrument
tion control. Safety considerations involve prevention miscount.
of retained objects in the patient, which may result in Complex instruments such as certain self-retaining
injury or serious surgical site infection and liability retractors or instruments with hollow lumens must be
for the surgical team and facility. Inventory control disassembled for effective decontamination and steril-
is addressed by preventing loss of instruments left ization. Distal tips from metal Yankauer suction tubes,
attached to disposable drapes when placed into the outer sheaths of Poole suction tubes, and stylets from
trash or sent out with the laundry. Infection con- Frazier or Baron suction tubes must be removed in
trol involves containment of contaminated instru- order for the sterilant to reach every surface of every
mentation, and the decontamination process begins item.
in the operating room with wiping or rinsing off The parts and pieces of these instruments and all
blood from instruments with sterile water. An instru- instruments capable of being disassembled must have
all parts accounted for in the instrument count pro- 4. Be organized: Place every instrument in the same
cedure to prevent the potential for foreign items to be place on the sterile instrument table or Mayo
retained in the patient’s wound. The closing count totals stand after each use. This helps to keep an ongoing
of instruments and other countable items are reconciled count efficient and enhance accountability.
and documented on the patient’s operative record as
correct or incorrect according to facility policy. Any
incorrect count requires repeat counts until the totals OVERVIEW OF PROCESSING
are correct. If no resolution is achieved, the surgeon OPTIONS
is notified and a careful search of the environment is
repeated. Following failed attempts to locate a lost item, The surgical processing department has several methods
an x-ray of the surgical site may need to be taken. A of processing, packaging, and sterilizing surgical instru-
resolved count is documented as correct if the miss- ment sets. The most common sterilization methods are
ing item is located. If the missing item is not located, steam under pressure, chemicals in gas or gas plasma
then the count is documented as incorrect and all steps form, and chemicals in solution. The characteristics of
in the search process are recorded on the appropriate the instrument set are the determining factors as to which
forms designated by the facility. method of sterilization is appropriate. Most metallic
Accountability during a surgical procedure can be instruments made of stainless steel, titanium, silver, and
managed by developing a few simple habits when func- copper can be sterilized by steam because they can toler-
tioning in the scrub role. Some suggestions include, but ate high heat and moisture. Heat- and moisture-sensitive
are not limited to, the following: instruments made of plastic or synthetics are commonly
sterilized by chemicals in gas or gas plasma form. Items
1. One-for-one: Every time an armed/loaded needle commercially packaged and processed by industrial man-
holder is passed to the surgeon or assistant, ufacturers are usually sterilized by radiation or micro-
retrieve the used needle back on the instrument waves. These methods are not available in hospitals. Each
before passing the next suture. item processed in the surgical processing department has
2. Be consistent: Establish the setup by always setting a specific method for safe processing that is described in
up the same way, in the same order. If an instru- writing by the manufacturer. Recommendations for per-
ment is not in its place, it will likely be obvious to missible weight limits of prepared instrument trays are
the eye. set by the Association for the Advancement of Medical
3. Be tidy: Do not permit instruments to accumulate Instrumentation (AAMI) to ensure adequate sterilization
and clutter the sterile field. It is difficult to locate processing and prevention of worker injuries from trays
instruments when they are stacked, piled up, or that are too heavy. Instrument packaging and processing
randomly placed. is described in Chapter 16 of this text.
SUMMARY according to the standardized inventory lists that

are placed within the tray and may be used as preop-
Instrument sets are assembled according to the
erative and closing count sheets during the surgical
types of procedures for which they will be used. The
procedure.
sets are packaged in wrapped trays or rigid closed
Whether one is working in the operating room
containers and processed to render them sterile
or in a sterile processing department, careful han-
according to the manufacturer’s recommendations.
dling of surgical instrumentation is the responsibility
The contents of the individual sets are determined
of all those who decontaminate, prepare, package, or
use these vital components of safe surgical proce- other oils, which act as a barrier to steam
dures. Examples of proper care and handling include penetration to instrument surfaces.
the following: ●● All instruments must be thoroughly decon-
●● Instruments should be used for their taminated, with all traces of blood and tissue
intended purpose. removed prior to packaging and sterilization.
●● Items should not be dropped, tossed, thrown, ●● Jagged edges of sharp instruments must be
or piled on top of each other in basins or removed from service and sharpened or
trays after use. replaced to prevent damage to the patient’s
tissues.
●● Heavy instruments should not be placed on
top of lighter instruments. ●● Powered equipment must never be sub-
merged in liquid to prevent damage to inter-
●● Sharp edges or points of instruments should
nal motors.
be handled with care to prevent damage to the
instrument and sharp injury to personnel. ●● Trays should be carried, handled, and stored
in a manner that prevents instruments from
●● Instruments must not soak in saline solutions,
shifting within and being damaged.
which may cause pitting of the metallic
surfaces. ●● The manufacturer’s instructions should be
followed regarding processing and steriliza-
●● Stiff-feeling instruments should be lubricated
tion of specialty instrumentation.
with water-soluble solutions, not mineral or
BIBLIOGRAPHY Marvin, E. (1999, February). Instrument inventory sys-

tems: Or what it takes to never lose another towel
Association of Surgical Technologists, Inc. (2018). clip. Infection Control Today, 3(2), 60–62.
Surgical technology for the surgical technologist: A Phillips, N. M. (2017). Berry and Kohn’s operating room
positive care approach (5th ed.). Clifton Park, NY: technique (13th ed.). St. Louis, MO: Mosby-Elsevier.
Cengage Learning.
Barrett, A. (1999, March). Instrument standardization.
Infection Control Today, 3(3), 60–63.
CHAPTER 5
SOFT TISSUE
FOUNDATION SETS

After reading this chapter the learner should be able to: Short Foundation Set
1. List the rationale for establishing baseline foundation sets. Excisional Set
2. Describe how a foundation set can be augmented for use by many specialties. Clamps
Grasping Forceps
3. Discuss why keeping the number of instruments to a minimum benefits the
Dissection Instruments
patient and team.
Debulking Instruments
Probes and Dilators
Evacuation and Instillation Instruments
INTRODUCTION Instruments
Soft tissue sets are groups of instruments used to work with tissue Approximation and Closure
Instruments
layers such as the epidermis, dermis, adipose, subcutaneous, muscle, Specialty Specific Instruments
fascia, peritoneum, mucosal, and fibrous tissues. The length of the Medium Foundation Set
instruments in a soft tissue set will vary according to the procedure Soft Tissue Dissection
to be performed and the depth at which the pathology is located. For Clamps
example, procedures performed near the surface of the body use short Grasping Forceps
(approximately 4.00 to 6.00) to intermediate-length instrumentation. Dissection Instruments
Mid-depth procedures commonly use medium-length instruments Debulking Instruments
(approximately 6.50 to 8.00), and deep procedures, such as laparotomy, Probes and Dilators
Evacuation and Instillation Instruments
require long instruments (approximately 8.50 to 12.00). Extra-long
instrumentation used in bariatric procedures may require 180 to 200 Instruments
instruments to reach deep structures in extremely obese patients. Approximation and Closure
When planning the instrumentation needs for a deeper procedure, Instruments
Specialty Specific Instruments
take into consideration that the superficial tissue layers must be entered
Long Foundation Set
first. This process uses shorter instruments followed by medium-length
Laparotomy Set
instruments for dissection. The long instruments are used to perform Clamps
the intended procedure in those deep tissue planes. For wound closure, Grasping Forceps
the steps would be reversed. Facilities that designate short and long sets Dissection Instruments
will require one of each set for most abdominal procedures. This chap- Debulking Instruments
ter describes three foundation or baseline sets from which procedures Probes and Dilators
can be performed through soft tissue at three tissue depths. Extra-long Evacuation and Instillation Instruments
foundation add-on sets may be available for facilities that perform Retraction and Exposure
Instruments
Approximation and Closure
Instruments
Specialty Specific Instruments
Extra-Long “Add-On” Set
95
SHORT FOUNDATION SET

open bariatric procedures. The outlined sets are
as follows: Short foundation sets can be used for superficial pro-
1. Short foundation set: Excisional soft tissue cedures, excisions, and biopsies. Most procedures
set performed near the surface of the body will utilize
variations of this collection of instruments as a foun-
2. Medium foundation set: Soft tissue dissec-
dation. Surgeon-specific requests and preferences can
tion set
be added as standard or as “add-ons” when the set is
3. Long foundation set: Laparotomy set opened for use.
This chapter will describe and discuss the soft
tissue aspect of short to medium-length instru-
ment set planning by category. The last founda-
tion set—the laparotomy set—contains the longest Excisional Set
instruments that are typically contained within a Excisional sets are commonly used to dissect tissue
set. It is not cost effective to include all possible located above the fascial layers, although they may also
instruments that could potentially be needed in be used for small patients or children. The instrumenta-
every set. Routine sequencing of instrumentation tion is typically not longer than 7.00 unless the patient
needs for the tissue layers will help the surgical is significantly obese. Many excisional procedures are
technologist or other scrub person decide which performed to obtain biopsies, realign tissues as in scar
foundation set is the most useful for each proce- revision, or procure tissue for autografting.
dure. Specialty trays can be added to complete the
setup. The soft tissue sets in this chapter will form
the foundation for the creation of specialty sets in
subsequent chapters.
Excisional Set—CLAMPS

Size: 5.00
Characteristics: Curved or straight jaws; horizontally
FIGURE 5-1
serrated along the full length of the jaws
Uses: Used for clamping of superficial or pediatric
tissues and for hemostasis
Notes: Short, fine hemostat
continues
Chapter 5 Soft Tissue Foundation Sets 97
Excisional Set—CLAMPS continued
Kelly clamp
Size: 5.50
Characteristics: Curved or
straight jaws; horizontally
serrated two-thirds of jaws
from tip
Uses: Used on finer tissue and
blood vessels for hemostasis
FIGURE 5-2
Notes: Slightly larger
than Halsted mosquito;
functionally identical to Crile
clamp/hemostat, differing
only in length of horizontal
serrations in jaws; nicknames
include stat, snap, and tag
Crile clamp
Size: 5.50; 6.250
serrated along full length of
jaws
FIGURE 5-3
functionally identical to Kelly
clamp/hemostat,
differing only in length of
serrations in jaws;
nicknames include stat, snap,
and tag
continues
Rochester-Pean clamp
Size: 6.250; 6.750; 7.250; 8.00; 16.00
FIGURE 5-4
serrated along full length of jaws
Uses: Used for clamping of thicker tissue and
vessels for dissection or hemostasis
Notes: Longer and heavier than Kelly or Crile
clamps/hemostats
Rochester-Pean, Crile, and

Halsted mosquito clamps
Size: Rochester-Pean—6.250; Crile—5.50; Halsted
FIGURE 5-5
mosquito—5.00
Characteristics: All three clamps/hemostats available
in curved or straight jaws with horizontal serrations
along full length of jaws
Notes: Relative size comparison demonstrates variety
of clamps/hemostats with similar functional
properties © 2019 Cengage®. Photo by Margaret Rodriguez.
Mixter clamp
Size: 5.250; 6.50; 7.00
Characteristics: Nearly right-
angled jaw with horizontal
serrations that run full
length of jaws
Uses: Used to clamp
across deep vessels at a
FIGURE 5-6
90-degree angle or to pass
a suture under a vessel or
structure
Notes: Also referred to as a
right-angle or Gemini
clamp/hemostat; may have
© 2019 Cengage®.
continues
Schnidt clamp
Size: 6.50
Characteristics: Slightly curved
jaw with horizontal serrations
running two-thirds the length
from the tip
Uses: Used to clamp across
FIGURE 5-7
deep vessels at a 90-degree
angle or to a pass suture
under a vessel or structure
Notes: Also called Adson or
tonsil clamp/hemostats;
similar to right-angle clamp;
however, less acute angle;
clamp from box lock to tip;
however, provides additional
length with longer shanks
Adson and right-angle clamps

Size: Adson (Schnidt) 6.50; right angle (Mixter) 6.50
Characteristics: Both clamps/hemostats have
curved or angled jaws with horizontal serrations
FIGURE 5-8
Notes: A free tie may be mounted on either clamp
to create a “tie-on-a-passer”; both provide
additional length to reach deeper, fine tissues
continues
Kocher clamp
Size: 5.50; 6/250; 8.00
straight jaws with 2 3 1
sharp teeth at tip and
horizontal serrations that run
the full length of the jaws
Uses: Used on heavy tissue
such as fascia or thick
FIGURE 5-9
ligaments
Notes: Also known as Ochsner
or Rochester-Ochsner
clamps/hemostats/forceps;
provides secure clamping
or traction due to presence of
teeth at the tip
© 2019 Cengage®.
Excisional Set—GRASPING FORCEPS
Allis tissue
forceps
Size: 5.00; 6.00
Characteristics: Straight
or curved jaws with fine
interlinking teeth at the tips
tissue traction
FIGURE 5-10
Notes: Allis-Adair tissue

forceps have more
numerous and finer teeth at
the tips
continues
Excisional Set—GRASPING FORCEPS continued
Adson tissue forceps

Size: 4.50
Characteristics: Short, fine, tweezer-shaped tissue
forceps that may have only horizontal serrations
FIGURE 5-11
in the jaws (smooth) or 1 3 2 teeth at the tips;
sides of the forceps taper considerably at the
distal portion toward the tips
Uses: Used for grasping, stabilizing, and
manipulating superficial tissues as in placement of
skin staples or sutures; may be used in place of larger
tissue forceps in pediatric, plastic, or minor procedures
Notes: Also referred to as Adson “pick-ups” with or without teeth Courtesy of Scanlan International.
Brown-Adson tissue
forceps
Size: 4.50
Characteristics: Short, fine,
tweezer-shaped tissue forceps
with multiple interlacing teeth
FIGURE 5-12
at the tips; sides of forceps
taper considerably at the
distal portion toward the
tips as seen in Adson tissue
forceps
Uses: Used for grasping,
stabilizing, and manipulating
superficial tissues
Notes: Selection is based upon
surgeon’s preference Courtesy of Sklar Instruments.
DeBakey tissue forceps

Size: 6.250; 7.750; 9.500
Characteristics: Atraumatic pattern of serrations that
FIGURE 5-13
nest into both sides of the jaws; lengths vary according
to depth of surgical procedure
Uses: Allows for secure, atraumatic grasping of tissues
such as intestines, vessels, and ureters without potential
for perforation
Notes: Designed initially for vascular surgery; however,
have become common in intestinal trays Courtesy of Scanlan International.
continues
Excisional Set—GRASPING FORCEPS continued
Dressing
forceps
Size: 4.50; 5.00; 5.250; 6.00;
8.00; 10.00; 12.00
Characteristics: Various
FIGURE 5-14
lengths of medium-weight,
tweezer-style tissue forceps
with horizontal serrations in
the jaws and no teeth at the
tips
Uses: Used with gauze packing
because it does not get
caught up in the teeth
Notes: Sometimes called “smooth
pick-ups” or “plain pick-ups” Courtesy of Sklar Instruments.
Tissue forceps with

teeth
Size: 4.50; 5.00; 5.50; 6.00; 8.00;
10.00
FIGURE 5-15
with 1 3 2 teeth at the tips
Uses: Used for stabilization,
traction, or manipulation of
intermediate to heavy tissue
Notes: Sometimes called “rat
tooth” or “pick-ups with teeth”
Excisional Set—DISSECTION INSTRUMENTS
#3 Scalpel handle
Size: #3 4.750; 5.00; #3L 8.50
Characteristics: Flat, calibrated handle with narrow,
FIGURE 5-16
grooved slide tip for application of disposable scalpel

blades; 3L (long) provides additional length of handle
shaft for use in deeper tissues
Uses: With scalpel blade, used as “skin knife,” or a second clean blade is used as a “deep knife”; ruler can be used to
measure tissue specimens or defects; blunt handle end can be used for blunt tissue separation
Notes: #3 and #3L are compatible with #10, #11, #12, or #15 scalpel blades; two standard-length handles are included
in most sets © 2019 Cengage ®
.
continues
Excisional Set—DISSECTION INSTRUMENTS continued
#7 Scalpel handle
Size: #7 6.50; #9 4.750
FIGURE 5-17
Characteristics: Thin, light, flat scalpel handle,
longer than the #3 handle with narrow, grooved tip for
application of disposable scalpel blades; #9 functionally
identical to #7; however, shorter in length
Uses: Thin handle prevents obstruction of view in
narrow surgical fields such as in the nose or throat;
#9 handle used for superficial incisions such as in plastic
surgery, podiatry, or pediatric procedures
Notes: #7 and #9 handles are compatible with
#10, #11, #12, or #15 blades © 2019 Cengage®.
Metzenbaum scissors
Size: 5.750; 7.00; 80
FIGURE 5-18
Characteristics: Thin, straight, or more commonly,
curved blades with sharp or blunt tips
Uses: Used for light to intermediate sharp tissue
dissection; tips may be used to separate tissue
planes bluntly before cutting
Notes: Usually longer than Mayo scissors Courtesy of Scanlan International.
Mayo scissors
Size: 5.50; 6.750
Characteristics: Heavier,
shorter, straight, or curved
bladed scissors, commonly
with blunt tips
Uses: Straight are used to
cut suture, mesh, or other
FIGURE 5-19
nontissue items; curved are
used for intermediate to heavy
tissue dissection
Notes: Straight Mayo scissors
are called “suture” scissors;
both are found in nearly every
instrument set for every specialty
because they are so commonly
used
continues
Excisional Set—DISSECTION INSTRUMENTS continued
Mayo and Metzenbaum scissors

Size: Mayo scissors 6.250; Metzenbaum scissors 8.00
Characteristics: Straight and curved heavy Mayo scissors;
longer, finer, curved Metzenbaum
Notes: A comparison is shown between the three scissors
FIGURE 5-20
most likely found in nearly every surgical instrument tray for
nearly every specialty
Lister bandage
scissors
Size: 7.250
Characteristics: Heavy, angled
scissors with one longer,
flattened tip
Uses: Allows for cutting
FIGURE 5-21
dressings and removing
circumferential bandages
without lacerating the patient’s
covered skin
Notes: Angled, heavy, blunted
tip; sometimes called “nurse’s
scissors.” May be included in
sterile instrument sets for cutting
sterile draping materials
Excisional Set—DEBULKING INSTRUMENTS

None Can be added if wound debridement is required
Excisional Set—PROBES AND DILATORS

None Can be added if sinus tract or fistula is present
Excisional Set—EVACUATION AND INSTILLATION INSTRUMENTS
Luer-Lok three-ring syringe

Size: 10 mL
FIGURE 5-22
Characteristics: Plastic, calibrated, 10-mL, three-ring,
Luer-Lok syringe; disposable after use
Uses: Used with disposable hypodermic needles to inject
medications into tissues
Notes: Glass, reusable control syringes may be used
instead for medication injection Courtesy of Joe Fortunato.
Frazier suction tips

Size: 5 Fr.; 7 Fr.; 8 Fr.; 10 Fr.; 12 Fr.; various lengths
Characteristics: Various lengths and diameters
(measured in units of French) of hollow lumen
FIGURE 5-23
suction tips that are angled; have thin stylets for
dislodging of debris such as clots or tissue; finger
hole that provides variable vacuum pressure
Uses: Commonly used in ear/nose/throat (ENT), plastic
surgery, neurosurgery, podiatry, and superficial or
narrow anatomical structures
Notes: Suction pressure is increased when finger is placed
over vent hole and decreased when removed,
preventing inadvertent damage to delicate structures Courtesy of Sklar Instruments.
Yankauer suction tip

Size: 11.750
Characteristics: Long, curved, hollow cannula
suction with removable tip
FIGURE 5-24
Uses: Designed to reach into the oropharynx and may
also be used by the anesthesia provider to suction
secretions during anesthesia reversal
Notes: Metal, nondisposable tips may be included
with set; however, disposable may be preferred;
reusable style has a screw tip that allows for thorough
decontamination and cleaning of the lumen; may also
be called a “tonsil” or “oral” suction tip Courtesy of Sklar Instruments.
Excisional Set—RETRACTION AND EXPOSURE INSTRUMENTS
Army-Navy retractors
Size: 8.50
FIGURE 5-25
Characteristics: Handheld, thin, flattened, smooth-
tipped, double-ended, right-angle (deep and
superficial) retractors
Uses: Used frequently in pairs for atraumatic
exposure of relatively superficial wounds
Notes: Also called USA retractors or U.S. Army-
Navy retractors Courtesy of Sklar Instruments.
Senn retractors
Size: 6.50
Characteristics: Handheld, small, double-ended
retractor with smooth-ended, right-angle tip on one
FIGURE 5-26
end and sharp or dull three-prong rake in opposite
direction on the other end
Uses: Used mainly in pairs for exposure in small,
superficial wounds
Notes: Care must be taken when handling sharp rake
ends to prevent puncture of sterile gloves or sharps
injury to team members; surgeon will choose which end
is appropriate Courtesy of Sklar Instruments.
Ragnell retractors
Size: 6.00
FIGURE 5-27
Characteristics: Handheld, small, double-ended retractor
with smooth-ended, right-angle tip on both ends, facing
opposite directions
Uses: Mainly used in pairs for exposure of superficial
tissue layers
Notes: Often found in plastic surgery, podiatry, or pediatric
trays for minor procedures or very superficial wounds Courtesy of Sklar Instruments.
Weitlaner retractor
Size: 4.00; 5.50; 6.50; 8.00; 9.50
Characteristics: Self-retaining, two-sided, dull or sharp,
outward-facing prongs with ratchet and finger-press
FIGURE 5-28
release and ring handles

Uses: Provides exposure of surgical site at superficial level
without requiring an assistant to hold wound edges
apart with handheld retractors
Notes: Sharp prongs require care when handling to
prevent sharps injury or glove punctures; retractor
should be handed to surgeon in the closed position for
placement in tissues Courtesy of Sklar Instruments.
Excisional Set—APPROXIMATION AND CLOSURE INSTRUMENTS
Derf needle
holder
Size: 4.750
Characteristics: Short, straight,
fine, ringed, and ratcheted
needle holder with horizontal
serrations and groove in both
jaws
Uses: Used for superficial
FIGURE 5-29
suturing with fine-gauge
suture/needle combinations
Notes: Sets should include
a pair of same-sized needle
holders

Size: 4.750
needle holder available
without serrations (smooth) in
the jaws or with fine, cross-
hatched, diamond-patterned
serrations
FIGURE 5-30
Notes: Smooth jaws prevent
deformation of delicate needles
or breaking of very fine-gauge
suture materials; sets should
include a pair of same-sized
needle holders
continues
Excisional Set—APPROXIMATION AND CLOSURE INSTRUMENTS continued
Olsen-Hegar
needle holder
Size: 4.750; 5.50; 6.50
needle holder with cross-
hatched, diamond-patterned
serrations, groove, and built-in
scissors in the jaws
FIGURE 5-31
Uses: Used in procedures
for superficial suturing and
cutting of suture material
Notes: Having suture scissors built
in saves time when an assistant
is unavailable; sets should
needle holders
Crile-Wood needle
holder
Size: 6.00; 7.00; 8.00; 9.00
Characteristics: Straight,
medium-sized, ringed, and
ratcheted needle holder with
cross-hatched, diamond-
patterned serrations and
groove
FIGURE 5-32
Uses: Typically used for suturing
to the level of the fascia with
intermediate-gauge suture
Notes: Sets should include at least
one pair of same-sized needle
holders
continues
Excisional Set—APPROXIMATION AND CLOSURE INSTRUMENTS continued
Mayo-Hegar
needle holder
Size: 5.250; 6.00; 7.00; 8.00; 9.00
FIGURE 5-33
groove
to the level of the fascia;
intermediate- to heavy-gauge
suture
Notes: Sets should include at
least one pair of same-sized
needle holders; one of the most
commonly used needle holders
for all specialties and surgical
procedures due to the wide
variety of lengths available
Excisional Set—SPECIALTY SPECIFIC INSTRUMENTS

None Add specialty instruments as appropriate
MEDIUM FOUNDATION SET excisional breast biopsy, excision of a lipoma, place-

ment of percutaneous tubes, ostomy take-down, and
Soft Tissue Dissection incision and drainage of superficial abscess or other
Soft tissue dissection sets can be used for most areas procedures that involve tissue layers within the reach of
of the body that do not surpass a tissue depth of 60 to the instruments on the set. Longer instruments may be
80. Examples of these procedures include hernia repair, added as needed.
Soft Tissue Dissection—CLAMPS

Size: 5.00
FIGURE 5-34
serrated along the full length of the jaws
Uses: Used for clamping of superficial or pediatric
tissues and for hemostasis
Notes: Short, fine hemostat
Kelly clamp
Size: 5.50
from tip
FIGURE 5-35
continues
Soft Tissue Dissection—CLAMPS continued
Crile clamp
Size: 5.50; 6.250
jaws
Notes: Slightly larger than
FIGURE 5-36
Halsted mosquito; functionally
identical to Kelly clamp/
hemostat, differing only in
length of serrations in jaws;
and tag
Size: 6.250; 6.750; 7.250; 8.00; 16.00
FIGURE 5-37
Uses: Used for clamping of thicker tissue and
vessels for dissection or hemostasis
Notes: Longer and heavier than Kelly or Crile
clamps/hemostats
continues
Moynihan
clamp
Size: 8.50
Characteristics: Angled jaw
similar to Mixter right-angle;
horizontal serrations in jaws
Uses: May be used to pass a
tie or bluntly separate tissue
planes or dissect vessels or
FIGURE 5-38
nerves
Schnidt clamp
Size: 6.50
from the tip
FIGURE 5-39
angle or to pass a suture
length with longer shanks
continues
Rochester-Ochsner clamp
Size: 6.250; 6.750; 7.250; 8.00; 16.00
FIGURE 5-40
Uses: Used for clamping of thicker tissue and vessels for
dissection and hemostasis
Notes: Longer and heavier than Kelly or Crile clamps/
hemostats; similar to Rochester-Pean clamp
Soft Tissue Dissection—GRASPING FORCEPS
Allis tissue
forceps
Size: 5.00; 6.00
tissue traction
FIGURE 5-41
Notes: Allis-Adair tissue forceps
have more numerous and
finer teeth at the tips
continues
Soft Tissue Dissection—GRASPING FORCEPS continued
Babcock
tissue forceps
Size: 6.250; 7.250; 8.250
Characteristics: Ringed and
ratcheted instrument with
rounded, opened tips with
no teeth
FIGURE 5-42
Uses: Grasping, manipulation,
and traction on delicate
tubular tissues such as
ureters, fallopian tubes, and
intestines without perforation
or occlusion
Notes: Atraumatic design; found
in intestinal, laparotomy, and
hysterectomy trays

Size: 4.50
forceps that may have only horizontal serrations in
FIGURE 5-43
the jaws (smooth) or 1 3 2 teeth at the tips; sides
of the forceps taper considerably at the
distal portion toward the tips
Uses: Used for grasping, stabilizing, and
manipulating superficial tissues as in placement of skin
staples or sutures; may be used in place of larger tissue
forceps in pediatric, plastic, or minor procedures
Notes: Also referred to as Adson “pick-ups” with or without teeth
continues
Brown-Adson
tissue forceps
Size: 4.50
Characteristics: Short, fine,
tweezer-shaped tissue forceps
with multiple interlacing teeth
FIGURE 5-44
at the tips; sides of forceps
taper considerably at the
distal portion toward the
tips as seen in Adson tissue
forceps
Uses: Used for grasping,
stabilizing, and manipulating
superficial tissues
Notes: Selection is based upon
surgeon’s preference Courtesy of Sklar Instruments.

Size: 6.250; 7.750; 9.500
FIGURE 5-45
Characteristics: Atraumatic pattern of serrations that nest into both sides of the jaws; lengths vary according to depth of
surgical procedure
Uses: Allows for secure, atraumatic grasping of tissues such as intestines, vessels, and ureters without potential for
perforation
Notes: Designed initially for vascular surgery; however, have become common in intestinal trays
Dressing forceps
Size: 4.50; 5.00; 5.250; 6.00;
8.00; 10.00; 12.00
FIGURE 5-46
tips
pick-ups” or “plain pick-ups”
continues
Tissue forceps
with teeth
Size: 4.50; 5.00; 5.50; 6.00; 8.00;
10.00
FIGURE 5-47
Soft Tissue Dissection—DISSECTION INSTRUMENTS
#3 Scalpel handle
Size: #3 4.750; 5.00; #3L 8.50
grooved slide tip for application of disposable
FIGURE 5-48
scalpel blades; 3L (long) provides additional length
of handle shaft for use in deeper tissues
Uses: With scalpel blade, used as “skin knife,” or a
second clean blade is used as a “deep knife”; ruler
can be used to measure tissue specimens or defects;
blunt handle end can be used for blunt tissue separation
Notes: #3 and #3L are compatible with #10, #11, #12,
or #15 scalpel blades; two standard-length handles are included in most sets © 2019 Cengage®.
#7 Scalpel handle
Size: #7 6.50; #9 4.750
FIGURE 5-49
Characteristics: Thin, light, flat scalpel handle, longer than the #3 handle with narrow, grooved tip for application of
disposable scalpel blades; #9 functionally identical to #7; however, shorter in length
Uses: Thin handle prevents obstruction of view in narrow surgical fields such as in the nose or throat; #9 handle used for
superficial incisions such as in plastic surgery, podiatry, or pediatric procedures
Notes: #7 and #9 handles are compatible with #10, #11, #12, or #15 blades
© 2019 Cengage®.
continues
Soft Tissue Dissection—DISSECTION INSTRUMENTS continued
Metzenbaum scissors
Size: 5.750; 7.00; 80
FIGURE 5-50
Characteristics: Thin, straight, or more
commonly, curved blades with sharp or blunt
tips
Uses: Used for light to intermediate sharp tissue dissection; tips may be used to separate tissue planes bluntly before
cutting
Notes: Usually longer than Mayo scissors Courtesy of Scanlan International.
Mayo scissors
Size: 5.50; 6.750
with blunt tips
FIGURE 5-51
used for intermediate to
heavy tissue dissection
both are found in nearly
every instrument set for every
specialty because they are so
commonly used Courtesy of Sklar Instruments.
Lister bandage
scissors
Size: 7.250
Characteristics: Heavy,
angled scissors with one
longer, flattened tip
FIGURE 5-52
Uses: Allows for cutting
without lacerating the
patient’s covered skin
Notes: Angled, heavy, blunted
tip; sometimes called
“nurse’s scissors.” May be
included in sterile instrument
sets for cutting sterile draping
materials
Soft Tissue Dissection—DEBULKING INSTRUMENTS

Soft Tissue Dissection—PROBES AND DILATORS

Soft Tissue Dissection—EVACUATION AND INSTILLATION INSTRUMENTS

Size: 10 mL
FIGURE 5-53
Characteristics: Plastic, calibrated 10-mL, three-ring,
Frazier suction tips

Size: 5 Fr.; 7 Fr.; 8 Fr.; 10 Fr.; 12 Fr.; various lengths
Characteristics: Various lengths and diameters
FIGURE 5-54
(measured in units of French) of hollow lumen
suction tips that are angled; have thin stylets for
dislodging of debris such as clots or tissue; finger
hole that provides variable vacuum pressure
Uses: Commonly used in ear/nose/throat (ENT), plastic surgery, neurosurgery, podiatry, and superficial or narrow
anatomical structures
Notes: Suction pressure is increased when finger is placed over vent hole and decreased when removed, preventing
inadvertent damage to delicate structures Courtesy of Sklar Instruments.

Size: 11.750
Characteristics: Long, curved, hollow cannula suction
FIGURE 5-55
with removable tip

Notes: Metal, nondisposable tips may be included with set; however, disposable may be preferred; reusable style has a
screw tip that allows for thorough decontamination and cleaning of the lumen; may also be called a “tonsil” or “oral”
suction tip
Soft Tissue Dissection—RETRACTION AND EXPOSURE INSTRUMENTS
Size: 8.50
FIGURE 5-56
tipped, double-ended, right-angle (deep and superficial)
retractors
Uses: Used frequently in pairs for atraumatic exposure of
relatively superficial wounds
Notes: Also called USA retractors or U.S. Army-Navy retractors Courtesy of Sklar Instruments.
Senn retractors
Size: 6.50
FIGURE 5-57
with smooth-ended, right-angle tip on one end and
sharp or dull three-prong rake in opposite direction on the other end
Uses: Used mainly in pairs for exposure in small, superficial wounds
Notes: Care must be taken when handling sharp rake ends to prevent puncture of sterile gloves or sharps injury to team
members; surgeon will choose which end is appropriate
Ragnell retractors
Size: 6.00
FIGURE 5-58
with smooth-ended, right-angle tip on both ends, facing
opposite directions
Uses: Mainly used in pairs for exposure of superficial tissue layers
Notes: Often found in plastic surgery, podiatry, or pediatric trays for minor procedures or very superficial wounds
Richardson-Eastman retractors
Size: 10.00
Characteristics: Handheld, medium-sized, double-ended
retractor with smooth-ended, right-angle tip on both ends,
FIGURE 5-59
facing the same direction, with one end deeper than the
other
Uses: Retraction of medium-length tissue layers, providing
exposure of surgical site
Notes: Double-ended configuration provides additional
options for use individually or in pairs for various wound
depths; atraumatic; smooth edges are compatible with all tissue types
continues
Soft Tissue Dissection—RETRACTION AND EXPOSURE INSTRUMENTS continued
Size: 9.50
FIGURE 5-60
Characteristics: Handheld; various sizes; single-ended
retractor with smooth-ended, right-angle tip and various
shapes of operator handles
Uses: Retraction of shallow to medium-length tissue layers, providing exposure of surgical site
Notes: Trays often include sets of graduated blade sizes; may be used individually or in pairs for exposure of
various wound depths
Gelpi self-retaining retractor

Size: 7.00
Characteristics: Self-retaining, ring-handled, two-sided,
sharp, outward-facing prongs with ratchet and finger-
FIGURE 5-61
press release
Uses: Provides exposure of surgical site at superficial
level by holding wound edges open without
requirement of additional personnel to hold
retractors
should be handed to surgeon in the closed position
for placement in tissues
Weitlaner self-retaining retractor

Size: 4.00; 5.50; 6.50; 8.00; 9.50
Characteristics: Self-retaining, two-sided, dull or sharp,
outward-facing prongs with ratchet and finger-press
FIGURE 5-62
release and ring handles
Uses: Provides exposure of surgical site at
superficial level without requiring an assistant
to hold wound edges apart with handheld
retractors
should be handed to surgeon in the closed position
for placement in tissues Courtesy of Sklar Instruments.
Soft Tissue Dissection—APPROXIMATION AND CLOSURE INSTRUMENTS
Webster
needle holder
Size: 4.750
Characteristics: Short,
straight, fine, ringed, and
ratcheted needle holder
available without serrations
FIGURE 5-63
(smooth) in the jaws or
with fine, cross-hatched,
diamond-patterned
serrations
Notes: Smooth jaws prevent
deformation of delicate needles
or breaking of very fine-gauge
suture materials; sets should
needle holders
Crile-Wood needle
holder
Size: 6.00; 7.00; 8.00; 9.00
FIGURE 5-64
groove
Uses: Typically used for
suturing to the level of the
fascia with intermediate-
gauge suture
needle-holders
continues
Soft Tissue Dissection—APPROXIMATION AND CLOSURE INSTRUMENTS continued
Mayo-Hegar
needle holder
Size: 5.250; 6.00; 7.00; 8.00; 9.00
medium sized, ringed, and
FIGURE 5-65
groove
to the level of the fascia;
intermediate- to heavy-gauge
suture
needle holders; one of the most
commonly used needle holders
for all specialties and surgical
procedures due to the wide
variety of lengths available Courtesy of Sklar Instruments.
Soft Tissue Dissection—SPECIALTY SPECIFIC INSTRUMENTS

None Added as needed
LONG FOUNDATION SET Laparotomy Set

Instrument sets that are used below the level of the The laparotomy foundation set should be designed
fascia and enter the peritoneal cavity include many of with the type of procedures performed at that facility
the instruments from the excisional and short sets. The in mind. The foundation set described here is intended
main difference in these sets is instrument length. In to be a baseline for the construction of a functional set
some circumstances, extraordinarily long instruments that can be used for the majority of procedures per-
in excess of 100 to 140 and even up to 180 may be formed within the open abdominal cavity. The design
opened and added to the long setup for extremely obese of this set should take into consideration that the
patients. Placing the extra-long instruments in the tray weight of the wrapped set cannot exceed 25 pounds.
as a standard is not cost effective for the few times they If the set is more than 25 pounds wrapped weight,
will be used. In facilities where the extra-long instru- it should be divided into two trays to prevent lifting
ments are used frequently, it may be wise to establish a strain on the surgical technologist or other scrub per-
tray of extra-long soft tissue instruments complete with son and facilitate proper sterilization by steam under
its own count sheet for inventory and accountability. pressure.
Laparotomy Set—CLAMPS
Kelly clamp
Size: 5.50
from tip
FIGURE 5-66
Crile clamp
Size: 5.50; 6.250
jaws
Uses: Used for clamping of
thicker tissue and vessels for
FIGURE 5-67
dissection or hemostasis
Notes: Longer and heavier
than Kelly or Crile
clamps/hemostats;
and tag
continues
Laparotomy Set—CLAMPS continued
Size: 6.250; 6.750; 7.250; 8.00; 16.00
FIGURE 5-68
Uses: Used for clamping of thicker tissue and vessels for
dissection or hemostasis
Notes: Longer and heavier than Kelly or Crile clamps/
hemostats Courtesy of Sklar Instruments.
Moynihan clamp
Size: 8.50
similar to Mixter right-angle;
horizontal serrations in jaws
Uses: May be used to pass a
tie or bluntly separate tissue
FIGURE 5-69
planes or dissect vessels or
nerves
Schnidt clamp
Size: 6.50
from the tip
FIGURE 5-70

length with longer shanks Courtesy of Sklar Instruments.
continues
Laparotomy Set—CLAMPS continued
Mixter clamp
Size: 5.250; 6.50; 7.00
Characteristics: Nearly right-
angled jaw with horizontal
serrations that run full length
of jaws
FIGURE 5-71
Notes: Also referred to as a
right-angle or Gemini
clamp/hemostat; may have
© 2019 Cengage®.
Laparotomy Set—GRASPING FORCEPS
Allis tissue
forceps
Size: 5.00; 6.00
tissue traction
Notes: Allis-Adair tissue FIGURE 5-72
forceps have more
numerous and finer teeth at
the tips
continues
Laparotomy Set—GRASPING FORCEPS continued
Babcock
tissue
forceps
Size: 6.250; 7.250; 8.250
ratcheted instrument with
rounded, opened tips with
FIGURE 5-73
no teeth
Uses: Grasping, manipulation,
and traction on delicate
tubular tissues such as
ureters, fallopian tubes, and
intestines without perforation or
occlusion
Notes: Atraumatic design; found
in intestinal, laparotomy, and
hysterectomy trays
Foerster sponge
forceps
Size: 9.50
Characteristics: Ratcheted
and ringed, straight or slightly
curved, long, atraumatic,
open-ring tips
FIGURE 5-74
Uses: Used with radiodetectable
gauze 4 3 4 sponges to
make sponge sticks for use
in deep wounds to absorb,
bluntly dissect, or move
structures gently away from
operative area; may also be used
for hemostasis of large bleeding
tissue edges as in cesarean
section on edges of edematous,
open uterine layers
Notes: Also called ring forceps Instrument: © 2019 Cengage®.
continues

Size: 4.50
FIGURE 5-75
forceps that may have only horizontal serrations in the
jaws (smooth) or 1 3 2 teeth at the tips; sides of the forceps taper considerably at the distal portion toward the tips
Uses: Used for grasping, stabilizing, and manipulating superficial tissues as in placement of skin staples or sutures; may
be used in place of larger tissue forceps in pediatric, plastic surgery, or minor procedures
Notes: Also referred to as Adson “pick-ups” with or without teeth
Gerald tissue forceps

Size: 7.00
Characteristics: Thin, fine,
tweezer-style forceps with
2 3 1 teeth at tip and
stop-peg in between to
FIGURE 5-76
prevent excessive closing
pressure; jaws may be
straight or curved. Distal tips
taper to thinner diameter than
handle widths
Uses: Used primarily for
grasping and manipulation of
fine or delicate tissues
Notes: Often found in neurosurgery
or spine trays Courtesy of Sklar Instruments.

Size: 6.250; 7.750; 9.500
Characteristics: Atraumatic pattern of serrations
FIGURE 5-77
that nest into both sides of the jaws; lengths vary
according to depth of surgical procedure
Uses: Allows for secure, atraumatic grasping of
tissues such as intestines, vessels, and ureters
without potential for perforation
Notes: Designed initially for vascular surgery;
however, have become common in intestinal trays Courtesy of Scanlan International.
continues
Russian tissue
forceps
Size: 6.00; 8.00; 9.00; 10.00;
14.00
Characteristics: Tweezer-
style forceps available in
various lengths with relatively
FIGURE 5-78
atraumatic, semicircular
serrations at the tips and
cupped depression in the
jaws
Uses: Commonly used for
handling intermediate to thick
tissue layers or flaps
Notes: Similar to Selman tissue
forceps, but heavier and not
circular jaws. Often used for
Microfibrillar Collagen Hemostat
and must be kept dry Courtesy of Sklar Instruments.
Dressing forceps
Size: 4.50; 5.00; 5.250; 6.00;
8.00; 10.00; 12.00
FIGURE 5-79
tips
pick-ups” or “plain pick-ups”
continues
Tissue forceps
with teeth
Size: 4.50; 5.00; 5.50; 6.00; 8.00;
10.00
FIGURE 5-80
Laparotomy Set—DISSECTION INSTRUMENTS
#3 Scalpel handle
Size: #3 4.750; 5.00; #3L 8.50
FIGURE 5-81
grooved slide tip for application of disposable scalpel
blades; 3L (long) provides additional length of handle
shaft for use in deeper tissues
Notes: #3 and #3L are compatible with #10, #11, #12, or #15 scalpel blades; two standard-length handles are included
in most sets © 2019 Cengage ®
.
#4 Scalpel handle
Size: #4 5.750; #4L 8.500
Characteristics: Flat, calibrated handle with FIGURE 5-82
narrow, grooved tip for application of disposable scalpel blades; #4L (long) provides additional length of handle shaft for
use in deeper tissues
Notes: #4 and #4L are compatible with #20, #21, #22, or #25 scalpel blades. Bigger handle than the #3 or #3L handles.
May be included in cardiac or trauma sets if #3 handles are standard in other instrument sets
© 2019 Cengage®.
continues
Laparotomy Set—DISSECTION INSTRUMENTS continued
#7 Scalpel handle
Size: #7 6.50; #9 4.750
FIGURE 5-83
Characteristics: Thin, light, flat scalpel handle; longer than the #3 handle with narrow, grooved tip for application of
disposable scalpel blades; #9 functionally identical to #7; however, shorter in length
Uses: Thin handle prevents obstruction of view in narrow surgical fields such as in the nose or throat; #9 handle used for
superficial incisions such as in plastic surgery, podiatry, or pediatric procedures
Notes: #7 and #9 handles are compatible with #10, #11, #12, or #15 blades
© 2019 Cengage®.
Metzenbaum scissors
Size: 5.750; 7.00; 8.00; 9.00; 11.00
FIGURE 5-84
Characteristics: Thin, straight, or more commonly,
curved blades with sharp or blunt tips
Uses: Used for light to intermediate sharp tissue
dissection; tips may be used to separate tissue planes bluntly before cutting
Notes: Usually longer than Mayo scissors
Mayo scissors
Size: 5.50; 6.750; 9.00
with blunt tips
FIGURE 5-85
used for intermediate to heavy
tissue dissection
both are found in nearly every
instrument set for every specialty
because they are so commonly
used
Laparotomy Set—DEBULKING INSTRUMENTS

Laparotomy Set—PROBES AND DILATORS

Laparotomy Set—EVACUATION AND INSTILLATION INSTRUMENTS

Size: 10 mL
FIGURE 5-86
Characteristics: Plastic, calibrated, 10-mL, three-ring,
Poole suction tip

Size: 6.750; 7.750; 10.00; lumen size: 23 Fr.; 30 Fr.; 32 Fr.
Characteristics: Various diameters and lengths of hollow
FIGURE 5-87
cannulas with removable, screw-on outer multiholed
sheath (guard); may be straight or angled at tubing
attachment; disposable tips are available
Uses: Suction tip used in abdominal procedures around intestines; with outer sheath/guard removed, may be used in
vaginal procedures as a finer suction tip
Notes: Numerous holes in the sheath reduce occlusion when used around intestinal structures, which may block some,
but not all, holes; sheath is removable for use of inner cannula and for decontamination and cleaning; also called
“intestinal” suction tip Courtesy of Sklar Instruments.

Size: 11.750
Characteristics: Long, curved, hollow cannula suction
FIGURE 5-88
with removable tip

Notes: Metal, nondisposable tips may be included with set; however, disposable may be preferred; reusable style has a
screw tip that allows for thorough decontamination and cleaning of the lumen; may also be called a “tonsil” or “oral”
suction tip Courtesy of Sklar Instruments.
Laparotomy Set—RETRACTION AND EXPOSURE INSTRUMENTS

Size: 1.00 to 3.00 widths; 7.250 and 13.00 lengths
FIGURE 5-89
Characteristics: Flat, long sheet of metal capable of
being bent into various angles and curvatures; available
in different widths
Uses: Shorter lengths frequently used in neurosurgery; longer, standard lengths used frequently in abdominal, pelvic, and
thoracic procedures; may be used during midline abdominal wound closure to protect deep structures
Notes: Uncomfortable to user’s hand for long periods; once bent, may not return to completely flat configuration, giving it
the appearance of a ribbon Courtesy of Sklar Instruments.
Size: 8.50
FIGURE 5-90
tipped, double-ended, right-angle (deep and superficial)
retractors
Uses: Used frequently in pairs for atraumatic exposure of
relatively superficial wounds
Notes: Also called USA retractors or U.S. Army-Navy retractors Courtesy of Sklar Instruments.
Richardson-Eastman retractor
Size: 10.00
Characteristics: Handheld, medium-sized, double-ended
retractor with smooth-ended, right-angle tip on both ends,
FIGURE 5-91
facing the same direction, with one end deeper than the
other
Uses: Retraction of medium-length tissue layers, providing
exposure of surgical site
Notes: Double-ended configuration provides additional
options for use individually or in pairs for various wound
depths; atraumatic, smooth edges are compatible with
all tissue types Courtesy of Sklar Instruments.
Deaver retractor
Size: 7.00; 10.00, 12.00; 13.00 length; 0.750; 1.00; 1.50;
FIGURE 5-92
2.00; 3.00 widths

Characteristics: Handheld, flat, curved, rigid, rounded tip
retractor with various handle styles for user comfort
Uses: Used for deep tissue retraction; often used in addition to self-retaining retractors
Notes: Care should be taken when “toeing in” (lifting handle up causes distal tip to dig deeper into tissue layers). Similar
to malleable retractor in blade thickness; however, not meant for reshaping
continues
Laparotomy Set—RETRACTION AND EXPOSURE INSTRUMENTS continued
Size: 9.50
FIGURE 5-93
Characteristics: Handheld; various sizes; single-ended
retractor with smooth-ended right-angle tip and various
shapes of operator handles
Uses: Retraction of shallow to medium-length tissue layers providing exposure of surgical site
Notes: Trays often include sets of graduated blade sizes; may be used individually or in pairs for exposure of various
wound depths
Balfour self-retaining retractor

Size: 7.00 opening spread; 2.00 blade depth
Characteristics: Self-retaining, multipart abdominal retractor with
two fenestrated, right-angle wire sides attached to a double slide
FIGURE 5-94
bar; center or bladder blade attachment available
Uses: Retraction of lateral abdominal or pelvic wound edges; with
additional attachments, retraction of inferior and/or superior wound
edges is possible
Notes: Available in different sizes, blade depths, and center blade
sizes; some styles have additional side-arm attachments for
enhanced wound exposure; must be disassembled for thorough
decontamination and cleaning; removable parts such as wing nuts
and screws must be accounted for during instrument counts Courtesy of Sklar Instruments.
Laparotomy Set—APPROXIMATION AND CLOSURE INSTRUMENTS
Webster needle
holder
Size: 4.750
fine, ringed, and ratcheted needle
holder available without serrations
FIGURE 5-95
(smooth) in the jaws or with fine,
cross-hatched, diamond-patterned
serrations
Uses: Used for superficial suturing
with fine-gauge suture/needle
combinations
Notes: Smooth jaws prevent deformation
of delicate needles or breaking of
very fine-gauge suture materials; sets
should include a pair of same-sized
needle holders
continues
Laparotomy Set—APPROXIMATION AND CLOSURE INSTRUMENTS continued
Crile-Wood needle
holder
Size: 6.00; 7.00; 8.00; 9.00
Characteristics: Straight, medium
sized, ringed, and ratcheted needle
holder with cross-hatched, diamond-
FIGURE 5-96
patterned serrations and groove
Uses: Typically used for suturing to the
level of the fascia with intermediate-
gauge suture
Notes: Sets should include at least one
pair of same-sized needle holders
Mayo-Hegar needle holder

Size: 7.00; 8.00; 10.50
Characteristics: Straight, medium
sized, ringed, and ratcheted needle
holder with cross-hatched, diamond-
patterned serrations and groove
FIGURE 5-97
Uses: Typically used for suturing to the
level of the fascia; intermediate- to
heavy-gauge suture
Notes: Sets should include at least one
pair of same-sized needle holders;
one of the most commonly used
needle holders for all specialties and
surgical procedures due to the wide
variety of lengths available
Laparotomy Set—SPECIALTY SPECIFIC INSTRUMENTS

Note: Self-retaining retractor of the surgeon’s choice should be added if Balfour retractor does not provide the needed
exposure. Specialized noncrushing vascular and intestinal clamps may also be required for cases in which resection
and anastomosis are to be performed.
Extra-Long “Add-On” Set routinely should create extra-long “add-on” instrument

Patients with deep adipose tissue pose a particularly sets to meet the needs of the surgical team in per-
complex problem. With the advent of bariatric pro- forming these challenging procedures. The majority of
cedures, more manufacturers are producing longer instruments listed previously can be found in lengths
instrumentation for open surgery with lengths up to suitable for this purpose.
200. Surgical facilities that perform bariatric procedures
SUMMARY manageable by the surgical technologist or other

scrub person and are not intended to be the only
Selecting the correct foundation is beneficial to the
groupings used by every surgical team. Each facility
patient, surgeon, and team. The baseline instru-
should have a committee of surgical technologists
mentation is determined by the depth of the target
or other scrub personnel and circulating nurses to
tissue to be operated on. Constructing foundation
determine the selection of surgical instrumentation
sets with the appropriate quantities of instruments of
that best represents the practices of the majority of
varying types will differ between facilities and sur-
surgeons and procedures. Establishing foundation
geon’s preferences. The foundation sets represented
sets may also be useful for training new personnel
in this chapter are designed to be cost effective and
and standardizing count sheets.
BIBLIOGRAPHY
Instrument tray weight limits; 1096 - Care and handling
of surgical instruments (August 13, 2016). Retrieved
from www.pfiedler.com/1096/files/assets/basic-html
/page15.html
CHAPTER 6
PLASTIC SURGERY
INSTRUMENTATION

Basic Plastic Surgery After reading this chapter the learner should be able to:
Instrumentation 1. Describe the instrumentation used in plastic surgery.
Clamps 2. Discuss the delicate features of plastic surgery instruments.
Grasping Forceps 3. List six instruments that are not used in other surgical procedures.
Evacuation Instruments
Retraction and Exposure INTRODUCTION
Instruments
Plastic surgery requires predominantly delicate instrumentation that
Closure Instruments
provides the surgeon the ability to work with fine tissues without caus-
Measuring Instruments ing damage at the cellular level. Meticulous handling of the tissues gives
Basic Plastic Surgery Procedures the patient the best chance for aesthetic healing. Patients who go to
Rhytidectomy-Browlift a plastic surgeon are seeking an improvement or restoration of form,
Blepharoplasty function, or both. The main things patients see at the end of the pro-
Surface and Subsurface cedure are the closure and the overall external appearance. Although
Procedures
some plastic surgeons use microsurgery in their plastic surgical prac-
Debridement and Excisional tices, microsurgery is covered in a separate chapter because it is shared
Procedures
with other specialties, such as neurosurgery and gynecology.
Liposuction
Breast Augmentation-Reduction
Procedures
BASIC PLASTIC SURGERY INSTRUMENTATION
Basic plastic surgery sets have some of the common elements found in the soft
tissue foundation sets. The soft tissue foundation sets have several instruments
that are not commonly used in plastic surgery; therefore, it may be more
functional to assemble a basic plastic surgery set that serves as the foundation
for plastic surgical cases. Infrequently used instruments or highly specialized
collections can be packaged together as procedure-specific add-on sets, such
as for facelifts. The rationale for having add-on instrumentation is multifold:
1. Specialty instruments are quite expensive. To package all of the instru-
ments in one tray would require extensive duplication of instruments
that are not commonly used for most cases.
2. Plastic surgery instruments are very delicate. The more they are pro-
cessed and handled, the greater the risk to their tiny points and tips.
136
Chapter 6 Plastic Surgery Instrumentation 137
3. Steam sterilization causes sharp edges to dull. mean more tips. Extremely delicate instruments
Repeated exposure to steam causes the metal are sometimes wrapped individually within the
instruments to soften over time. The blades will assembled tray.
not hold a sharp edge. Dull scissors tear and rip
The predominant instrumentation for plastic sur-
tissue. This damages wound edges and causes
gery consists of gentle grasping, delicate dissection,
irregular scars.
and meticulous closure of soft tissue. Modification of
4. Unused instruments cause clutter on the field. bony tissue is discussed in a later chapter. Hemostasis
The risk for retained foreign objects is increased is accomplished with fine-tipped clamps and needle-
when there are extraneous items within the point cautery. Some surgeons believe that cautery leaves
sterile field. devitalized tissue in the wound that causes increased
5. The maintenance of the instrumentation is time inflammation and potentiates infection. Surgeons who
consuming. Many instruments need tip protectors do not prefer cautery frequently use 2/0, 3/0, or 4/0 silk
in place during sterilization. More instruments or absorbable synthetic ties for hemostasis.
Basic Plastic Surgery Instrumentation—CLAMPS

Size: 5.00
FIGURE 6-1
Notes: Hemostasis; holding (tagging) suture ends

Size: 3.50
Characteristics: Straight or curved with short
jaw; serrations full length of jaw; shorter and
heavier than Halsted
FIGURE 6-2
Notes: Hemostasis; holding suture ends
continues
Basic Plastic Surgery Instrumentation—CLAMPS continued

Size: 5.00
FIGURE 6-3
Characteristics: Straight or curved with short
jaw; lighter weight and more delicate than
Halsted; serrated full length of jaw
Notes: Hemostasis; commonly used in plastic
surgery
Kelly clamp
Size: 5.50
Characteristics: Curved
or straight; jaw is one-
third of shank. Horizontal
serrations halfway down
the jaw
FIGURE 6-4
Notes: Hemostasis.
hemostat, and stat
Rankin clamp
Size: 6.250
FIGURE 6-5
Characteristics: Curved or straight; jaw is one-third of shank; lighter

weight than Kelly, but slightly longer.
Notes: Hemostasis
continues
Crile clamp
Size: 5.500; 6.250
curved or straight; jaw is half
the length of the shank
Uses: Holding suture ends.
FIGURE 6-6
hemostat; available in
delicate weight for pediatrics
Hemostasis; Found in most
sets as the standard hemostat

Size: 5.500; 6.250; 7.250
Characteristics: Horizontal serrations full length of
FIGURE 6-7
jaw; curved or straight; heavy-style instrument; jaw
is proportionate to shanks
Notes: Shorter styles: sometimes referred to as
hemostat or Kelly; longer styles: sometimes referred
to as a long or extra-long Kelly
continues
Moynihan
clamp
Size: 5.00; 7.00
weight with horizontal
serrations along the full length
of the short, right-angled jaw.
FIGURE 6-8
Used as a passer for suture
around a stalk of tissue. Can
be used to tease strands of
tissue apart
Notes: Commonly used for
circumferential blunt dissection
of tubular structures; can be
used for passing suture around
or through meticulous vascular
beds of tissue. Similar to Adson
tonsil clamp
Schnidt clamp
Size: 7.50
Similar to Adson tonsil clamp,
but more slender jaw. Used
FIGURE 6-9
as a passer for suture around
a stalk of tissue. Can be used
to tease strands of tissue
apart
Notes: Referred to as tonsil clamp
continues
Adson clamp
Size: 7.250
FIGURE 6-10
or straight. Jaw is slightly
heavier and more curved than
Schnidt clamp. Used as a
passer for suture around a
stalk of tissue. Can be used
to tease strands of tissue
apart
Notes: Referred to as tonsil clamp;
very useful as a passer for suture
around tissue
Kocher clamp
Size: 5.500; 7.250
serrations full length of
jaw; curved or straight tip;
heavy-style instrument; jaw
is proportionate to shanks;
FIGURE 6-11
1 3 2 tooth at tip. Firm grasp
of tissue; can be used for
hemostasis of a pedicle; good
for holding fascia
Notes: Name is sometimes
used interchangeably with
Oschner, although it is a heavier
instrument. The teeth/tooth at
the tip of jaw help to enclose the
tissue within the confines of the
jaws
Instrument: © 2019 Cengage®.

Basic Plastic Surgery Instrumentation—GRASPING FORCEPS
Allis forceps
Size: 5.50; 6.00; 7.250
4 3 5 or 5 3 6 along the
edge of the tip of the jaw; the
jaw can be straight or angled;
intermediate weight
FIGURE 6-12
Notes: One of the most
commonly used instruments
in the surgical setup
Allis Adair forceps

Size: 6.50
9 3 10 along the edge of the
tip of the jaw; straight
FIGURE 6-13
continues
Basic Plastic Surgery Instrumentation—GRASPING FORCEPS continued
Dressing
forceps
Size: 50 to 120
FIGURE 6-14
tissue
Notes: Commonly found in
pairs in a set. Shorter styles
are sometimes referred to as
thumb forceps. Referred to as
smooth “pick-ups”
Tissue forceps
Size: 50 to 120
1 3 2 tips with teeth for
traction. Medium-weight
FIGURE 6-15
tissue
“pick-ups”
Adson forceps
Size: 4.750
FIGURE 6-16
Characteristics: Delicate tip with wide thumb grasp area;
straight or curved tip forceps. Can be smooth, serrated,
or 1 3 2 toothed tip. Grasp fine tissue edges. Often
used in pairs for closure.
approximation; extra-fine teeth are available Courtesy of Scanlan International.
continues
Brown-Adson
forceps
Size: 4.750
Characteristics: Delicate,
longitudinally 8 3 8 toothed
FIGURE 6-17
tips with wide thumb grasp
area
plastic surgery for a delicate,
but secure grasp
Broli-Adson forceps
Size: 6.00
FIGURE 6-18
Characteristics: Flat wide handle with longer
narrow tip. Resemble standard Adson forceps
at the thumb grip. Straight or curved serrated tip.
Available with 1 3 2 teeth
Notes: Delicate tissue in deeper plane
DeBakey forceps
Size: 6.00; 7.750
FIGURE 6-19
Characteristics: Intermediate-weight forceps
with longitudinal fine teeth and matching
grooves
Notes: Atraumatic forceps; the favorite tool of many
surgeons; the straight tips narrow toward the distal
end and interdigitate. Also known as cartilage forceps Courtesy of Scanlan International.
continues
Gerald forceps
Size: 7.00
Characteristics: Light- to
FIGURE 6-20
shanks have a stop peg to
grasping of tissue
dissection
Jansen forceps
Size: 6.50
FIGURE 6-21
Characteristics: Intermediate-weight bayonet
forceps with serrations at the tip; the shanks
have a stop peg to prevent overcompensated
grasping of tissue
Notes: Commonly used during nasal
procedures or for a small area that requires
the surgeon’s hand to be out of the line of vision; useful for nasal packing Courtesy of Sklar Instruments.
Wilde forceps
Size: 6.50
80-degree-angled forceps
with serrated tips. Used in
nasal procedures
Notes: Useful for inserting nasal
packing
FIGURE 6-22
Basic Plastic Surgery Instrumentation—DISSECTION INSTRUMENTS
Scalpel #3
Size: #3
FIGURE 6-23
Characteristics: Nickel-plated, ridged grip
for thumb and forefinger; handle is marked
in centimeters and millimeters for use in
measurement of tissue
Notes: Blade assembly fits size 10 series disposable
blades (10-11-12-15) © 2019 Cengage®.
Scalpel #7
FIGURE 6-24
Size: #7
Characteristics: Nickel-plated, ridged grip for
thumb and forefinger; shank is thin for fine incision
management
Notes: Blade assembly fits size 10 series disposable
blades (10-11-12-15) © 2019 Cengage®.
Beaver handle
Size: 3.750
FIGURE 6-25
Characteristics: Stainless steel with rounded handle;
used for delicate tissue dissection
Notes: Slotted blade assembly accepts fine disposable
mini-blades referred to as beaver blades; flat end of
blade fits into slot, and handle chuck is turned like a
screw motion until blade is held secure; also called
miniature blade handle © 2019 Cengage®.
Standard operating
scissors
Size: 4.50; 5.00; 5.50; 6.00; 6.50
scissors; sharp-blunt or
sharp-sharp tips can be
straight or curved
FIGURE 6-26

continues
Basic Plastic Surgery Instrumentation—DISSECTION INSTRUMENTS continued
Mayo scissors
Size: 6.250
Characteristics: Heavy
operating scissors with blunt-
blunt tips. Can be straight or
curved
Notes: Found in most
instrument sets in both curved
FIGURE 6-27
on the field
Metzenbaum scissors
Size: 5.50; 7.00; 8.00; 9.00; 11.00; 14.50
Characteristics: Fine, lightweight
scissors with blunt-blunt tips; jaws
FIGURE 6-28
are half the length of the shanks;
available in curved and straight
styles
Notes: Found on most instrument
sets; the most commonly used style
is curved. Should not be used to
cut suture or dressings.
continues
Stevens
tenotomy
scissors
Size: 4.50
Characteristics: Jaws are
wedge shaped and can be
curved or straight; tips are
FIGURE 6-29
sharp-sharp; ring-handles are
standard. Micro styles have
spring handles
Notes: Incision into narrow
spaces; jaw shape allows
scissors to spread and visualize
channel as it is cut
© 2019 Cengage®.
Martin scissors
Size: 8.00
FIGURE 6-30
Characteristics: Tip is wedge shaped; the curved
blades have fine serrations for traction. Used for
cutting cartilage
Notes: The wedge-shaped tip is used for blunt
entry into a cartilaginous area; the serrations
provide a secure cutting surface after dissection
of the planes Courtesy of Sklar Instruments.
Iris scissors
Size: 3.750; 4.00; 4.50
Characteristics: Fine scissors with sharp-sharp tips;
jaws are straight or curved and one third to one half
FIGURE 6-31
the length of the shanks; the ring handles are standard

or flattened into a ribbon style for a wider stabilizing
grip. Available in right-angle jaw
Notes: Standard ring handles; gold handle has carbon
blade inserts
continues
v
Littler scissors
Size: 4.50
FIGURE 6-32
Characteristics: Slight curve; narrowed blunt-blunt tip
with suture-carrying hole
Notes: Used for undermining tissue
Joseph scissors
Size: 5.750
tips; sharp-sharp. Jaw is very
short. Shanks are longer
rhinoplasty. Short jaws permit
deeper cutting without the
FIGURE 6-33
shanks interfering with the
dynamic motion
Laine Kindal scissors
FIGURE 6-34
Size: 7.200
Characteristics: Short sharp-sharp jaw with a
curve. Slightly heavier than Joseph scissors.
Available in tenotomy wedge-tip styles
Notes: Good for undermining tissue
continues
Foman
scissors
Size: 5.250
Characteristics: Fully curved
tip, blunt-blunt or sharp-sharp
FIGURE 6-35
Aufrecht scissors
Size: 6.50; 7.50
shanks with curved blunt-
blunt tips. Central ridge down
the blade
FIGURE 6-36
facelift and nasal procedures
continues
Gorney scissors A.
B.
Size: 5.200 (A. basic curved); 4.50 (B. swan neck); 8.00
(C. shears)
Characteristics: Tips can be sharp-sharp or narrow
blunt-blunt with serrated blades. Shear style has
FIGURE 6-37
a spring handle with double-action box lock for
increased power at the cutting surface
Notes: Heavy-duty dissection of fascial tissue
C.
Ragnell scissors
Size: 4.750 to 10.250
FIGURE 6-38
Characteristics: Curved blunt-blunt flattened
tips
Notes: Good for undermining tissue
Jabaley scissors
Size: 4.750
Characteristics: Intermediate weight, sharp-
FIGURE 6-39
sharp tips. Can be curved or straight
Notes: Good for hand surgery
continues
Lister
bandage
scissors
Size: 7.250
Notes: Angled blades with
probe-wedge tip for cutting
FIGURE 6-40
Utility scissors
Size: 6.50; 7.50
Characteristics: Durable lightweight metal; the jaws are right
FIGURE 6-41
angles; the upper blade is blunt; the lower serrated blade
is slightly longer with a wedge-probe tip; ring handles are
heat-stable plastic and have a larger thumb handle for wide
stabilization
Notes: Used to cut thick dressing material. Not used on tissue
Notes: Not used for patient tissue. Some manufacturers coat the
blades with fluoride to prevent adhesive tape buildup. Handles
can be plastic color coded. Autoclavable Courtesy of Sklar Instruments.
Size: 4.250; 4.750
one-quarter the length of
the shanks, and the jaws
FIGURE 6-42
have one serrated blade at a

45-degree angle; available in
angled styles; tips are blunt-
blunt
Notes: Used only for cutting
wire suture or small-to-
intermediate pins
continues
Spencer stitch
scissors
Size: 3.50
Characteristics: Blades
available in curved or straight
styles. One blade has a hook
that slides under the stitch
before cutting
Notes: Used for removing
FIGURE 6-43
sutures from patient
Basic Plastic Surgery Instrumentation—EVACUATION INSTRUMENTS

Size: 5 Fr.; 7 Fr.
FIGURE 6-44
Notes: May be included as reusable with set, but
disposable is preferred
Adson suction tube

Size: 5 Fr.; 7 Fr.
FIGURE 6-45
continues
Basic Plastic Surgery Instrumentation—EVACUATION INSTRUMENTS continued
Baron suction tube

Size: 5 Fr.; 7 Fr.
FIGURE 6-46
Notes: May be included as reusable with set,
but disposable is preferred
Basic Plastic Surgery Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS
Senn retractor
Size: 6.50
FIGURE 6-47
Notes: Double-ended for exposure of surface
layers; flat, right-angled end and a rake end
that face opposite directions
Ragnell retractor
FIGURE 6-48
Size: 6.00
Notes: Double-ended for exposure of surface layers.
One end is smaller. Both ends are rounded and
face opposite directions
Mathieu retractor
Size: 6.50
FIGURE 6-49
Notes: Double-ended for exposure of surface layers;

flat, right-angled end and a rake end that face the
same direction
continues
Basic Plastic Surgery Instrumentation—RETRACTION AND EXPOSURE

INSTRUMENTS continued
Crile retractor
Size: 4.50
Characteristics: Double-ended, right-angle retractor; flat
FIGURE 6-50
spine; one end is slightly larger than the other and faces
opposite direction. Squared-shape blade with rounded
edges
Notes: The ends point in opposite directions. When the
working end is in the tissue, the opposite end serves as
the finger grip. Available in tiny pediatric sizes up to large
blades for deep procedures in adults
Army-Navy retractor
FIGURE 6-51
Size: 8.250
Characteristics: Double-ended, right-angle retractor; open
area down the spine of the hand grip. One end is larger
than the other. Both blades angle in same direction
Notes: Commonly used in pairs
Volkman retractor
Size: 4.50; 8.00; 8.50; 9.00
FIGURE 6-52
steel; one to six prongs; sharp and blunt prong styles
Notes: Open or closed handle styles. Care is taken not to
perforate through skin surface when in use
Murphy retractor
Size: 7.50
FIGURE 6-53
Characteristics: Single-ended, prong-tipped;
stainless steel; two to six prongs; sharp and blunt
prong styles; Egyptian ankh–shaped handle with
thumb hooks and finger ring for secure grasp
Notes: Care is taken not to perforate through skin
surface when in use
© 2019 Cengage®.
continues

Freeman retractor
Size: 6.50
FIGURE 6-54
Notes: This retractor is somewhat flexible under
traction; prongs are very sharp. Good for holding
large flaps. Care is taken not to perforate through
skin surface when in use
Bear claw retractor

Size: 4.750
FIGURE 6-55
Notes: This retractor is somewhat flexible under traction;
prongs are very sharp. Good for holding large flaps. Care
is taken not to perforate through skin surface when in
use
Joseph skin hook

Size: 6.50
Notes: Small, sharp, double
prong; wide prongs; used in
pairs. Care is taken not to
FIGURE 6-56
perforate through skin surface
when in use
continues

Gilles skin
hook
Size: 7.00
Notes: Small, sharp, single
prong; used in pairs. Care
FIGURE 6-57
is taken not to perforate
through skin surface when
in use
Kleinert skin hook

Size: 6.50
FIGURE 6-58
Characteristics: Single rounded hook
Notes: Small, sharp, single prong; used in pairs. Care
is taken not to perforate through skin surface when
in use
Thimble hook retractor

Size: Flexible metallic band to fit around the surgeon’s finger
FIGURE 6-59
(approximately 4.50)
Characteristics: Open ring with two sharp prongs (Millard style)
Notes: Surgeon can retract and dissect with two hands without using a
forceps
continues

Lead hand
Size: Universal one size
Characteristics: Malleable hand-shaped form. Reusable or disposable styles
Uses: Used to hold fingers in a stationary position during the surgical procedure
Notes: Can be used for either right or left hand. Available in aluminum disposable styles
FIGURE 6-60
Jansen retractor
Size: 4.50
FIGURE 6-61
Characteristics: Screw mechanism causes retraction arms to
spread tissues; rake tips (3 3 3 or 4 3 4 prongs) hold tissue in
position. Blunt
Notes: Small incisions near the surface
Alm retractor
Size: 4.00
FIGURE 6-62
arms to spread tissues; rake tips (4 3 4 prongs) hold
tissue in position. Sharp
Notes: Commonly used in podiatry or hand procedures.
Can be used in other tiny incisions
Weitlaner retractor
Size: 4.00; 5.50; 6.50; 8.00; 9.50
FIGURE 6-63

lock; tips have sharp or blunt 4 3 3 rake prongs
that interdigitate when closed
more than one can be used at opposing ends of
the incision; used by almost every surgical service.
Curved style is known as a cerebellar retractor Courtesy of Sklar Instruments.
continues
Basic Plastic Surgery Instrumentation—CLOSURE INSTRUMENTS
Derf needle holder

Size: 4.750
Uses: Superficial suturing
Notes: Short serrated jaw for
small needles
FIGURE 6-64
Webster needle
holder
Size: 4.750
Uses: Superficial suturing
Notes: Smooth or serrated
jaw for small needles
FIGURE 6-65
continues
Basic Plastic Surgery Instrumentation—CLOSURE INSTRUMENTS continued
Halsey needle holder

Size: 5.00
Notes: Superficial suturing with
smaller needles
FIGURE 6-66
Baumgartner needle
holder
Size: 5.250
Characteristic: Heavier cross-
serrated jaws for firmer hold
on larger needles
Notes: For closure where a
heavier, shorter needle holder FIGURE 6-67
is needed
continues
Olsen-Hegar needle holder

Size: 5.50; 6.00
with cross-serrated jaws;
scissors built in at the box
locks
weight suture
Notes: Commonly used by
FIGURE 6-68
plastic surgeons when placing
multiple individual stitches
Kaye needle holder

Size: 4.750
Characteristics: Small jaws with diamond dust
surface. Scissors built into box locks
FIGURE 6-69
Uses: Used for 5-0 or smaller suture
Notes: Used by surgeons when placing multiple
individual tiny stitches
continues
Crile-Wood needle holder

Size: 6.00; 7.00
Uses: Used for light- to
FIGURE 6-70
most sets
Mayo-Hegar needle
holder
Size: 6.250; 7.00; 8.00, 120
Uses: Used for intermediate- to
heavy-weight suture FIGURE 6-71
most sets
Basic Plastic Surgery Instrumentation—MEASURING INSTRUMENTS
Metal ruler
FIGURE 6-72
Size: 6.00
Notes: Stainless steel; graduated in inches, centimeters,
and millimeters
Freeman nipple-marking template
FIGURE 6-73
Size: 18 mm to 52 mm
Notes: Used to measure and mark the circumference of neoareola
created during reduction or reconstruction of a breast; can be double-
sided in two increments; commonly called a “cookie cutter”; dipped in
pigment dye and placed on surface of breast mound
McKissock keyhole pattern breast-marking

template
FIGURE 6-74
Notes: Used to mark reconstruction lines created by reduction
mammoplasty
Maxwell nipple-marking template

FIGURE 6-75
Notes: Used to measure and mark the circumference of neoareola
created during reduction or reconstruction of a breast.
Commonly called a “cookie cutter.” Dipped in pigment dye and
placed on surface of breast mound
BASIC PLASTIC SURGERY Large volumes of tissue removal (including dermis

and epidermis) may require procurement of a full-
PROCEDURES thickness flap from another site on the patient to cover
the defect. This flap may require the use of a plastic
Rhytidectomy-Browlift surgery and a short foundation set. Vascular structures
Facelift, or rhytidectomy and browlift procedures, and nerves are carefully preserved in a flap to ensure
require the surgeon to undermine or dissect under viability of the tissue reconstruction.
a flap of skin on the face without damaging vessels
and nerves to tighten and firm the outer surface. The
instrumentation is designed to tunnel and separate tis- Liposuction
sue planes. The foundation set used is the basic plastic Subsurface adipose tissue can be removed with mini-
surgery set. mal surface tissue disruption. Preparation of adipose
tissue for removal is performed by instilling 1 L of
sterile normal saline or Ringer’s lactate solution mixed
Blepharoplasty with 30 to 50 mL 1% lidocaine and 1 to 2 mL epineph-
Blepharoplasty is a procedure that removes excess skin rine 1:1000 followed by modulated cannulated suc-
and subsurface fat pads from around the periorbital tion. The cannulae are disposable and not reused. The
rim. The incisions are marked preoperatively, and the tumescent solution dosage will be dependent on the
tissue is excised by fine #15 scalpel blades during the patient’s physiology and surgeon’s preference. The use
procedure. The basic plastic surgery set is sufficient of lidocaine minimizes postoperative pain, and the epi-
for this procedure, although some surgeons have addi- nephrine causes vasoconstriction to prevent excessive
tional preferences for fine scissors or retractors. The blood loss. Several liters can be mixed and used. Care
use of plastic or metallic corneal shields is advised to is taken not to use more than 7 mg/kg of 1% lidocaine
prevent corneal abrasions during lid tissue dissection or 500 mg of 1% lidocaine, as that dose is considered
and excision. potentially toxic.
The fluid can be injected manually or by an infusion
pump machine. The instilled fluid creates tumescence
SURFACE AND SUBSURFACE (referred to as “wet technique”) to fluff up the adipose
PROCEDURES for removal. The amount of adipose tissue mixed with
The outer and inner layers of skin are subject to modi- tumescence removed will be double the amount of
fication during plastic surgery procedures. Some modi- instilled fluid. Debulking the subsurface adipose tissue
fications are aesthetic, and others are restorative. Loss with sharp cannulae causes the surface to have a more
of external body covering can be serious and requires regular configuration. Liposuction cannulae are dispos-
prompt restoration to prevent permanent disfigure- able and are available from several vendors. Adipose
ment or death. Excess subsurface tissue can cause exter- removal can be performed with vacuum suction alone
nal deformity and is commonly removed by debulking or by ultrasonic-assisted technology. Results are depen-
by liposuction. dent on the elasticity of the skin and its resiliency for
remodeling.
Tiny 1-cm skin incisions are made with #11 or #15
Debridement and Excisional Procedures blades using a #7 scalpel from the basic plastic surgery
Surface debridement involves trimming devitalized or set. Retractors and clamps are not used. Most areas of
diseased tissue with curettes or other sharp dissector. the body are subject to liposuction. The instrumenta-
Special instruments are not commonly used for this tion ranges from heavy- to delicate-caliber suction tips.
procedure. The basic plastic surgery set or the soft The tiny incisions are sutured using Webster needle
tissue foundation set can be used for smaller areas of holders and 3/0 or 4/0 nylon or other monofilament,
debridement or excision. nonabsorbable sutures. The use of absorbable sutures
is not advised because the wounds tend to seep fluid used for the mastectomy to prevent potential seeding
for several days, hastening the absorption or hydroliza- of cancer cells.
tion of the suture. Tensile strength is then lost. Braided The instruments for reconstruction are used to
suture can support infection in the interstices of its dissect a tissue pocket for an implant or create a pat-
structure and should be avoided. tern for reconstruction after reduction mammoplasty.
Many patients will have simultaneous surgery on the
opposite breast for symmetry. Insurance usually covers
Breast Augmentation-Reduction
bilateral procedures for breast symmetry. Measurement
Procedures and positioning of areolar sections require both breasts
Breast procedures are performed to restore, increase, or to be exposed to provide equal sizing and placement.
decrease the size of the breasts. Most of the procedure
involves soft tissue incision and dissection. Plastic sur-
geons are concerned with the breast’s form and exter-
nal appearance, so they utilize delicate tissue handling SUMMARY
with fine instrumentation. Most surgeons will use the Plastic surgery is essentially a process of soft tissue
basic plastic surgery set as the foundation for breast modification for the purpose of improving form
procedures. and function. Compact tissue modification, not
If a mastectomy is performed immediately before described here, can sometimes be part of a plastic
reconstruction, additional soft tissue instrumentation surgery procedure, especially in head and neck
with heavier hemostatic clamps will be needed. The procedures, and will be discussed in subsequent
reconstruction should be performed with a separate chapters.
sterile field and instrumentation than the instruments
CHAPTER 7
GENERAL SURGERY
INSTRUMENTATION

General Surgery Major After reading this chapter the learner should be able to:
Laparotomy Tray 1. Describe the anatomic boundaries of the organs of the abdomen.
Major Laparotomy Tray 2. Select instrumentation of the appropriate length for the size of the patient.
Gastrointestinal Instrumentation 3. Discuss the differences between instruments used in the upper abdomen and the
for Open Procedures lower abdomen.
Cholecystectomy Add-Ons
Liver and Stomach Add-Ons
Lower Gastrointestinal
Instrumentation for Open INTRODUCTION
Procedures General surgery involves procedures of the soft tissues of organs and
Bowel Resection Add-Ons organ systems. Surgical procedures involving tissues on the surface of
Rectal-Anal Instruments the body require the use of depth-appropriate instruments. For example,
Hemorrhoidectomy and Rectal mastectomy (removal of a breast and adjacent components) can differ
Excision between patients based on breast size. Consideration for the volume of
tissue is key. Most surface, or external, procedures can be performed
using a minor procedure set. The major laparotomy set would be used
in major abdominal surgical interventions and procedures.
However, patients with large areas of bulky tissue may require the
addition of individual long dissection and grasping instruments for
areas such as the axilla. The building blocks for surgical case prepara-
tion in general surgery are the minor procedure tray and the major
laparotomy tray.
GENERAL SURGERY MAJOR LAPAROTOMY TRAY

The major laparotomy tray will be used as a building block within the
sterile field. The instrumentation within the tray (Table 7-1) is augmented
with specialty procedural add-on instrumentation for specific procedures
as needed.
166
CHAPTER 7 General Surgery Instrumentation 167
TABLE 7-1 Major laparotomy tray count sheet

Poole suction tip 1 ea. Deaver retractor 20 1 ea.
60, 80, and 100 DeBakey 2 ea. Richardson retractor, 2 ea.
forceps small
#3, #4, #7 knife handle 1 ea. Richardson retractor, 1 ea.
large
Mayo scissors straight 1 ea.
Kelly retractor, 2½0 1 ea.
Mayo scissors curved 1 ea.
Gelpi retractor 1 ea.
70 and 90 Metzenbaum 1 ea.
scissors Beckman-Weitlaner 1 ea.
Ferris-Smith forceps 2 ea. Balfour retractor and blades 1 ea.
Adson tissue forceps with 2 ea. Harrington retractor 3 ea.
teeth
Allis tissue forceps 60 4 ea.
Brown-Adson tissue forceps 2 ea.
Allis tissue forceps 100 4 ea.
Russian tissue forceps 2 ea.
Babcock tissue forceps 6¼0 2 ea.
Cushing thumb tissue forceps 2 ea.
Babcock tissue forceps 9¼0 2 ea.
© 2019 Cengage®.
Halsted mosquito forceps 6 ea.
curved Pennington clamp 2 ea.
Crile hemostats 5½0 straight 6 ea. Schnidt tonsil forceps 7½0 4 ea.
Crile hemostats 5½0 curved 6 ea.

Rochester-Pean forceps 80 6 ea.
Kocher clamp 6¼0 4 ea.
Mixter forceps 7¼0 curved 2 ea.
Backhaus towel clamp 4 ea.
Foerster sponge forceps 2 ea.
Mayo-Hegar needle 2 ea.
holder 60
holder 80
holder 10½0
Green retractor 2 ea.
Goelet retractor 2 ea.
U.S. Army retractor 2 ea.
Ribbon retractor ¾0 1 ea.
Ribbon retractor 1¼0 1 ea.
Deaver retractor 10 1 ea.
MAJOR LAPAROTOMY TRAY
Adson forceps
Size: 4.750
FIGURE 7-1
Characteristics: Delicate tip with wide thumb
grasp area; straight or curved tip forceps. Can
be smooth, serrated, or 1 3 2 toothed tip
Notes: Several types with and without teeth used
for tissue approximation; extra-fine teeth are
available Courtesy of Scanlan International.
Scalpel #3
Size: #3
FIGURE 7-2
Notes: Blade assembly fits size 10 series © 2019 Cengage®.
disposable blades (10-11-12-15)
Scalpel #4
Size: #4
FIGURE 7-3
Notes: Blade assembly fits size 20 series
disposable blades (20-21-22-23-25) © 2019 Cengage®.
Scalpel #7
Size: #7
FIGURE 7-4
Characteristics: Nickel-plated, ridged grip for

thumb and forefinger; shank is thin for fine
incision management
Notes: Blade assembly fits size 10 series
disposable blades (10-12-15) © 2019 Cengage®.
continues
MAJOR LAPAROTOMY TRAY continued

Size: 6.00 ; 7.750; 8.00; 9.00
FIGURE 7-5
longitudinal fine teeth and matching grooves
Uses: Used for most vascular and general surgery procedures
Notes: Atraumatic forceps; the favorite tool of many surgeons; the straight tips narrow toward the distal end and
interdigitate
Ferris Smith tissue

forceps
Size: 7.00
Characteristics: Heavyweight
forceps with wide platform
handles with cross-hatched
FIGURE 7-6
grooves for a firm grip; the
teeth are 1 3 2 or 2 3 3
over serrated tips
Uses: Used for firm or fibrous
tissue
colorectal surgery for grasping
the perineal fascia during
abdominal perineal resection
Brown-Adson forceps
Size: 4.750
Characteristics: Delicate,
longitudinally toothed tips
with wide thumb grasp area
FIGURE 7-7
Notes: Several types with and
without teeth used for tissue
approximation; commonly
used in plastic surgery.
Brown Adson forceps are
available in straight and
angled styles
continues
Cushing forceps
Size: 7.00; 7.250
FIGURE 7-8
Characteristics: Lightweight to intermediate-
weight instrument with fine 1 3 2 teeth at the tip
Uses: Used on very delicate tissue
Notes: Frequently used during dissection;
Cushing forceps have several styles. Some have
gutch insets, scraper ends, or bayonet handles Courtesy of Scanlan International.
Delicate Adson tissue forceps

Size: 4.750
FIGURE 7-9
Characteristics: Delicate, serrated tip with wide
thumb grasp area; straight or curved tips with
1 3 2 teeth
Notes: Several types with and without teeth used
for tissue approximation; extra-fine teeth are available Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Russian tissue forceps

Size: 6.00; 8.00; 9.00; 10.00
weight to heavyweight forceps
with circular, fitted, groovelike
serrations at the tips
FIGURE 7-10
Uses: Atraumatic grip for fine to
moderately thick tissue
Notes: Sometimes referred to
as Mayo Russians
continues
Mayo dissecting
scissors
Size: 6.250
operating scissors can have
blunt-blunt, sharp-sharp,
or sharp-blunt tips; can be
straight or curved
FIGURE 7-11
instrument sets in both curved
Metzenbaum scissors
FIGURE 7-12
Size: 5.50; 7.00; 8.00; 9.00; 11.00; 14.50
Characteristics: Fine, lightweight scissors with
blunt-blunt tips; jaws are one-half the length of
the shanks; available in curved and straight styles
Uses: Dissection of fine tissue
Notes: Found in most instrument sets; the most commonly used style is curved Courtesy of Scanlan International.
Yankauer suction tube with

removable tip
FIGURE 7-13
Size: 11.750
Characteristics: Long angled tube with removable
screw tip; hand grip is ridged; stainless steel;
some are chrome plated
Uses: Suction fluids and substances; good for
oropharyngeal suctioning
Notes: Disposable models are preferred; reusable Yankauer tips have a screw tip that must be
removed for cleaning and processing; the screw tip is a counted item; sometimes known as
tonsil suction, Pynchon, or Andrews-Pynchon suction Courtesy of Sklar Instruments.
continues
Poole suction tube

Size: 10.00
FIGURE 7-14
Characteristics: Medium-length, stainless-
steel tube with screw-on perforated cover
to prevent suction lesions of viscera during
intraabdominal suctioning; cover is used to
perform deep suctioning during irrigation;
available in curved and straight styles
Uses: Primarily used in intracavitary suctioning

Size: 5.00
Characteristics: Straight or curved with short jaw; serrated
FIGURE 7-15
full length of jaw
Crile clamp
Size: 5.500; 6.250
FIGURE 7-16
Characteristics: Horizontal serrations full length of jaw;
curved or straight; jaw is one-half length of shank
Notes: Also called clamp, tag, snap, or hemostat; available
in delicate weight for pediatrics

Size: 5.500; 6.250; 7.250; 8.00; 9.00; 10.250; 12.00
FIGURE 7-17
jaw; curved or straight; heavy-style instrument;

jaw is proportionate to shanks
hemostasis
Notes: Do not confuse this with a basic Pean as
noted earlier; serrations are different; shorter styles sometimes referred to as
hemostat or Kelly; longer styles sometimes referred to as a long or extra-long Kelly Courtesy of Sklar Instruments.
continues
Kocher Forceps
Size: 5.50
style-instrument; jaw is
proportionate to shanks; 1 3 2
tooth at tip
FIGURE 7-18
pedicle; good for holding fascia
Notes: Name is sometimes used
interchangeably with Oschner,
although it is a heavier instrument;
the teeth/tooth at the tip of the
jaw help to enclose the tissue
within the confines of the jaws
© 2019 Cengage®.
Mixter clamp
Size: 11.00
Characteristics: Right angle
FIGURE 7-19
© 2019 Cengage®.
continues
Lorna towel clamp

Size: 3.50; 5.250
Characteristics: Penetrates
the drape and locks with
ratchets
Notes: The short style is usually
found on plastic trays, head
FIGURE 7-20
and neck sets, or peripheral
vascular sets for securing
circumferential towels; this
is the most common type
of perforating towel clamp;
sometimes used to grasp fibrous
tissue during excision of large
breast masses
Foerster sponge
forceps
Size: 7.00; 9.50
handles with open, oval,
serrated, or smooth grasping
edges; shanks are straight or
mildly curved at the box
locks; intermediate weight
Uses: Used for grasping and FIGURE 7-21
edges of the uterus for
hemostasis
Notes: Firmly grasps structures with
moderate traction; commonly
used for sponge forceps and
prepping; also known as ring
forceps; curved forceps are
commonly used in amniotic
and placental removal from
the endometrial cavity during
childbirth © 2019 Cengage®.
continues
Mayo-Hegar needle
holder
Size: 5.00; 6.00; 7.00; 8.00; 10.50
FIGURE 7-22
weight to heavyweight suture
Green retractor
FIGURE 7-23
Size: 8.50
Characteristics: Intermediate weight; open, narrow,
right-angled blade; open handle
Uses: Commonly used in neck or intermediate-tissue-depth procedures
U.S. Army retractors

Size: 8.50
FIGURE 7-24
Characteristics: Double-ended for exposure
of surface layers if adipose layer is thick; also
known as Army-Navy retractor

Size: 13.00; width 3/40 to 2.00
FIGURE 7-25
Characteristics: Flat piece of chromium-plated

copper that is easily shaped to the desired
retraction form
Uses: Used to secure and protect viscera during
abdominal procedures
Notes: Size denotes width of blade Courtesy of Sklar Instruments.
continues
Deaver retractor
Size: 12.00; sizes 1.00; 1.50; 2.00; 3.00; 4.00
Characteristics: Flat, semi-firm, large, curved
FIGURE 7-26
blade with “S” curve at hand grip for traction;
size is denoted for width of blade; slightly flexible;
hollow grip handle available
Notes: Pediatric Deaver blade is measured in increments of 1/80 up
to 7/80; when used to retract an organ, a moist laparotomy sponge
should be placed between the retractor blade and the structure;
available in flat or hollow grip handle Courtesy of Sklar Instruments.
Size: 9.50
Characteristics: Right-angle retractor; blade
FIGURE 7-27
width can vary; handle can be open loop
style (A.) or hollow closed (B.); both have
finger ridges for a secure grip
Notes: Single-ended; similar to Kelly retractor, but has a shorter blade;
common blade size 2.00 3 3/40 is used frequently for open
appendectomy (appendicele)
Kelly retractor
Size: 9.500; 9.750; 10.00
FIGURE 7-28
Characteristics: Right-angle retractor; blade
length can vary; handle can be open loop style
(shown) or hollow closed; both have finger
ridges for a secure grip
Notes: Single-ended; similar to Richardson retractor,
but has a longer blade Courtesy of Sklar Instruments.
Gelpi retractor
Size: 6.750
Characteristics: Double sharp prongs with ratchet lock;
arms are slightly
curved; with or without ball stops
FIGURE 7-29
Uses: Used for hernias and other soft tissue incisions

Notes: Commonly found in general and orthopedic surgery
Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 continues
Beckman retractor
Size: 12.50
FIGURE 7-30
Characteristics: Double-armed blades with ratchet lock;
tips are mounted on hinged arms and have sharp 4 3 4
rake prongs
Uses: Used for small deep incisions
© 2019 Cengage®.
Balfour retractor
Size: 7.00; 10.00
Characteristics: Adjustable, lateral, side-wall solid or open
retractor blades that
traverse a stainless-steel bar into a locking position; a
curved Mayo-style bladder
blade attaches with a wing nut; incision and body wall
FIGURE 7-31
are supported on three sides
Uses: Used for abdominal incisions
Notes: Bladder blade can be used alone as a retractor
during cesarean sections; observe for wing nut during
the counting procedure; this retractor disassembles for
cleaning
and processing
Size: 9.00; 12.00
FIGURE 7-32
Characteristics: Flat, large, curved blade
with hollow hand grip for traction; size is
denoted for width of blade; slightly flexible;
heart-shaped viscera protector at the tip to
prevent perforation
Uses: Used to retract the liver
Notes: Commonly called “sweetheart” or “valentine” retractor Courtesy of Sklar Instruments.
continues
Allis forceps
Size: 5.50
Characteristics: Used to hold
edges of tissue
FIGURE 7-33
Babcock tissue
forceps
Size: 6.250; 8.250; 9.50
Characteristics: Ring-
handled forceps with a
circumferential jaw that has
longitudinal serrations across
the edge of the tip of the
jaw; intermediate weight to FIGURE 7-34
lightweight; atraumatic
Uses: Used to hold delicate
tissues and tubular structures
Notes: Has a soft touch and feels
mildly malleable
continues
Pennington hemostatic
forceps
Size: 6.00; 8.00
handles with open, triangular,
serrated grasping edges;
shanks and jaws are straight
FIGURE 7-35
stabilizing large cut edges
of tissue intended for
approximation
cesarean section to grasp
the incised edges of the uterus;
provides hemostasis of the
uterine vessels embedded in
the myometrium; used by body
piercing personnel to stabilize
cutaneous tissue for perforation Courtesy of Sklar Instruments.
Metal Ruler
FIGURE 7-36
Size: 6.00
Characteristics: Stainless steel graduated in mm
Schnidt hemostatic
forceps, closed rings
Size: 7.500
jaw; the jaw is one-fourth the
FIGURE 7-37
Uses: Commonly used for
tonsils; used for passing
suture around or under tissue
clamp
GASTROINTESTINAL use of the medium and long foundation sets described

in Chapter 5. Superficial and preperitoneal procedures
INSTRUMENTATION FOR on an adult, such as herniorrhaphy, utilize the medium
OPEN PROCEDURES foundation set unless the patient is extremely obese.
Organs in the gastrointestinal system are commonly Organs in the lower gastrointestinal region include
divided into upper and lower sections according to the the small bowel, large bowel, appendix, mesentery,
depth of the organs, tissue type, blood supply, innerva- omentum, rectum, and anus. Most of the lower
tion, and disease state. Organs in the upper aspect of gastrointestinal organ depth ranges from intraperitoneal
the gastrointestinal and digestive region include the to below the pelvic rim. Preparations for procedures
esophagus, stomach, liver, gallbladder, pancreas, spleen, in the lower gastrointestinal area require the use of
and inferior diaphragm. Preparation for procedures in medium, long, and possibly the extra-long foundation
the upper gastrointestinal compartment requires the sets described in Chapter 5.
Cholecystectomy Add-Ons
CHOLECYSTECTOMY ADD-ONS
Lovelace gallbladder
forceps
Size: 7.25″
forceps with angled shaft
and open, cross-serrated,
1.00 triangular tips; locks with
ratchets
FIGURE 7-38
© 2019 Cengage®.
Collin (Judd-DeMartel) gallbladder forceps

Size: 6.00
FIGURE 7-39
Characteristics: Straight; ring-handled, wide, oval,

open-tipped forceps; locks with ratchets
continues
CHOLECYSTECTOMY ADD-ONS continued
Desjardin (Rochester) g allstone

forceps
FIGURE 7-40
Size: 9.00
Characteristics: Long, oval-tipped forceps;
ring handles; no ratchets; slightly curved shanks
Mixter gallstone forceps

Size: 9.00
FIGURE 7-41
Characteristics: 45-degree angle jaws with oval tips;
ring handles
Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Mayo common bile duct probe
FIGURE 7-42
Size: 10.00
Notes: Available in 15 fr and 18 fr;
Flexible with ball tip; Serrated flange finger grip Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Mayo gallstone scoop
FIGURE 7-43
Size: 11.00
Characteristics: Double-ended rod with
scoop on each end for stone retrieval Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Desjardin gallstone scoop
FIGURE 7-44
Size: 11.00; 17 Fr. to 27 Fr.
Characteristics: Single-ended, reverse-direction stone scoop
with bullet-shaped tip; malleable Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Ferguson gallstone scoop

FIGURE 7-45
Size: 9.50
Characteristics: Double-ended,
spoon-style stone scoop
continues
CHOLECYSTECTOMY ADD-ONS continued
Mayo common duct scoop
FIGURE 7-46
Size: 10.50
Characteristics: Oval scoop tip
with serrated fingertip grip; silver plated; malleable
Oschner trocar
(modified Philadelphia
FIGURE 7-47
style)
Size: 12 Fr. to 28 Fr.
Characteristics: Used to drain
bile from gallbladder using
negative pressure or suction; connector port on the side can be used to
pass cholangiogram catheter or attach suction tubing Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Randall Kidney stone forceps

Size: 7.500; 7.750; 8.250; 9.250
FIGURE 7-48
Characteristics: Ring-handled, intermediate-weight forceps
with angled tip; available in full curve, three-quarter curve,
half curve, or one-quarter curve; sometimes used for
common duct exploration
© 2019 Cengage®.
Liver and Stomach Add-Ons list is a collection of instrumentation primarily used

These instruments can be wrapped individually or in the adult population. Pediatric application will be
collectively as preferential specialty sets. Each facility designated as appropriate. Instrumentation in this list is
will have various procedures and procedural modifica- not all-inclusive and can be modified as needed.
tions that require the use of individual instruments. Right-angled clamps from the cholecystectomy may
Pediatric facilities, for example, will use smaller or be added to this collection for controlled dissection of
lighter versions of similar instruments. Patient indi- nerves and fine vessels. Splenectomy and pancreatic
viduality will indicate instrumentation based on body procedures use a combination of cholecystectomy and
habitus, disease states, and anomalies. The following liver/stomach add-ons.
LIVER AND STOMACH ADD-ONS
Bookwalter table-mounted r etractor
FIGURE 7-49
Characteristics: Table mounted, self-retaining retractors provide
adequate exposure; extra-large bed–mounted retractor with a
variety of retractor blades available
Wishbone retractor
Characteristics: Upright single supporting post with split two-piece wishbone
frame from which retractor blades are secured
FIGURE 7-50
Notes: Multiple retractor blades available, including Deaver, fence blades, hoes,
Kelly, malleable, Mayo blades, and Richardson
© Cengage®.
Esophageal dilator
FIGURE 7-51
Characteristics: Flexible tube with tapered tip
used to dilate esophageal strictures or stent
esophagus during surgical procedures on the
fundus of the stomach
Courtesy of Cook Surgical, Bloomington, Indiana.
Benson pylorus dilator
FIGURE 7-52
Size: 5.750
Characteristics: Ring handle with right-angle blunt tips; separation of the ring
handles spreads the tips
Mayo-Robson forceps
FIGURE 7-53
Size: 10.00
Characteristics: Available in curved and straight designs; long,
wide jaws with longitudinal serrations; intermediate weight;
blunt tips; useful for grasping large segments of friable tissue
continues
LIVER AND STOMACH ADD-ONS continued
Scudder intestinal clamp
FIGURE 7-54
Size: 9.50
Characteristics: Straight, wide, smooth jaws with blunt tips;
no serrations
Mayo-Noble dissecting scissors
FIGURE 7-55
Size: 6.50
Characteristics: Heavier than basic Mayo-style scissors; one
curved; one straight
Doyen abdominal
scissors
Size: 7.00
Characteristics: Heavier than
basic Mayo-style scissors;
FIGURE 7-56
available in curved and straight
LOWER GASTROINTESTINAL feature the ability to reload and reuse the device for
the same patient several times before disposal. Other
INSTRUMENTATION FOR facilities use a disposable instrument for each use.
OPEN PROCEDURES Regardless of which style of stapler is planned for
use, the device is never opened and dispensed or
Bowel Resection Add-Ons flipped to the sterile field. The impact of hitting the
Lower bowel procedures involve traumatic or atrau- metal table causes the staples to misalign and possi-
matic occlusion of bowel segments. Selection of bly can cause a misfire that would be harmful to the
instruments includes consideration for adequate patient. The sterile package should be opened and its
numbers of crushing and noncrushing clamps. contents handed directly to the scrub person using
Intestinal anastomosis is performed with specially sterile technique.
designed staplers. Some facilities use staplers that
Instrumentation specific to bowel surgery can be through the abdomen and perineum simultaneously.
added directly to the setup with medium and long Contamination of the sterile abdominal table can occur
foundation sets. Some procedures will require a s econd when the same instruments are used for the rectal part
sterile table when the approach requires entrance of the procedure.
BOWEL RESECTION ADD-ONS
Doyen clamp
FIGURE 7-57
Size: 9.00
Uses: Atraumatic grasping
Notes: Light weight non-crushing clamp with slightly flexible
feel
Allen clamp
Size: 8.00
weight; jaw is straight with
longitudinal serrations 1 3 2
teeth at the tip
FIGURE 7-58
fine tissue pedicle
Notes: Resembles a 1 3 2
toothed Kocher clamp, but
lighter weight
Dennis clamp
Size: 9.00
FIGURE 7-59
Characteristics: Longitudinal serrations
continues
BOWEL RESECTION ADD-ONS continued
Mayo-Robson forceps
Size: 10.00
FIGURE 7-60
Characteristics: Available in curved and straight
designs; long, wide jaws with longitudinal serrations;
intermediate weight; blunt tips; useful for grasping
large segments of friable tissue
Foss anterior resection clamp

Size: 11.50
FIGURE 7-61
Characteristics: S-shaped curve with smooth jaws one-third the length of
the shanks; ratchets
Foss intestinal clamp

Size: 11.750
FIGURE 7-62
Quantity: 2
Characteristics: Right-angle clamp with reverse-angle ring handles;
longitudinal serrations; ratchets
Brunner intestinal clamp

Size: 9.50
FIGURE 7-63
Characteristics: Bayonet shape with longitudinal
serrations; ratchets
Fehland intestinal clamp

Size: 9.750
FIGURE 7-64
Characteristics: Right-angle jaws measuring 3.50; ring handles

and ratchets; partial longitudinal serrations
continues
Payr clamp
FIGURE 7-65
Size: 6.00; 8.00; 11.00; 13.750
Characteristics: Cushing bowel clamp used during
resection; long dolphin-shaped jaw with blunt tip;
locks by double-action hinges
Bainbridge forceps
Size: 6.00; 7.250
FIGURE 7-66
Characteristics: Ring handle with ratchets; longitudinal serrations
with cross-serrations at the tip; straight or curved
Instruments provided by www.sontecinstruments.com.
Ferguson scissors
FIGURE 7-67
Size: 7.00
Characteristics: Angled or flat
Busch scissors
Size: 6.50
FIGURE 7-68
Characteristics: Curved on side
Dubois scissors
Size: 10.50
FIGURE 7-69
Characteristics: Heavy weight with blunt-blunt tips for

deep dissection of the lower colon in the pelvis
continues
Terminal end stapler (TA)

Size: 30 mm; 45 mm; 55 mm; 90 mm
Characteristics: Right-angle stapler with pistol-style hand grip;
FIGURE 7-70
cartridges with needed size of staples are opened and used
with the reusable applicator; three sizes; disposable styles
of preloaded applicators are available; also called terminal
anastomosis (TA)
Uses: To close the terminal angle of a tube with a linear double
row of titanium staples
© 2019 Cengage®.
End-to-end anastomosis stapler

(EEA) or intraluminal stapler
(ILS)
FIGURE 7-71
Size: 21 mm to 34 mm diameter
Characteristics: Long, cylindrical, circular
stapler used for end-to-end anastomosis
of a tube; a circular knife trims the anastomotic rim when the
wing-shaped hand grips are depressed; the excised tissue
should be intact circles when removed from the instrument;
curved or straight; multifire instrument can be loaded with
25-mm, 28-mm, or 31-mm circular stapling head with a built-in knife © 2019 Cengage®.
Gastrointestinal
anastomosis stapler
(GIA)
Size: 50 mm; 60 mm; 90 mm
Characteristics: Two-piece
linear stapler that is used
FIGURE 7-72
to staple a transected tube
in a side-to-side fashion;
reusable instrument can be
reloaded with cartridges; has
a two-step function; GIA has
a central knife that is used to
open the tubes after stapling
© 2019 Cengage®.
RECTAL-ANAL INSTRUMENTS
Hemorrhoidectomy and Rectal Excision patient’s midsection elevated on a bolster or positioning
Procedures of the rectum and anus are commonly per- device. Some rectal procedures on female patients are
formed with the patient in the prone position and the performed in the lithotomy position.
HEMORRHOIDECTOMY AND RECTAL EXCISION
Buie pile clamp

Size: 8.50
FIGURE 7-73
Characteristics: Jaw is one-fourth the length of the shanks
with a curved, interlocking, angiotribe surface
Courtesy of Jarit Surgical Instruments, a division of Integra LifeSciences Corporation.
Fergusen angiotribe clamp
FIGURE 7-74
Size: 6.50; 7.50
Characteristics: Jaw is one-fourth the length of the shanks with a curved
interlocking surface; curved or straight
McGivney hemorrhoid grasping forceps
FIGURE 7-75
Size: 7.250
Characteristics: Tips resemble Allis forceps; angled shanks with ring handles
and locking ratchets; used to grasp hemorrhoidal tissue through barrel of
band applicator; use with McGivney hemorrhoid grasping forceps
McGivney hemorrhoid ligator

FIGURE 7-76
Size: 7.00
Characteristics: Pistol grip with spring tension; complete
compression of hand grip discharges latex band around target
tissue
continues
HEMORRHOIDECTOMY AND RECTAL EXCISION continued
Sims scissors
A.
Size: 8.00
Characteristics: Long blades with sharp-sharp
tips; used for deep dissection; intermediate
FIGURE 7-77
weight
A. Straight
B. Curved
B.
Miller rectal scissors
FIGURE 7-78
Size: 6.750
Characteristics: Bayonet scissors with serrated
blades used to dissect the anal ridge; blunt-
blunt tips
Kelly fistula scissors
FIGURE 7-79
Size: 6.250
Characteristics: Intermediate-weight scissors with sharp-
sharp tips; available with one serrated blade
Locklin scissors
FIGURE 7-80
Size: 6.250
Characteristics: Intermediate weight with curved shanks and
sharp-sharp tips angled at 25 degrees
LaGrange scissors
FIGURE 7-81
Size: 4.250
Characteristics: Curved with angled shanks and one serrated blade
continues
Quimby scissors
Size: 5.00
FIGURE 7-82
Characteristics: Deeply curved blades; available with one
serrated blade
Goldman-Fox scissors
FIGURE 7-83
Size: 5.00
Characteristics: Curved shanks with sharp-sharp, wedge-shaped tips; one
serrated blade; used for wound debridement
Yeoman biopsy forceps
FIGURE 7-84
Size: 100; 140; 160
Characteristics: Ring handle or pistol grip handle style; straight jaws
with basket; rotating shaft
© Cengage®.
FIGURE 7-85
Pratt rectal probe
Size: 7.750
Characteristics: Blunt silver probe Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
FIGURE 7-86
Buie fistula probe
Size: 5.50
Characteristics: Blunt silver probe with serrated finger flange Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
FIGURE 7-87
Rosser crypt hook
Size: 6.750
Characteristics: Curved stainless-steel hook with blunt tip Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Buie suction tip

FIGURE 7-88
Size: 16.00
Characteristics: Long, angled suction tube with finger hole vacuum control; used with
rigid proctoscopes and sigmoidoscopes Courtesy of Sklar Instruments.
continues
FIGURE 7-89
Hill-Ferguson manual retractor
Size: 8.50
Characteristics: Scoop-shaped blade in right angle measuring 2.2 cm 3 6.4 cm Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Sawyer retractor
FIGURE 7-90
Size: 11.00
Characteristics: Scoop-shaped blade measuring
7/80 3 2.50 in moderate right angle; available in three size blades Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Fansler-Ives anoscope
FIGURE 7-91
Size: 3.250
Characteristics: Circumferential speculum with central plastic obturator; 1.250 outer
diameter
Hirschman anoscope
FIGURE 7-92
Size: 2.250; 2.800; 3.50
Characteristics: Circumferential speculum with central metallic obturator; available in
three sizes
Hirschman proctoscope
Size: 5.50
FIGURE 7-93
Characteristics: Circumferential speculum with narrow 7/80 lumen for examination
of the rectum; metallic obturator
Rigid sigmoidoscope
Size: 25 cm
FIGURE 7-94
Characteristics: Circumferential
speculum with 15-mm lumen; used for
examination to the level of the sigmoid
colon; metallic obturator
continues
Chelsea-Eaton anal speculum

Size: 2.750
FIGURE 7-95
Characteristics: Single-blade retractor with solid metallic obturator
Barr anal self-retaining retractor
FIGURE 7-96
Size: 8.00; opens to 2.750 3 7/80
Characteristics: Ring handled with bilateral scooped blades that retract with
locking ratchets
Gosset self-retaining retractor
FIGURE 7-97
Size: Opens to 3.50; 4.00; 5.00
Characteristics: Available in three sizes; smallest is used in pediatrics; two open side
blades that extend laterally for exposure
Pratt rectal speculum
FIGURE 7-98
Size: 8.00
Characteristics: Blades measure 3.50 3 1.00 locks open with a set screw
© 2019 Cengage®.
Sims rectal speculum

Size: 6.00 FIGURE 7-99
Characteristics: Fenestrated blades measure 3.50 3 5/80; locks open with
a set screw; long and narrow
© 2019 Cengage®.
Bodenhammer rectal speculum

FIGURE 7-100
Size: 6.00
Characteristics: Solid blades measure 3.50 3 0.750; useful for small or
stenosed orifices
continues
Mayo-Adams self-retaining r etractor
FIGURE 7-101
Size: Opens to 6.750
Characteristics: Lateral open blades with posterior
distracting blade held by a wing nut; ring handles with
locking ratchets
Smith (Buie) anal retractor
FIGURE 7-102
Size: Opens to 4.00
Characteristics: In two sizes: 2.50 or 4.00 blades; opens
on sliding bar without ratchets; blades swivel to permit
displacement of securing slide bar
SUMMARY
Procedures on the gastrointestinal system will com- Most of the clamps and graspers are common to
monly require the use of both medium and long foun- many services, but they are the most important
dation sets in addition to specialty instrumentation. instruments associated with general surgery.
CHAPTER 8
GYNECOLOGIC
INSTRUMENTATION

After reading this chapter the learner should be able to: Basic Gynecologic
1. Select instrumentation for open pelvic procedures on the female patient. Instrumentation
2. Select instrumentation for vaginal procedures. Clamps
3. Select instrumentation for cesarean birth. Grasping Forceps
Specialty Graspers
Obstetric Forceps
Dissection
Debulking
Evacuation and Instillation
Gynecologic procedures can be performed by an abdominal incision,
Probes and Dilators
vaginal incision, laparoscopic procedure, or other endoscopic method
Closure
through the cervix. This chapter will explore instrumentation for
Basic Gynecologic Procedures
abdominal and vaginal procedures. Laparoscopic instrumentation is
Abdominal Hysterectomy
discussed in Chapter 15.
Vaginal Hysterectomy
Vaginal-Perineal Procedures
Dilation and Curettage
Cesarean Section
195
BASIC GYNECOLOGIC INSTRUMENTATION
CLAMPS
Crile clamp
Size: 5.500; 6.250
curved or straight; jaw is
one-half length of shank
Notes: Clamp, tag, snap, and
hemostat
FIGURE 8-1

Size: 5.500; 6.250; 7.250; 8.00; 9.00; 10.250; 12.00
FIGURE 8-2
jaw; curved or straight; heavy-style instrument; jaw
is proportionate to shanks
Notes: Do not confuse this with a basic Pean as
noted earlier; serrations are different; shorter styles
are sometimes referred to as hemostat or Kelly;
longer styles are sometimes referred to as a long or
extra-long Kelly Courtesy of Sklar Instruments.
continues
CHAPTER 8 Gynecologic Instrumentation 197
CLAMPS continued
Schnidt clamp
Size: 7.50
jaw; the jaw is one-fourth the
FIGURE 8-3
Similar to Adson tonsil clamp
Notes: Referred to as
tonsil clamp
Adson clamp
Size: 7.250
jaw; the jaw is one-quarter
the length of the shanks;
curved or straight
FIGURE 8-4
Notes: Very useful as a passer
for suture around a pedicle
continues
CLAMPS continued
Moynihan
clamp
Size: 7.00
weight with longitudinal
serrations along the full length
of the short, slightly right-
angled jaw
FIGURE 8-5
Notes: Commonly used
for circumferential blunt
dissection of tubular
structures; can be used for
passing suture around or through
meticulous vascular beds of
tissue such as mesentery. Similar
to Adson tonsil clamp
Wertheim pedicle
clamp
Size: 9.750
Characteristics: Heavy, right-
angle clamp with longitudinal
serrations the distal half of the
jaw to the angle of flexure; jaw
measures 2 inches
Notes: Grasp lower angle of
FIGURE 8-6
hysterectomy
continues
CLAMPS continued
Kocher clamp
Size: 5.500
style-instrument; jaw is
proportionate to shanks
FIGURE 8-7
1 3 2 tooth at tip. Firm grasp
of tissue; can be used for
hemostasis of a pedicle;
good for holding fascia.
Straight Kochers are good
for holding the cervix during
circumferential incision into the
hysterectomy
Notes: Name is sometimes
used interchangeably with
Oschner, although it is a heavier
instrument; the teeth/tooth at
the tip of the jaw help to enclose
the tissue within the confines of
the jaws
© 2019 Cengage®.
Phaneuf clamp
Size: 8.00
or angled clamp with
1 3 2 teeth at tip; horizontal
serrations
Notes: Used to grasp the
pedicles
FIGURE 8-8
continues
CLAMPS continued
Hysterectomy
clamp
Size: 7.250
clamp with longitudinal
serrations
Notes: Used only in gynecologic
surgery
FIGURE 8-9
Heaney clamp
Size: 8.250
Characteristics: Curved with
cross-serrations; one grasping
tooth is located 1.5 cm
from tip
surgery
FIGURE 8-10
continues
CLAMPS continued
Heaney
hysterectomy
clamp
Size: 8.250
Characteristics: Curved with
horizontal serrations; two
grasping teeth along jaw
FIGURE 8-11
surgery
Heaney-Ballentine
clamp
Size: 8.500
straight with short jaw and
longitudinal serrations. One
tooth 1.5 cm from tip
FIGURE 8-12
Notes: Used only in
gynecologic surgery
GRASPING FORCEPS
Dressing
forceps
Size: 50 to 120
FIGURE 8-13
tissue
to as thumb forceps
Tissue forceps
Size: 50 to 120
tips with teeth for traction.
Medium-weight tissue
FIGURE 8-14
forceps
Adson forceps
Characteristics: Delicate tip with wide thumb grasp area;
straight or curved tip forceps. Can be smooth, serrated,
or 1 3 2 toothed tip
approximation; extra-fine teeth are available Courtesy of Scanlan International.
continues
GRASPING FORCEPS continued
Singley
forceps
Size: 9.00
FIGURE 8-16
weight forceps with circular
fenestrated tips; the serrations
run horizontally across the
fenestration; the shanks
have a stop peg to prevent
overcompensated grasping of
tissue
as ring-tip pick-ups
Russian forceps
Size: 6.00; 8.00; 9.00; 10.00
weight to heavyweight
forceps with circular, fitted,
FIGURE 8-17
groovelike serrations at the
tips
as Mayo Russians. Common
on most gynecology sets
Kelly forceps
FIGURE 8-18
Size: 9.00
Characteristics: Intermediate-weight forceps with 1 3 2,
2 3 3, or 3 3 4 teeth
Notes: Frequently used in hernia or gynecologic procedures
for grasping fascial edges Courtesy of CareFusion, a division of Becton, Dickinson and Co.
continues
Bozeman forceps
Size: 11.00
FIGURE 8-19
Characteristics: Long, intermediate-weight
instrument with horizontal serrations the full
length of the slightly curved jaw
Notes: Used as a grasper. Not for hemostasis.
Can be used to remove an intrauterine device
(IUD) from the uterus. Used only in gynecologic
surgery Courtesy of Sklar Instruments.
Babcock forceps
Size: 6.250; 8.250; 9.50
forceps with circumferential
jaws with horizontal serrations
across the edge of the tip of
the jaw; intermediate weight
to lightweight; atraumatic.
Used to hold delicate tissues
FIGURE 8-20
and tubular structures like
fallopian tubes
Notes: Has a soft touch and
feels mildly malleable
continues
Pennington
clamp
Size: 6.250; 8.00
handles with open, triangular,
serrated grasping edges;
shanks and jaws are straight
FIGURE 8-21
cesarean section to grasp the
incised edges of the uterus;
provides hemostasis of the
uterine vessels embedded in
the myometrium; used by body
piercing personnel to stabilize
cutaneous tissue for perforation
Foerster sponge
forceps
Size: 7.00; 9.50
handles with open, oval,
serrated or smooth grasping
edges; shanks are straight
or mildly curved at the box
locks; intermediate weight.
Used for grasping and
FIGURE 8-22
edges of the uterus for
hemostasis. Folded radiopaque
sponges can be positioned in
the jaws to create sponge sticks
with moderate traction;
commonly used for sponge
forceps and prepping; also
known as ring forceps; curved
forceps are commonly used in
amniotic and placental removal
from the endometrial cavity
during childbirth. Also known as
sponge stick and ring forceps © 2019 Cengage®.
continues
Allis forceps
Size: 5.00; 5.50; 6.00; 7.250;
10.00
graspers with atraumatic
teeth 4 3 5 or 5 3 6 along
the edge of the tip of the
jaw; the jaw can be straight
or angled; intermediate
FIGURE 8-23
weight. Good for anterior and
posterior repair of vaginal
tissue
Notes: One of the most
commonly used instruments
in the surgical setup; longer
Allis forceps are used in
general surgery; angled
Allis forceps are used in
hemorrhoid ligation for
occlusion banding or for
rupturing the amniotic
membrane during childbirth Courtesy of Sklar Instruments.
Allis Adair forceps

Size: 6.50
graspers with atraumatic
teeth 9 3 10 along the edge
of the tip of the jaw; straight
Notes: Tip of jaw is very wide;
commonly used in place of
FIGURE 8-24
Pratt T clamp for grasping
edges under traction
continues
Pratt T clamp
Size: 6.00
Characteristics: Firm straight
clamp in one length that is
shaped like a T on the tip
Notes: Used to grasp vaginal
mucosa to be removed;
crushing and tissue
FIGURE 8-25
damaging
Braun single tooth tenaculum
FIGURE 8-26
Size: 9.750
Characteristics: Long grasping instrument with one
opposing set of sharp points
Notes: Used to grasp the uterine cervix; known as
single tooth
Jacob tenaculum
Size: 8.50
Characteristics: Available
straight and curved sideways;
serrated jaws; 2 3 2 teeth on
the tip
FIGURE 8-27
uterine cervix
continues
Schroeder
tenaculum
Size: 10.00
Characteristics: 2 3 2 sharp
teeth on the tips
uterus during procedures;
also known as Schroeder-
FIGURE 8-28
Braun; also called a double-
toothed tenaculum
Billroth tumor forceps

Size: 10.750
opposing tips that penetrate,
pierce, and hold tissue;
straight; intermediate to
inward. Locks with ratchets.
FIGURE 8-29
Used to grasp large fibroid
tumors
Notes: Strong perforating
clamp
continues
Collin Segund
tenaculum
Size: 10.750
opposing tips that penetrate,
pierce, and hold tissue;
straight; intermediate to
FIGURE 8-30
inward. Locks with ratchets.
Used to grasp large fibroid
tumors
Notes: Strong perforating clamp
Lahey traction forceps

Size: 6.250, 8.00
grasper with 3 3 3 sharp
teeth in opposing jaws;
intermediate weight with
locking ratchets. Shorter than
a Billroth tenaculum. Used to
grasp fibrous tissue
FIGURE 8-31
general surgery to grasp
fibrous breast or thyroid
tissue
SPECIALTY GRASPERS
Somer uterine elevator

Size: 90
FIGURE 8-32
Characteristics: Curved open jaws that cup the uterine
fundus; sometimes referred to as “lemon squeezer”
Notes: Noncrushing grasper with ratchets
Doyen tumor screw

Size: 29 mm
FIGURE 8-33
Characteristics: Corkscrew pattern tip with round
handle grip; used to grip myomas for traction during
excision
Notes: Sometimes referred to as myoma screw
Membrane forceps
Size: 100
Characteristics: Looks like a
curved Allis forceps
Notes: Used in obstetrics to
rupture the amniotic sack.
Sometimes referred to as
Iowa forceps
FIGURE 8-34
continues
SPECIALTY GRASPERS continued
Randall forceps
Size: 8.00
FIGURE 8-35
Characteristics: Ring-handled grasper with no ratchets. Open
ovoid fenestrations at the tips. Lightweight
Notes: Used in gynecologic procedures to grasp polyps from the
interior of the uterus. Can be used to remove an intrauterine
device (IUD) from the uterus. Sometimes called a polyp forceps
Hulka tenaculum with uterine e levator
FIGURE 8-36
Size: 9.50
Characteristics: Single- or double-tooth uterine tenaculum with
posterior elevating sound
Notes: Used for mobilizing the uterus during laparoscopic procedures
© 2019 Cengage®.
OBSTETRIC FORCEPS
Bill traction handle

Size: Universal
Characteristics: Cross T handle that attaches to obstetrical
FIGURE 8-37
delivery forceps
Notes: Used to securely hold obstetrical forceps while
applying traction to the fetal head
Elliott obstetrical forceps FIGURE 8-38
Size: 12.50
Characteristics: Open blades with hand grip
Notes: Used to grasp the fetal head for delivery;
interlocking pair
continues
OBSTETRIC FORCEPS continued
Keilland obstetrical forceps
FIGURE 8-39
Size: 15.50
Characteristics: Straight-angle forceps; handle is narrow
and smooth; open blades with smooth hand grip
Notes: Used to grasp the smaller fetal head for delivery;
interlocking pair Courtesy of Sklar Instruments.
Luikart obstetrical forceps
FIGURE 8-40
Size: 15.50
Characteristics: Straight-angle forceps; handle is narrow
and smooth; closed blades with smooth hand grip
Notes: Used to grasp the smaller fetal head for delivery;
interlocking pair Courtesy of Sklar Instruments.
Piper obstetrical forceps
FIGURE 8-41
Size: 17.50
Characteristics: Reverse-angle forceps; open blades
with smooth hand grip
Notes: Used to grasp the fetal head for delivery;
interlocking pair. Longer shaft Courtesy of Sklar Instruments.
Simpson obstetrical forceps
FIGURE 8-42
Size: 14.00
Characteristics: Open blades with smooth interlocking
handle
Notes: Used to grasp the fetal head for delivery
Simpson-Luikart obstetrical f orceps

FIGURE 8-43
Size: 14.00
Characteristics: Closed blades with interlocking handle
Notes: Used to grasp the fetal head for delivery
DISSECTION
Standard
operating
room scissors
Size: 4.50; 5.00; 5.50; 6.00; 6.50
scissors; sharp-blunt tips can
be straight or curved
FIGURE 8-44
Mayo scissors
Size: 6.250
curved
instrument sets in both
curved and straight styles;
FIGURE 8-45
curved are used on patient
tissue; straight are used to
cut suture
continues
DISSECTION continued
Mayo-Nobel
scissors
Size: 6.50
Characteristics: Heavy straight
scissors. Blunt-blunt tips
Notes: Same style as regular
FIGURE 8-46
Mayo scissors but heavier
Metzenbaum scissors
Size: 5.50; 7.00; 8.00; 9.00; 11.00; 14.50
FIGURE 8-47
Characteristics: Fine, lightweight scissors with blunt-blunt
tips; jaws are half the length of the shanks; available
in curved and straight styles. Dissection of fine tissue.
Good for dissection of the bladder flap
Notes: Found on most instrument sets; the most commonly used style is curved. Should not be used to cut suture
Harrington scissors
Size: 11.50
scissors with blunt-blunt
tips; jaws are one-fourth the
length of the shanks
FIGURE 8-48
Notes: Dissection of
intermediate to fine tissue
continues
DISSECTION continued
Jorgenson scissors
Size: 9.00
FIGURE 8-49
Characteristics: Sharp angle to jaw; blunt-blunt
tips
Notes: Some gynecologic surgeons use these
scissors for separating the uterine cervix from the
vaginal cuff
Lister bandage
scissors
Size: 5.50; 7.250
Characteristics: Angled blunt-
blunt scissors. Lower blade
has a protective wedge tip
to protect underlying tissue
FIGURE 8-50
when in use
Notes: Cuts heavy dressing
material and can be used
to remove circumferential
dressings without harming
the patient’s skin. Is some
times used to extend the lower
uterine segment incision during
cesarean section. Can be used
to cut the umbilical cord
Umbilical scissors
Size: Universal
Notes: Used only for cutting the umbilical cord.
Wide blades
FIGURE 8-51
DEBULKING
Sims uterine
curette
Size: Handle 11.00; tip size 00 to
01 to 6
FIGURE 8-52
oval, sharp debulking surface on
a long, malleable shank; sharp
on one side, blunt on the other
Notes: Used inside the uterus to
remove endometrial tissue
Banjo curette
FIGURE 8-53
Size: 14 mm
Characteristics: Extra-large, sharp uterine curette used for retained placental fragments. Important to have on hand for
difficult placental delivery or suspected placental accreta
Notes: Known also as Loundsbury curette Courtesy of Sklar Instruments.
Kevorkian endocervical curette
FIGURE 8-54
Size: Universal
Characteristics: Rectangular, small, sharp cutting tip
Notes: Used to obtain endocervical tissue in fractions without
mixing the specimen with endometrial material Courtesy of Sklar Instruments.
Thomas curette
Size: Handle 11.00; tip size
1 to 6
Characteristics: Hoop-
shaped, oval, blunt debulking
surface on a long, malleable
FIGURE 8-55
shank
Notes: Used inside the uterus
to remove endometrial tissue.
Blunt for use on friable
postpartum uterine tissues
continues
DEBULKING continued
Gaylor punch
Size: 9.00
Characteristics: Ring handle
with box lock joint; locking.
Tips have round cutting jaw;
curved shanks and tips.
Procurement of a sharply
FIGURE 8-56
Notes: Primarily used in
gynecologic procedures;
after procurement of tissue
sample, care is taken to
extract the specimen using a
small needle without damaging it

Tischler punch
Size: 9.750
Characteristics: Oval cutting surface with a cup-style
FIGURE 8-57
jaw; cup interdigitates with lower jaw for cleaner cut on
tougher tissue; ring-style handle; no ratchets; 6 3 3 3 1.5
mm specimen. Procurement of a sharply dissected tissue
specimen from the uterine cervix
Notes: Primarily used in gynecologic procedures; after
procurement of tissue sample, care is taken to extract the
specimen without damaging it Courtesy of CareFusion, a division of Becton, Dickinson and Co.
EVACUATION AND INSTILLATION INSTRUMENTS
Yankauer suction tube with

removable tip
FIGURE 8-58
Size: 120
Characteristics: Long, angled tube with removable screw
tip; hand grip is ridged; stainless steel; some are chrome
plated; useful during amniotomy
Notes: Disposable models are preferred; reusable Yankauer
tips have a screw tip that must be removed for cleaning and processing;
the screw tip is a counted item; sometimes known as tonsil suction Courtesy of Sklar Instruments.
continues
EVACUATION AND INSTILLATION INSTRUMENTS continued
Poole suction tube

Size: 120
FIGURE 8-59
Characteristics: Medium-length, stainless-steel
tube with screw-on perforated cover to prevent
suction lesions of viscera during intraabdominal
suctioning; cover guard is used to perform deep suctioning during irrigation. Disposable styles are preferred. Outside
diameter is 32 Fr. Primarily used in intracavitary suctioning. Good for amniotic fluid during amniotomy
Notes: Cover is removable for fine-tip suctioning
Novak endometrial suction curette
FIGURE 8-60
Size: 23 cm
Characteristics: Hollow tube with staggered sharp tip
Notes: Luer-Lok hub for aspiration or irrigation
Jarcho cannula
Size: 10.00
FIGURE 8-61
Characteristics: Latex acorn tip secures the tip of the
cannula against the cervix during instillation of dye or
contrast and mobilization of the uterus
Notes: Used in combination with a uterine tenaculum; has
a self-retaining support that attaches to the ring handles
of the uterine tenaculum Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Kahn cannula
Size: 10.00
FIGURE 8-62
Characteristics: Latex acorn tip secures the tip of the
cannula against the cervix during instillation of dye or
contrast and mobilization of the uterus
Notes: Used in combination with a uterine tenaculum.
Has a self-retaining support that attaches to the ring
handles of the uterine tenaculum Courtesy of CareFusion, a division of Becton, Dickinson and Co.
RETRACTION AND EXPOSURE
Auvard weighted speculum

Size: 2 lb; 2.5 lb; 3.0 lb
FIGURE 8-63
Characteristics: Single-end vaginal retractor with weight on dependent
edge; rounded, scoop blade is available in straight, angled, and extra
long
Notes: Sterile glove can be applied over weight to collect blood and
drainage
Garrigue weighted speculum

Size: 2 lb; 2.5 lb; 3.0 lb
FIGURE 8-64
Characteristics: Single-end vaginal retractor with weight on dependent
edge; squared flat blade is available in straight, angled, and extra long
Notes: Sterile glove can be applied over weight to collect blood and
drainage
Jackson retractor
Size: 7.00
FIGURE 8-65
Characteristics: Single squared end with straight edge
Notes: Manual vaginal retractor
Sims retractor
FIGURE 8-66
Size: Small; medium; large
Characteristics: Single-ended retractor with scoop-blunt edge
Sims double retractor

FIGURE 8-67
Size: Small; medium; large

Characteristics: Double-ended retractor with scoop-blunt
edge. Blades face the same direction
continues
RETRACTION AND EXPOSURE continued
Tauber retractor
FIGURE 8-68
Size: 9.250
Characteristics: Angled, lateral wall vaginal retractor with
3.50 3 1.750 blade used in pairs. Sometimes referred to
as shovels or spatula retractors
Notes: Good for use during vaginal hysterectomy Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Heaney retractor
Size: 10.50
FIGURE 8-69
Characteristics: Right-angled vaginal retractor used in pairs.
4.50 3 1.00 blade
Notes: Rounded at the tip
Lateral side retractor

Size: 10.00
FIGURE 8-70
Characteristics: Ring-handled, right-angle, self-
retaining vaginal side wall retractor with ratchets
Notes: Used for lax vaginal tissue when
observation of the uterine cervix is necessary
Pederson speculum
Size: Small (3.50) or medium (4.50)
Notes: Narrow, rounded, self-retaining, duck-bill blades.
Locks open with a screw. Can be used for select
pediatric or geriatric patients. Right-angle handle
FIGURE 8-71
continues
DeVilbiss speculum
Size: 4.00
Notes: Parallel opening duck-bill speculum. Locks open with a
FIGURE 8-72
screw. Straight handle
Gutman speculum
Size: 3.50
Notes: Anterior-posterior duck-bill speculum. Right-angled handle. Locks open with
FIGURE 8-73
a screw
Graves speculum
Size: 4.50
Notes: Anterior-posterior duck-bill speculum. Right-angled handle. Locks
open with a screw
FIGURE 8-74
Balfour retractor
Size: 10.00
Characteristics: Lateral abdominal wall retractor with adjustable, scoop-shaped bladder
FIGURE 8-75
retraction blade; can be used with or without bladder blade. Some types have open or
closed side wall blades
Notes: Care is taken if any of the screws or wing nuts are removable. They are counted
items. Bladder blade attachment can be used to retract the bladder during cesarean
section without the abdominal portion
continues
O’Sullivan-O’Connor retractor
Size: 8.00
FIGURE 8-76
Characteristics: Circular retractor; may be wrapped separately; three
interchangeable retraction blades with two side wall stationary blades
Notes: Specifically designed for Pfannenstiel incision
DeLee retractor
FIGURE 8-77
Size: 8.00
Characteristics: Right-angle manual retractor with central scoop blade
Notes: Sometimes used for dissection of bladder flap during cesarean
section
Mayo retractor
FIGURE 8-78
Size: 10.00
Characteristics: Curved manual retractor with solid
ergonomic finger grip handle; blade is 2.750 wide and
curved under with blunt edges
Notes: Used for body wall Courtesy of Sklar Instruments.
PROBES AND DILATORS
Sims uterine sound

FIGURE 8-79
Size: 13.00
Characteristics: Probe-style malleable shaft with measurements marked in cm or inches;
slightly curved ball tip; finger grip is flat and corrugated for traction; silver plated
Notes: Used to sound the depth of the uterine cavity. Alternative use includes as a
tunneling probe under the skin © 2019 Cengage®.
Barr fistula probe

FIGURE 8-80
Size: 11.50
Characteristics: One size; sterling silver probe; double-ended or with eyed tip for passing suture or seton drain; narrow,
rounded finger-grip handle; slightly malleable
Notes: Used to sound a duct, sinus, or fistula Courtesy of Sklar Instruments.
continues
PROBES AND DILATORS continued
Hegar dilators
Size: 3/5 mm up to 17/18 mm
Characteristics: Double ended; set of eight sizes.
Each end is a progressive size for dilating the
uterine cervix. Slightly rounded tip
FIGURE 8-81
Notes: Alternative use includes as a tunneling
probe under the skin
Hank dilators
Size: 11/12 Fr. to 21/22 Fr.
Characteristics: Graduated set of six; double
ended with a rim stop to minimize penetration
FIGURE 8-82
beyond the cervical os. Slightly tapered tip
Notes: Alternative use includes as a tunneling
probe under the skin
Pratt uterine dilators

Size: 11.50; 13 to 15 Fr.
Characteristics: Curved, double-ended,
blunt-tipped, probe-style dilators; each end
is progressively larger; solid and nonflexible;
stainless steel
FIGURE 8-83
Notes: Commonly used to dilate the uterine
cervix. Alternative use includes as a tunneling
probe under the skin.
continues
PROBES AND DILATORS continued
Goodell
dilator
Size: Universal
Characteristics: Mechanized
cervical dilator with tapered
ridged tips
Notes: Spring handle with
FIGURE 8-84
measuring gauge screw
stop to prevent overdilation
of the os
CLOSURE
Heaney
needle holder
Size: 8.50; 100
with medially curved
shanks; curved jaws with
FIGURE 8-85
cross-serrations. Used for
lightweight to intermediate-
weight suture
gynecologic and genitourinary
surgery; the curved tip
permits improved visualization
for intravaginal suturing
continues
CLOSURE continued
Mayo needle
holder
Size: 6.250; 7.00; 8.00; 120
Notes: Used for intermediate-
FIGURE 8-86
Commonly found in
most sets
Crile needle holder

Size: 6.00; 7.00
Notes: Used for lightweight to
FIGURE 8-87
continues
CLOSURE continued
Webster
needle
holder
Size: 5.250
FIGURE 8-88
holder
Deschamps ligature
carrier
Size: 8.00
Characteristics: Shaft with
medium-weight handle on
one end and curved eyed
needle tip; available in right
FIGURE 8-89
and left curvature and sharp
or blunt tip. Used for cerclage
of an incompetent cervix
Notes: Circumferential suturing
with a free suture. Also
known as aneurysm needle
continues
CLOSURE continued
Glassman visceral retainer

Size: Available in adult and pediatric sizes
Characteristics: Sterile, flexible, synthetic pad that
overlies organs during closure. Radiopaque with ring
that remains outside of body until retainer is removed
FIGURE 8-90
Notes: Protects organs from injury during closure.
Prevents incidental stitching through bowel
BASIC GYNECOLOGIC PROCEDURES vagina (rectocele), or a combination relaxed vaginal

outlet (enterocele).
Abdominal Hysterectomy
Abdominal hysterectomy instrumentation is based on Dilation and Curettage
the long and medium foundation sets from Chapter 5, Debulking the uterine cavity is performed by scraping the
with the addition of the following instruments. endometrial walls with sharp or blunt curettes. The endo-
Abdominal hysterectomy is performed to remove the metrium is peeled away and sent to pathology for analysis.
uterus and sometimes the ovaries and fallopian tubes. Removing lesions from the uterine cervix by
monopolar electrosurgery is done with instrumenta-
tion prefaced with either LEEP (loop electrical
Vaginal Hysterectomy excisional procedure) or LLETZ (large loop excision of
Vaginal hysterectomy instruments are usually long and the transformational zone).
curved. The long fundamental set with added vaginal The use of vaginal-uterine instrumentation can
retractors provides the exposure and manipulation facilitate abdominal gynecologic procedures by allow-
needed to remove the uterus and ovaries as appropriate. ing pelvic exposure by uterine manipulation. The
instrument is inserted into the cervix by vaginal access.
Cannulae in place for uterine manipulation can be
VAGINAL-PERINEAL PROCEDURES used for instillation of dye or contrast media to deter-
Vaginoplastic procedures involve working with the mine tubal patency during fertility studies. The most
vaginal mucosa. A medium foundation set is used for common dye is methylene blue mixed with sterile
perineal procedures. Vaginal sets commonly use long normal saline. If contrast media is used, the team must
curved instruments because the vaginal outlet obscures use x-ray lead aprons or other lead screening for per-
the observation of the instrument tip. sonnel safety.
The medium foundation set is used alone for inci- Cervical procedures can be performed for
sion and drainage of infected Skene’s or Bartholin’s patients with an incompetent cervix. Shirodkar and
glands. Colporrhaphy of the vagina is sometimes MacDonald procedures can be used to circumfer-
referred to as anterior or posterior repair for correction entially close the cervix with 5-mm Mersilene tape
of herniation of the bladder into the vagina (cystocele), to prevent preterm dilation of the cervix and loss of
urethral laxity (urethrocele), rectal herniation into the the pregnancy.
Cesarean Section In the rare event that the uterus must be removed
Cesarean section is the procedure performed for during the cesarean birth, the full medium set, long
the surgical delivery of a baby through an abdomi- set, abdominal hysterectomy instrumentation, and
nal incision. The primary instruments used are the cesarean instrumentation will be needed. In the case
medium and long foundation instruments with a
of severe infection or hemorrhage, some surgeons
few specialty additions primarily associated with the will remove the uterus as a lifesaving measure. It is
resuscitation of the baby after removal from the moth- not uncommon to remove the uterine body and leave
er’s uterus. the cervix, because the pelvic vessels are extremely
Sometimes the surgical team may be called in on engorged and difficult to manage in the deeper aspects
standby for a possible cesarean section during a vagi- below the pelvic rim. This is referred to as a supracer-
nal delivery. A section on vaginal delivery forceps is vical cesarean hysterectomy. The woman is rendered
included. sterile by this procedure.
SUMMARY combination to remove, repair, or remodel the female

reproductive system.
Gynecologic procedures require many of the
Keep in mind that the surgeon may need to per-
same instruments as are commonly used in
form an intravaginal procedure as part of an abdominal
other intraabdominal surgical procedures—such
open or endoscopic surgery. Preparation of dilation and
as general surgery—with the exception of heavy
curettage (D&C) instrumentation may be necessary. In
hemostatic clamps and graspers. The surgical
select surgeries it may be advisable to have a D&C set
approach can involve open and endoscopic methods
available on the cart just in case.
that complement each other and can be used in
CHAPTER 9
UROLOGIC
INSTRUMENTATION

After reading this chapter the learner should be able to: Open Urology Instrumentation
1. Select instrumentation appropriate for kidney surgery. Nephrectomy, Cystectomy,
2. Select instrumentation appropriate for open bladder surgery. and Prostatectomy
3. Select instrumentation appropriate for open prostate surgery. Instrumentation
Clamps
Grasping Forceps
INTRODUCTION Dissection Instruments
Probes and Dilators
Urologic surgical procedures commonly use multiple modalities. Soft tissue
surgery associated with urology will require the use of medium and long Instruments
foundation sets with the addition of dilation and probing instruments if the
tubular anatomic components, such as the ureters or urethra, are entered. Instruments
An endoscopic cystoscopy set up on a separate table should be pre- Testicular Instrumentation
pared and maintained throughout the entire urologic procedure because Clamps
periodic examination to ensure the integrity of the urinary system may Specialty Specific Instruments
be performed. The table should be placed to the side when not in use and Uroplasty Instrumentation
left intact until the case is completed. The circulating nurse will keep an
Probes and Dilators
accurate record of the fluid expansion medium (commonly sterile water)
instilled and returned (I&O, or in and out measurement). This is important Instruments
because the patient may be at risk for fluid retention and overload if the Circumcision
urinary system has an undetected leak into the preperitoneum, intraperito- Clamps
neal cavity, or retroperitoneum. The peritoneal membrane can absorb and Probes and Dilators
diffuse electrolytes, causing an imbalance in the patient. Severe imbalances
can cause the susceptible patient to develop congestive heart failure.
OPEN UROLOGY INSTRUMENTATION

Open surgical procedures performed on the urinary system require the use of
clamps and graspers that are angled or curved to accommodate the position
and shape of the target organs. Male genitourinary procedures are commonly
included in the urologic specialty service. In addition, most female repro-
ductive organ procedures are included in the gynecologic specialty service
described in Chapter 8. Endoscopic instrumentation for the genitourinary
systems of both sexes is described in Chapter 15.
229
Nephrectomy, Cystectomy, and

Prostatectomy Instrumentation foundation sets from Chapter 5 with the inclusion of
Surgical procedures involving the kidneys, bladder, and the following add-on set. Large patients may require the
prostate are performed using the medium and long use of the optional extra-long add-on set.
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—CLAMPS
Young renal pedicle clamp

Size: 9.250
FIGURE 9-1
Characteristics: Long, curved jaws with longitudinal
serrations with horizontal serrations near the blunt tip
Notes: Used in open nephrectomy procedures to ligate the
renal vessels
DeBakey peripheral vessel clamp

Size: 8.00
FIGURE 9-2
Characteristics: Curved shanks and forward curved jaws
with atraumatic DeBakey pattern of serrations in long jaws
Notes: Provides atraumatic hemostasis of moderate sized
vessels
Herrick pedicle clamp

Size: 9.50
FIGURE 9-3
Characteristics: Double-angle jaw with longitudinal serrations the full length of
the jaws
Notes: Used for secure ligation of heavy tissues and vasculature
Guyon-Pean vessel clamp

Size: 9.250
Characteristics: Double curved jaws with
FIGURE 9-4
horizontal serrations the full length of the jaws

Notes: Used for secure ligation of heavy tissues
and vasculature
CHAPTER 9 Urologic Instrumentation 231
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—CLAMPS continued
Bihrle needle holder/dorsal

clamp
FIGURE 9-5
Size: 11.00
Characteristics: Long, thin, right-angled clamp
with cross-hatched serrations in jaws
Notes: Used as a needle holder for suturing the
dorsal vein during open prostatectomy
Wertheim pedicle
clamp
Size: 10.50
Characteristics: Curved clamp
with long jaw length and
horizontal serrations
Notes: Used on heavy tissues
or vessels in deep tissues
FIGURE 9-6
Rochester-Pean forceps
Size: 10.250; 12.00; 14.00; 16.00
Characteristics: Medium-weight, straight or
FIGURE 9-7
curved clamps with horizontal serrations along full
length of the jaws and blunt tips
Notes: Multiple lengths available for use on
moderate to heavy tissues for hemostasis; may
be used as pedicle or hysterectomy clamps
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—GRASPING FORCEPS
Randall kidney stone forceps

Size: 7.500; 7.750; 8.250; 9.250
Characteristics: Long, thin, nonratcheted, ring-handled
FIGURE 9-8
forceps with various shank curvatures and fenestrated,
oval, serrated cup tips
Notes: Available in full curve, three-quarters curve, half-
curve, or one-quarter curve for grasping and extraction
of stones or polyps; complete set would include all four
curvatures Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Millen capsule forceps

Size: 9.500
FIGURE 9-9
Characteristics: Ring handle forceps with angled shank; jaw is
11 mm with 9 3 10 teeth
Notes: Used to grasp renal capsular tissue during nephrectomy
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—

DISSECTION INSTRUMENTS
Harrington-Mayo scissors
FIGURE 9-10
Size: 11.00
scissors with straight or curved blades and
blunt tips
Notes: Similar to Mayo scissors; however, longer length is appropriate for
deep tissues in thoracic, abdominal, colorectal, or genitourinary procedure Permission granted by Integra LifeSciences Corporation, Plainsboro, NY.
Jorgenson scissors
Size: 9.00
Characteristics: Long, heavy, strongly
FIGURE 9-11
curved blades with blunt tips

Notes: Commonly used in gynecology for
dissection of thick cervical tissue
continues

DISSECTION INSTRUMENTS continued
Thorek scissors
Size: 7.250; 10.00
FIGURE 9-12
Characteristics: Moderate-weight scissors with
fully curved blades and blunt tips
Notes: Similar to Jorgensen scissors; however,
lighter and thinner; used for lateral sharp
dissection of deep structures
© 2019 Cengage®.
Metzenbaum-Nelson scissors
FIGURE 9-13
Size: 9.00; 10.00; 11.00; 12.00; 14.00
Characteristics: Long scissors with straight
shanks and straight or curved blades and
blunt tips
Notes: Used in bariatric or thoracic procedures
Satinsky scissors
Size: 9.50
FIGURE 9-14
Characteristics: Long, curved shanks;
forward-curved blades with blunt tips;
used for intermediate-weight, deep
tissues
Notes: Typically used in cardiothoracic
surgery. Double curvature allows for
precise cutting of rounded structures Courtesy of CareFusion, a division of Becton, Dickinson and Co.

PROBES AND DILATORS
Van Buren sounds

Size: 11.00; set of various numbers; sizes 8 Fr. to 40 Fr.
FIGURE 9-15
Characteristics: Multiple diameters of long,

curved, rigid, single-ended, smooth, tapered tip
urethral dilators with flattened base
Notes: Used in male patients; curved sounds
(dilators) can be used to probe the prostatic urethra
from the inferior or superior angle during open
prostatectomy; available in sets of 6, 12, or 17
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—RETRACTION AND

EXPOSURE INSTRUMENTS
Bookwalter table-mounted
retractor
Characteristics: Complex table-mounted,
self-retaining retractor with circular, oval, and
FIGURE 9-16
articulating rings onto which numerous retractor
styles are attached
Notes: Self-retaining retractors provide adequate
exposure with fewer team members; a separate
back table may be required for organization
and counting of all parts and attachments; may
require placement into more than one tray due to
weight limitations for sterilization Pilling branded instrumentation courtesy of Teleflex Medical.
Judd-Masson bladder retractor

Size: 90-mm spread
Characteristics: Self-retaining, slide-bar bladder
retractor with two 1” swivel blades; 1” center
blade available
FIGURE 9-17
Notes: Similar action to a Balfour retractor;
however, smaller and designed for open bladder
procedures
© 2019 Cengage®.
Kelly retractor
FIGURE 9-18
Size: 10.00
Characteristics: Handheld 2.50 3 3.00 right-
angle blade with smooth edges
Notes: Resembles a Richardson retractor; used
for moderate to heavy abdominal wall tissue
layer retraction Courtesy of Sklar Instruments.
continues
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—RETRACTION AND

EXPOSURE INSTRUMENTS continued
Foss retractor
Size: 9.50
FIGURE 9-19
Characteristics: Handheld, single-ended, curved, blunt-ended, slightly malleable
retractor; 1.750 blade width
Notes: Used for biliary duct retraction
Size: 12.00
Characteristics: Handheld, complex curved
FIGURE 9-20
body with 1.50 3 5.00 heart-shaped,
reinforced distal blade edges
Notes: Reinforced edges designed to prevent
trauma to deep liver or other friable tissues
of the abdominal cavity; complex curve
compensates for anatomic structures such as
ribs; heart shape designed to expose biliary ducts;
often called “sweetheart” retractor
Mayo retractor
FIGURE 9-21
Size: 10.00
Characteristics: Handheld, heavy, curved-back
shaft and folded-over, 2.750 wide, rounded-
head retractor
Notes: Wide, curved manual body-wall retractor;
rigid blade; head resembles Balfour bladder blade Courtesy of Sklar Instruments.
Nephrectomy, Cystectomy, and Prostatectomy Instrumentation—APPROXIMATION

AND CLOSURE INSTRUMENTS
Crile-Wood
needle holder
Size: 6.00; 7.00; 8.00; 9.00
Characteristics: Thin, tapered
jaws with cross-hatched
FIGURE 9-22
(diamond pattern) serrations
and center groove
Notes: Various lengths available;
appropriate for
intermediate-sized suture
needles
Mayo-Hegar needle
holder
Size: 5.250; 6.00; 7.00; 8.00;
9.00; 10.50; 11.50
Characteristics: Available in
multiple lengths; straight,
FIGURE 9-23
blunt jaws with cross-hatched
(diamond pattern) serrations
and center groove
Notes: Appropriate for medium
to heavy suture needles;
longer lengths for deep tissue
suturing
Sarot needle holder

Size: 7 1/80; 10.250
Characteristics: Shanks angled inward near
FIGURE 9-24
ratchets; short, tapered jaws with cross-

hatched (diamond pattern) serrations and
center groove
Notes: Used commonly in cardiovascular
procedures; secure holding of fine to
medium-sized suture needles
continues

AND CLOSURE INSTRUMENTS continued
Heaney
needle
holder
Size: 8.250
Characteristics: Curved jaws
FIGURE 9-25
with cross-hatched (diamond
pattern) serrations
Notes: Used commonly
in gynecologic vaginal
procedures; angled
orientation of mounted suture
needle provides enhanced
visualization in deep, narrow
spaces
Finochietto needle
holder
Size: 10.250
pattern) serrations and center
FIGURE 9-26
groove
Notes: Long needle holder
with angled jaws; similar to
Heaney needle holder; used
commonly for deep suturing
in thoracic, gynecologic, and
colorectal procedures
continues

AND CLOSURE INSTRUMENTS continued
Wangensteen needle holder

Size: 10.50
FIGURE 9-27
Characteristics: Long, straight needle holder; short,
straight jaws with cross-hatched (diamond pattern)
serrations
Notes: Used for suturing in deep tissues
Stratte needle holder

Size: 9.00
FIGURE 9-28
Characteristics: Long needle holder with
forward-curved, blunt jaws with cross-
hatched serrations and curved shanks
Notes: Curved configuration provides for
visualization in deep tissues
Testicular Instrumentation procedures are performed in a urologist’s office. The

Testicular procedures do not require long instrumenta- percutaneous implantation of testosterone-abating hor-
tion unless there is crypt orchidism or neoplasm involv- mones performed in physician’s offices has also greatly
ing the deep inguinal lymph nodes. Short and medium reduced the number of orchiectomy procedures pre-
foundation sets have adequate instrumentation for most viously performed for patients with prostate cancer.
testicular procedures. This particularly includes orchi- Orchiectomy for testicular cancer is still performed in
ectomy and vasectomy, which are less frequently per- the operating room. Dissection may require the addi-
formed in operating rooms currently. Many vasectomy tion of the following instrumentation.
Testicular Instrumentation—CLAMPS

Size: 3.50
Characteristics: Short, ringed, and ratcheted hemostat
with fine, fully horizontally serrated straight jaws
FIGURE 9-29
Notes: May be used for hemostasis, blunt dissection of

fine tissues, or tagging suture at the level of the tunica
continues
Testicular Instrumentation—CLAMPS continued
Pratt
T-shaped
forceps
Size: 6.00
ratcheted tissue forceps with
16-cm, concave, serrated
FIGURE 9-30
tips that sit perpendicular
to the shanks, giving it a
T-shape
Notes: Used for firm grasping
and holding of mucosal
tissue edges; however, may
crush delicate tissues
Bridge forceps
Size: 11.00; 12.00, 14.00; 18.00; 200
Characteristics: Ringed and ratcheted,
FIGURE 9-31
long, delicate hemostat with short,
straight or curved jaws with
horizontal serrations along full
jaw length
Notes: Used for deep or delicate tissue
hemostasis and dissection
Kantrowitz forceps
Size: 9.750
FIGURE 9-32
Characteristics: Tweezer-
style, fine tissue forceps with
distal jaw curvature, horizontal serrations,
1 3 2 teeth at tip, and stop-peg in center shaft
Notes: Used commonly for cardiovascular procedures
in deeper tissues; stop-peg prevents excessive tissue
compression during use Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Testicular Instrumentation—SPECIALTY SPECIFIC INSTRUMENTS
Backhaus towel clamp

Size: 3.50; 5.250
Characteristics: Ringed and ratcheted clip with
curved, perforating, single sharp prongs on
each tip
FIGURE 9-33
Notes: Regular length and shorter “baby” size;
designed for securing linen towels and drapes;
may also be used to isolate the spermatic cord
and provide gentle circumferential traction; may
also be used as a bone fracture reduction clamp;
often called towel clip rather than clamp
Uroplasty Instrumentation full urethra is involved, such as in hypospadias, then

Uroplasty involves repair or reconstruction of the the surgeon may need elements of the medium or long
meatus and/or the full length of the urethra. The extent foundation sets. The following instruments are useful
of the procedure and the body size of the patient will additions for open urethroplasty. The surgeon may
determine the type of instrumentation necessary for want an assortment of Robinson and Foley catheters on
the procedure. The short foundation set is usually all the sterile field. Endoscopic instrumentation for cystos-
that is needed for meatal procedures. However, if the copy is described in Chapter 15.
Uroplasty Instrumentation—PROBES AND DILATORS
Van Buren sounds

Size: 11.00; sets of various numbers; sizes 8 Fr.
to 40 Fr.
FIGURE 9-34
curved, rigid, single-ended, smooth, tapered tip
urethral dilators with flattened base
Notes: Used in male patients; curved sounds
(dilators) can be used to probe the prostatic
urethra from the inferior or superior angle during
open prostatectomy; available in sets of 6, 12, or 17 Courtesy of Sklar Instruments.
Dittel urethral sounds

Size: 11.50; sets of various sizes; sizes 8 Fr.
FIGURE 9-35
to 40 Fr.
straight, rigid, single-ended, smooth, tapered tip urethral dilators with flattened base
Notes: Used to dilate diameter of male urethra and may also be used to create a
stent for tubular suturing in female patients
continues
Uroplasty Instrumentation—PROBES AND DILATORS continued
LeFort urethral sounds

Size: 11.00; size 8 Fr. to 30 Fr.
FIGURE 9-36
curved, rigid, single-ended, smooth, tapered
tip urethral dilators with flattened base; threads
at tip for a filiform screw-on attachment
Notes: Curved, stainless-steel sounds; used to dilate male
urethra or create a stent for tubular suturing
McCrea urethral sounds
FIGURE 9-37
Size: 7.00; sizes 8 Fr. to 36 Fr.
Characteristics: Multiple diameters of
short, curved, rigid, single-ended, smooth,
tapered tip urethral dilators with flattened
base
Notes: Used primarily in pediatric surgery Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Uroplasty Instrumentation—APPROXIMATION AND CLOSURE INSTRUMENTS
Heaney
needle
holder
Size: 8.50
Characteristics: Curved jaws
FIGURE 9-38
pattern) serrations
Notes: Used commonly
in gynecologic vaginal
procedures; angled
orientation of mounted suture
needle provides enhanced
visualization in deep, narrow
spaces
Circumcision #7 scalpel with a #15 blade. A variety of disposable

Adult circumcision of the male foreskin requires the use plastic infant circumcision glans covers are available
of a short foundation set. Pediatric circumcision utilizes for use, often in the newborn nursery department.
minimal instrumentation with the exception of a glans Circumcision in older children is performed in a similar
cover, a hemostat or two, straight iris scissors, and a manner as in an adult.
Circumcision—CLAMPS
Gomco circumcision clamp

Notes: Multi-piece clamp that
separates the foreskin from the
glans with a bell-shaped dome
FIGURE 9-39
© Cengage®.
Circumcision—PROBES AND DILATORS
Bowman lacrimal
probes
Size: 5.00
Characteristics: Set of four
graduated, double-ended, malleable,
blunt-tipped probes/dilators
Notes: Designed for use in dilation and
probing of delicate lacrimal ducts;
in circumcision procedures, may
FIGURE 9-40
be used to peel foreskin away from

glans; double-ended probe
used to bluntly dissect adherent
foreskin from glans
SUMMARY with the surgeon before the case is started in order to

prepare one, just to be certain. If checking with the
Urologic surgery can combine open and endoscopic
surgeon in advance is not possible, a cystoscopy set
approaches during the same procedure. Accurate
with the necessary illumination source and expansion
scheduling by the surgeon facilitates adequate
medium can be placed on the case cart as “have
preparation by the surgical team. When an open
available” items and not opened unless actually needed.
urologic procedure is scheduled without listing the
This saves valuable time if the set is suddenly needed.
need for a cystoscopy setup, it is advisable to check
CHAPTER 10
BASIC BONE
AND JOINT
INSTRUMENTATION
Plates and Screws: Fracture After reading this chapter the learner should be able to:
Fixation Instrumentation 1. Select instrumentation appropriate for open bone procedures of the limbs.
Pins and Wires 2. Select instrumentation appropriate for open joint procedures.
Other Devices 3. Select instrumentation appropriate for fixation with screws, plates, wires, and pins.
Drills and Power Equipment
Drills and Devices
Bone Instruments
Small Bone Instruments INTRODUCTION
Large Bone Instruments Basic bone and joint procedures are performed by first making an inci-
Bone-Holding Forceps sion into the overlying soft tissues. This requires the use of soft tissue
Elevators, Osteotomes, Rasps, instrumentation that is appropriate for the depth of tissue to be incised
Curettes, and Awls and the position and type of the target bony or compact tissue.
Bone Cutters, Rongeurs, Pliers, Compact bone is also referred to as cortical bone by many
and Pin Cutters manufacturers. This type of bone is very solid and hard. In contrast,
Orthopedic Retractors and cancellous bone is softer and requires the use of specific instru-
Mallets
ments. Bone fragments are not permitted to remain in the surgical
Miscellaneous Bone Instruments
site at closure b
ecause they can become a barrier to wound healing.
Arthroscopic Instruments
Irrigation is supplied during drilling to maintain clear vision and
cooling of the bone. Casting materials are commonly used as rigid
support for bone postoperatively.
PLATES AND SCREWS: FRACTURE FIXATION

INSTRUMENTATION
Generic plates and screws are described here only for style. Each manufac-
turer has specific attributes and materials suitable for patient bone fixation,
such as stainless steel or titanium. Most facilities and surgeons refer to these
collective materials as “hardware.” Keep in mind that the use of plates and
screws requires instrumentation for measuring, positioning, tapping, drill-
ing, inserting, countersinking, and affixing the implanted device, regardless
of site. The number and configuration of threads on the screws will vary
according to type and size.
244
CHAPTER 10 Basic Bone and Joint Instrumentation 245
Removal of the implanted hardware will in turn patient’s body. Biological monitoring is essential for
require the use of specific screwdrivers or removal in-house assembled sets of plates and screws. Infection
instrumentation appropriate for the type of implant in around an implanted site can lead to osteomyelitis and
place. Use of the wrong removal tools can result in bro- failure to heal. Prepackaged screws and plates that have
ken or stuck screws. The retained hardware can act as a been sterilized by the manufacturer are preferred. The
mechanical barrier to surgical site healing. following chart lists commonly used styles of implants
Plates and screws are treated as implants because and their associated instrumentation without prefer-
they are retained for a prolonged period within the ence for one brand over the other.
PINS AND WIRES
Pins and wires

Uses: Used to align and unite bone segments
A.
Notes: Can be smooth or fully threaded; some
have a suture-passing hole
A. Kirschner wire
B.
B. Steinmann pin
C. Schanz partially threaded pin
FIGURE 10-1
D. Cerclage smooth wire C.
D.
K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
OTHER DEVICES
Washer
Size: Sized according to screw diameter
FIGURE 10-2
Uses: Used to seat screw in bone
Courtesy of Padgett Surgical Instrumentation, a division of Integra LifeSciences Corporation.
continues
OTHER DEVICES continued
Wrench
FIGURE 10-3
Size: Sized according to screw diameter
Notes: Size-appropriate wrench should be
available for securing the nut during torque
of the screw K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Hexagonal screwdriver with screw-holding tip
FIGURE 10-4
Size: 7.750
Notes: Tip is hexagonal shape
© 2019 Cengage®.
Cruciform screwdriver with screw-holding tip
FIGURE 10-5
Size: 6.50
Notes: Tip is cross shaped. Available in a variety of
lengths. K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Plate-bending iron
Size: 5.00; 5.50; 9.50
FIGURE 10-6
Uses: Used for custom bending
of implantable plate on the
sterile field
© 2019 Cengage®.
Plate-bending pliers
Size: 5.00
Notes: Pliers with flat tip for bending plates
FIGURE 10-7
© 2019 Cengage®.
continues
Plate-bending pliers with interchangeable anvils

Size: 10.00
FIGURE 10-8
Notes: Locking plate-bending pliers with interchangeable tips for
wide or narrow plates
French rod shaper
FIGURE 10-9
Size: 11.50
Uses: Used to bend rods on the sterile field
Plate-bending press
Size: 12.00
FIGURE 10-10
Uses: Used for heavy plate bending
Screw-holding forceps
FIGURE 10-11
Size: 3.50; 7.00
Uses: Holds the screw during insertion with a
pincer grasp
Drill bit
Size: Sized according to desired screw diameter
FIGURE 10-12
Uses: Used with a manual or powered drill
© 2019 Cengage®.
continues
Steinmann pin chuck

Size: Sized according to desired pin diameter
Notes: T handle for insertion and removal of Steinmann pins.
Also referred to as T-handle chuck.
FIGURE 10-13
FIGURE 10-14
Screw depth gauge
Size: 4.50; 6.250; 8.750
Notes: Cylindrical device for measuring the depth
of a desired screw hole © 2019 Cengage®.
Mini Fragment Set

Notes: Instruments, plates, and screws used to secure bones
FIGURE 10-15
A.
© 2019 Cengage®.
continues
t
B.
FIGURE 10-15
C.
© 2019 Cengage®.
Intramedullary nail extraction instrumentation

Notes: For removing intramedullary nails
FIGURE 10-16
© 2019 Cengage®.
continues
Total hip prosthesis

Notes: Artificial parts to replace a diseased hip
FIGURE 10-17
© 2019 Cengage®.
DRILLS AND POWER EQUIPMENT

Some surgeons prefer to use manual drills to create and lubrication of these complex devices are performed
holes for pins, wire, and screws. Cleaning, sterilization, according to the manufacturer’s recommendations.
DRILLS AND DEVICES
Bunnell drill
Notes: Accepts pins and wires up to 4.0 mm; key chuck stores in
handle
FIGURE 10-18
continues
DRILLS AND DEVICES continued
Ralks drill
Notes: Accepts pins and wires up to 6.35 mm
FIGURE 10-19
Universal drill
Notes: Long shank; accepts full-length pins and wires up to 6.35 mm
FIGURE 10-20
Stille-Sherman drill
Notes: Uses specific bits
FIGURE 10-21
continues
Stille drill
FIGURE 10-22
Moore drill
FIGURE 10-23
Martin drill
Notes: Chrome-plated drill with aluminum handle
FIGURE 10-24
Telescopic hand drill

Notes: Shaft elongates by an extended drill guide
FIGURE 10-25
continues
Kirschner drill
Notes: Shaft elongates by an extended drill guide
FIGURE 10-26
Battery power drill, saw, reamer combo

Notes: Battery powered drill, reamer oscillating, and
reciprocating saw. Disposable drill bits and blades are
affixed into drill/saw tip. Batteries are sterilized
separately
FIGURE 10-27
© 2019 Cengage®.
Nitrogen-powered drill
Notes: Hose and drill are processed disassembled
FIGURE 10-28
© 2019 Cengage®.
continues
Schmedberger drill
FIGURE 10-29
Notes: Manual drill with long shank and chuck
© 2019 Cengage®.
Counter sink
Size: 70
FIGURE 10-30
Notes: Helps to confirm the screw head only extends
minimally from the surface of the bone. Also available in
shaft only and various sizes.
© 2019 Cengage®.
BONE INSTRUMENTS robing, retracting, distracting, and approximating.

p
This collection of bone instrumentation can be used
Small Bone Instruments with an additional tray of soft tissue instruments.
Small bones and joints can be accessed by the use of
a short foundation set. Some facilities will design the Large Bone Instruments
contents of the small bone and joint sets to include Instruments similar to those found in small bone
the necessary soft tissue dissection instrumentation for instrumentation are commonly found in large bone sets
incision of skin to periosteum. All soft tissue is incised in larger sizes. Before performing a procedure on larger
to the level of the deepest periosteal layer in order to bones and joints, it is necessary to transect soft tissue
work on the compact and cancellous bony tissue. The such as skin, muscle, fascia, and periosteum. Deeper tis-
intended surgical procedure on a small bone or joint, sues will require the initial use of a medium foundation
such as a finger or toe, utilizes instrumentation spe- set. Patients with a large body habitus will require the
cialized for holding and grasping, debulking, cutting, use of longer instrumentation.
TABLE 10-1 Basic orthopedic instrument set count sheet

3 Knife handles: #3 3 2, #7 1 Wire cutting/suture scissors
1 Beaver knife handle 4 Mosquito clamps, curved
1 Mayo scissor, straight 8 Crile clamps, straight 3 4; curved 3 4
1 Mayo scissor, curved 4 Kelly clamps, curved
2 Metzenbaum scissors, curved: regular 2 Pean clamps, curved
and long
4 Kocher clamps
1 Bandage scissor
continues
TABLE 10-1 continued
1 Wire twisting clamp 2 Rasps, small and large

8 Towel clips, blunt 3 4, sharp 3 4 2 Langenbeck elevators
2 Sponge-holding forceps 2 Joker elevators
4 Adson forceps, smooth 3 2; with teeth 3 2 5–7 Key elevators
2 Tissue forceps with teeth 2 Chandler elevators
2 Crile-Wood needle holders 2 Freer dissectors
4 Mayo-Hegar needle holders 6 Bone curettes, #0 -#5
1 Malleable suture passer 3–4 Gouges, small to large
4 Senn retractors, blunt 3 2; sharp 3 2 5–7 Lambotte osteotomes, small to large
2 U.S. Army retractors 3 Bone cutters, small to large
4 Rake retractors, blunt 3 2; sharp 3 2 1 Pituitary rongeur
2 Weitlaner self-retaining retractors 1 Duckbill rongeur
2 Gelpi self-retaining retractors 2 Ruskin double-action rongeurs, straight and
curved
4 Hohmann retractors, small to large
1 Stille-Luer rongeur
3 Bennett retractors, small to large
1 Liston rongeur
3 Hibbs retractors, small to large
1 Nerve hook, blunt
2 Israel retractors
1 Ruler
2 Meyerding retractors
© 2019 Cengage®.
2 Pliers, needlenose; regular
2 Dingman bone-holding clamps
1 Mallet
2 Lowman bone-holding clamps
1 Lead hand
BONE-HOLDING FORCEPS
Dingman bone-holding forceps

Size: 7.50
FIGURE 10-31
Notes: Ring-handled forceps with ratchets; angled at the shank

with 2 3 2 teeth at the tip
continues
BONE-HOLDING FORCEPS continued
Lewin bone-holding forceps

Size: 7.00
FIGURE 10-32
Notes: Ring-handled forceps with ratchets; holds the bone circumferentially;
the circular jaw is serrated the full length
Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ
Locke phalangeal forceps

Size: 6.00
FIGURE 10-33
Notes: Ring-handled forceps with ratchets; circumferentially hold
bone of finger
Sesamoidectomy clamp
Size: 6.50
FIGURE 10-34
Uses: Used to grasp small bony segments in small
joints
Notes: Ring-handled clamp
Vogen sesamoid clamp

Size: 4.00
FIGURE 10-35
Uses: Opposition pin and prong tip is used to secure sesamoid bones for
removal
Notes: Pistol grip with finger rings
continues
Plate forceps
Size: 4.750
Uses: Used for holding mini plates
FIGURE 10-36
Notes: Ring-handled forceps with prong and plate
configuration at tip
© 2019 Cengage®.
Verbrugge bone-holding forceps

Size: 6.00, 7.250, 9.50, 10.250, 11.00
Notes: Angled bone grasper with a prong on one jaw and
serrations on the opposing jaw; locks with a screw or
ratchets.
FIGURE 10-37
© 2019 Cengage®.
Kern bone-holding forceps

Size: 6.00
Notes: Serrated grasping jaws; available with a
FIGURE 10-38
ratchet
continues
Lowmann bone-holding forceps
FIGURE 10-39
Size: 5.00; 7.00
Notes: Screw handle 1 3 2 serrated holding
prongs; shown with Gerston double traction bar.
Also called a turkey claw.
© 2019 Cengage®.
Bone reduction forceps

Size: 7.00; 9.00
FIGURE 10-40
Notes: Curved serrated bone approximation forceps with lock
Small bone reduction forceps

Size: 5.50
Notes: Curved, serrated bone approximation forceps with
FIGURE 10-41
ratchets. Also called a lobster claw.
Large bone reduction forceps

Size: 8.00
Notes: Curved, single, opposing-tooth bone
approximation forceps with ratchets
FIGURE 10-42
continues
Bone-holding forceps
Size: 6.00
Notes: Ring-tipped, angled grasper with
serrations for a secure
hold; ratchets
FIGURE 10-43
© 2019 Cengage®.
Fergusson bone-holding forceps
FIGURE 10-44
Size: 8.250
Notes: Quadruple-toothed grasping surface;
pressure grip handle with no lock
Langenbeck bone-holding forceps

Size: 8.250
FIGURE 10-45
Notes: Double-toothed grasping surface;
pressure grip handle with no lock
Pelvic reduction forceps

Size: 7.250; 9.50; 100
FIGURE 10-46
Notes: Double-opposing, sharp prong tips with ball stops in varied
angles; ring-handled grip with screw lock.
The shafts can also be angled.
continues
Lane bone-holding forceps

Size: 13.00
Notes: Toothed and serrated tips;
FIGURE 10-47
nonlocking and locking handles
Parham-Martin bone-holding forceps

Size: 8.50
Notes: Spring-loaded bone holder
FIGURE 10-48
that uses disposable bands to
hold bone fractures in
alignment
Lambotte bone-holding
forceps
Size: 8.00; 10.50; 11.50
FIGURE 10-49
Notes: Circumferential serrated jaws
that hold secure with ratchets; one
swivel jaw
continues
Farabeuf bone-holding forceps
FIGURE 10-50
Size: 7.250; 9.00; 10.00; 10.50
Notes: Adjustable toothed jaw for larger bones; nonlocking,
large locking, medium locking
Ulrich bone-holding
forceps
FIGURE 10-51
Size: 11.00
Notes: Speed lock with screw; one
swivel serrated jaw
ELEVATORS, OSTEOTOMES, RASPS, CURETTES, AND AWLS
Cobb elevator
FIGURE 10-52
Size: 9.50; 110
Characteristics: Rounded smooth tip can range between 0.50 to 1.250
wide. Handle is straight and hexagonal in design
Uses: To peel periosteum from bone © 2019 Cengage®.
McKenty elevator
FIGURE 10-53
Size: 5.50
Notes: Single-end blunt dissector with
semi-sharp edge
FIGURE 10-54
Freer elevator
Size: 7.50
Notes: Double-5-mm-ended dissector; one end is blunt,
the opposite end is sharp © 2019 Cengage®.
continues
ELEVATORS, OSTEOTOMES, RASPS, CURETTES, AND AWLS continued
Allerdyce elevator
FIGURE 10-55
Size: 7.50
Notes: Double-8-mm-ended dissector; one end
is blunt, the opposite end is semi-sharp
Smithwyick hook and elevator
FIGURE 10-56
Size: 12.00
Notes: Double-ended dissector; one end is a
blunt hook; the opposite end is a 5-mm
semi-sharp surface
Penfield elevator
Size: 7.00
FIGURE 10-57
Characteristics: Lightweight double-ended shank;
two styles; blunt-blunt double ended elevator; blunt
elevator/stripper end with wax impactor on the other
end
Notes: The tamp end is used to pack bleeding bone with wax © 2019 Cengage®.
Key periosteal elevator

Size: 6.750
FIGURE 10-58
Characteristics: Heavy hexagonal handle with 1/80 wide
single curved end. Straight edge of tip is slightly
beveled.
Notes: Used to strip muscle and periosteum from bone
© 2019 Cengage®.
McGlamry elevator
Size: 6.50
FIGURE 10-59
Notes: Single-end, wide-grooved dissectors used to

deglove the periosteal surface from bone; cutting
surface ranges from 11 mm to 17 mm
continues
FIGURE 10-60
Cushing elevator
Size: 15-mm edge
Notes: Single-ended dissector with a sharp edge
or serrated edge Courtesy of CareFusion, a division of Becton, Dickinson and Co.
FIGURE 10-61
Sedillot periosteal elevator
Size: 7.00
Notes: Single-ended dissector with rounded,
sharp edge Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Matson rib stripper and elevator
FIGURE 10-62
Size: 8.750
Characteristics: Double-ended instrument for stripping
and raising periosteum. Double pronged stripping end
is 2.5 cm and rounded elevator end is 1.6 cm wide.
© 2019 Cengage®.
Chandler elevator
FIGURE 10-63
Size: 7.50; 8.00; 9.00; 10.00
Notes: Single-ended blunt dissector
Darrach elevator
FIGURE 10-64
Size: 10.250; 130
Notes: Single-ended flat elevator with blunt edge
and cross-serrated surface; commonly used
in shoulder procedures
Mini Lambotte osteotome

Notes: Single-ended, chisel-tip dissector with

cutting range of 4 mm to 20 mm
© 2019 Cengage®.
continues
Smillie knife
FIGURE 10-66
Size: 6.750
Notes: Single ended with either a chisel or
indented tip
Alexander coastal periosteotome
FIGURE 10-67
Size: 7.00; 4 mm; 6 mm; 8 mm
Uses: Used with a mallet to dissect bone
Also known as Alexander rib rasp. Courtesy of Jarit Surgical Instruments, a division of Integra LifeSciences Corporation.
Hoke osteotome
FIGURE 10-68
Size: 5.50; 1/80 to 1/20
Uses: Used with a mallet to dissect bone
Lexer chisel
FIGURE 10-69
Size: 8.750
Uses: Used with a mallet for debulking
bone
Notes: Sharp, squared, single-ended cutting tool
Smith-Peterson osteotome
FIGURE 10-70
Size: 8.00
Uses: Used with a mallet for debulking bone
Notes: Sharp, squared, single-ended cutting tool;
curved or straight shaft
Smith-Peterson gouge
FIGURE 10-71
Size: 8.00
Uses: Used with a mallet for debulking bone
Notes: Sharp, scooped, single-ended cutting tool;
can cut a grooved surface; curved or straight shaft © 2019 Cengage®.
FIGURE 10-72
Joseph bone saw

Size: 7.50
Notes: Manual saw with straight or bayonet edge K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
continues
FIGURE 10-73
Langenbeck metacarpal saw
Size: 9.00
Notes: Straight, small bone saw
FIGURE 10-75 FIGURE 10-74

Rasp with straight serrations
Size: 7.00
Notes: Double-ended file with 3-mm and 4-mm straight-serrated surfaces K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Rasp with cross-serrations

Size: 7.00
Notes: Double-ended file with 3-mm and 4-mm cross-serrated surfaces K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Rasp duo purpose

Size: 7.00
Notes: Double-ended file with 5-mm
FIGURE 10-76
straight and cross-serrated surfaces
FIGURE 10-77
Joseph rasp
Size: 6.250
Notes: Single-ended file with fine cross-serrations
along a graduated oval edge measuring 8 mm at the widest surface K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Williger bone curette

FIGURE 10-78
Size: 5.50
Notes: Double-ended oval scoop
with 3-mm or 4-mm cutting
surfaces
FIGURE 10-79
Martini bone curette

Size: 5.50
Notes: Double-ended round scoop
with 4-mm or 5-mm cutting surfaces K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
continues
Brun curette
Size: 9.00
Uses: Used to scrape away bone
FIGURE 10-80
Notes: Straight or angled tips
with cupped cutting surfaces
© 2019 Cengage®.
Cobb curette
Size: 11.00
Uses: Used to scrape away
FIGURE 10-81
bone
Notes: Straight or angled
tips with cupped
cutting surfaces
© 2019 Cengage®.
Bone awl
FIGURE 10-82
Size: 6.250
Uses: Used for perforation of bone
Notes: Single-ended sharp tip
Rush awl FIGURE 10-83
Size: 7.50; 8.250; 8.50; 10.50

Notes: Single-ended sharp tip; pistol grip handle; can be used
as a grooved director for insertion of pins K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Kuntscher diamond awl

FIGURE 10-84
Size: 11.00
Notes: Single-ended, triangle-pointed tip
BONE CUTTERS, RONGEURS, PLIERS, AND PIN CUTTERS
Liston bone cutter
FIGURE 10-85
Size: 5.50 to 8.50
Characteristics: Bone cutter with sharp-sharp tips. Spring handle
Notes: Powerful cutting surface Copyright photo(s) courtesy of Roboz Surgical Instrument, Co.
Ruskin-Liston bone cutter
FIGURE 10-86
Size: 6.00
Quantity: 1
Notes: Spring-handled small bone cutter; double-action cutter Courtesy of Ruggles Surgical Instruments, a division of Integra LifeSciences Corporation
Ferris Smith Kerrison rongeur
FIGURE 10-87
Size: 7.00
Characteristics: Spring handle with slide mount 3-mm angled cutting surface.
Other available slide cutters are aligned in other directions
Notes: Image shown is an up-biter. Several sizes will be included in a set © 2019 Cengage®.
Blumenthal rongeur
FIGURE 10-88
Size: 6.00
Uses: Used to trim bone
Notes: Two angles
Hartman rongeur
FIGURE 10-89
Size: 5.750
Uses: Used to trim bone
Micro Friedman rongeur

Size: 5.50
FIGURE 10-90
Uses: Used for delicate bone dissection

Notes: Spring-handled bone cutter with cupped tips
continues
BONE CUTTERS, RONGEURS, PLIERS, AND PIN CUTTERS continued
Platypus nail remover forceps
FIGURE 10-91
Size: 5.50
Uses: Multitoothed jaw for grasping and removing nail
from digit
Nail nipper
FIGURE 10-92
Size: 5.50
Notes: Spring-handled nippers
with angled cutting surface;
locking handle to keep blades
closed when not in use
Mycotic nail nipper
FIGURE 10-93
Size: 6.00
Notes: Spring-handled nippers with heavy, angled cutting surface for coarse
and overgrown fungal nails; locking handle to keep blades closed when
not in use
Double-action parallel pliers and wire cutter

Size: 4.50
FIGURE 10-94
Uses: Used to cut bone alignment pins
Diamond pin and wire cutter

Size: 6.50
FIGURE 10-95
Notes: Cuts wire up to 2 mm
continues
Wire twister
Size: 6.00
FIGURE 10-96
Notes: Flat-edged, cross-serrated tips
Needle nose pliers

Size: 5.50
FIGURE 10-97
Notes: Cross-serrated with central groove for use with
cerclage wire
Flat nose cutter pliers

Size: 6.50
FIGURE 10-98
Notes: Combination pliers and cutter for cerclage wire;
horizontal serrations
Flat nose pliers

Size: 6.00
FIGURE 10-99
Notes: Delicate, cross-serrated, 2-mm tip for twisting
cerclage wire
continues
FIGURE 10-100
Flat nose pliers (heavy)
Size: 5.50
Notes: Heavyweight for larger pins and wires
K-wire pliers
Size: 5.50
FIGURE 10-101
Notes: Horizontal serrations along tapered tip for
grasping K-wire
Locking pliers
Size: 8.00; 9.50
FIGURE 10-102
Uses: Used for holding screws and pins securely
Notes: Self-locking pliers
Miltex pin puller

Size: 5.50
FIGURE 10-103
Notes: Cross-serrated jaws with central depression for
the pin grip
Front and side pin cutter

Size: 7.00
FIGURE 10-104
Notes: Double-action blades
continues
Pin cutter
Size: 10.00; 16.00; 22.00
FIGURE 10-105
Notes: Pin end cutter available in three sizes;
side cutter style available
Size: 4.750
Notes: Angled wire scissors;
notched seat for wire
at angle of jaw
FIGURE 10-106
Delicate wire cutter

Size: 4.750
FIGURE 10-107
Notes: Spring-handled wire cutters
continues
Double-action wire cutter
FIGURE 10-108
Size: 7.00; 8.50
Notes: Wire cutter available in two sizes
Demel wire guide
FIGURE 10-109
Size: 10.50; 11.00
Uses: Used to pass wire around
bone
Notes: Hole in tip
ORTHOPEDIC RETRACTORS AND MALLETS
INGE lamina spreader

Size: 6.50
Characteristics: Spring handle with locking ratchet
at handle base. Available with or without teeth for
FIGURE 10-110
traction. Used to separate the lamina during
spinal procedures
Notes: Handed up in closed position
© 2019 Cengage®.
Israel rake retractor

FIGURE 10-111
Size: 9.00
Characteristics: Right-angled blunt rake style
with four to six prongs; open handle; not flexible
© 2019 Cengage®.
continues
ORTHOPEDIC RETRACTORS AND MALLETS continued
Beckman retractor
Size: 6.750 to 12.50
FIGURE 10-112
Characteristics: Double-armed blades with
ratchet lock; tips are mounted on hinged arms
and have sharp 3 3 4 rake prongs. May be
used in pairs. Good for use during spinal or
other rounded surface, the arms fold down out
of the way
Notes: Used for small deep incisions. Handed
up in closed position © 2019 Cengage®.
Love nerve root retractor

Size: 8.50
FIGURE 10-113
Characteristics: Right angle retractor with curved
rounded tip at the end of the 7 mm blade.
Smooth flat handle
Notes: May be used in pairs
© 2019 Cengage®.
Gerzog mallet
FIGURE 10-114
Size: 7.50
Notes: Weight 10 oz
Kirk mallet
Size: 7.750
FIGURE 10-115
Notes: Weight 7 oz
Courtesy of Padgett Surgical Instrumentation, a division of Integra LifeSciences Corporation.
continues
Lightweight mallet
Size: 7.50
Notes: Head of mallet has nylon tapping
FIGURE 10-116
surface; these unscrew and must be
tightened before use.
Nylon heads are processed
disassembled
© 2019 Cengage®.
Orthopedic mallet
FIGURE 10-117
Size: 7.50
Notes: 10 head diameter. weight 11 oz
FIGURE 10-118
Ragnell retractor
Size: 5.750; 5.250
Notes: Smooth or serrated retracting surface that faces in
opposite direction Courtesy of Sklar Instruments.
FIGURE 10-119
Volkman rake retractor
Size: 8.50
Notes: Sharp or blunt prongs with open loop
handle; options include one to six prongs © 2019 Cengage®.
FIGURE 10-120
Senn retractor
Size: 6.250
Notes: Sharp or blunt three-pronged rake end with a smooth
right-angle retracting end that faces in an opposite direction Courtesy of Sklar Instruments.
Alm self-retaining retractor

FIGURE 10-121
Size: 2.750; 4.00

Notes: For small soft tissue retraction; sharp
prongs
continues
FIGURE 10-122
Mini-Hohman retractor
Size: 6.250
Notes: Single-prong manual distractor-retractor Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ
Volkmann hook
FIGURE 10-123
Size: 8.50
Notes: Single prong. Also referred to as a bone
hook.
Instruments provided by www.sonictecinstruments.com
Meyerding finger retractor
FIGURE 10-124
Size: 7.00
Notes: Retractor with single finger ring for
holding; retraction end can be smooth right
angle, toothed right angle, or pronged right angle Courtesy of Sklar Instruments.
Lead hand
Size: 9.50; 14.00
Uses: Used in the sterile field to hold hand stable
during the procedure
FIGURE 10-125
Notes: Flexible lead or aluminum hand-shaped
positioner
Hibbs retractor
Size: 9.50; 25 mm wide
Notes: Right-angle, toothed retractor with blades of
varying depth (50 mm, 75 mm, and 100 mm). Other
FIGURE 10-126
Hibbs have only one toothed end and the other end is
typically a hook-handle.
© 2019 Cengage®.
continues
Goelet retractor
FIGURE 10-127
Size: 7.50
Notes: Double-ended retractor
FIGURE 10-128
Murphy bone skid
Size: 12.00
Notes: Scoop end retractor-distractor.
Also called a hip skid K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Aufranc cobra
retractor
FIGURE 10-129
Size: 10.50
Notes: Serrated tip retractor-
distractor with cobra-
shaped end
© 2019 Cengage®.
Bennett bone elevator-

retractor
Size: 10.00
FIGURE 10-130
Notes: Wide-ended retractor
with curved lip
© 2019 Cengage®.
Ollier rake retractor

FIGURE 10-131
Size: 9.00
Uses: Used for retraction of heavy tissue
Notes: Four blunt prongs; similar to Israel rake
continues
Bristow-Bankhart humeral retractor

Size: 102 mm deep
FIGURE 10-132
Uses: Used for retraction and distraction of the shoulder joint
Notes: Two blunt prongs
Bristow Bankhart soft tissue
FIGURE 10-133
retractor
Size: 7.50
Uses: Used for soft tissue retraction in the
shoulder
Notes: Three blunt prongs K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Capsule retractor
FIGURE 10-134
Size: 10.00
Quantity: 1
Uses: Used for secure retraction of the
shoulder joint capsule
Notes: Three sharp prongs K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Smillie knee retractor

Size: 5.50
FIGURE 10-135
Quantity: 2
Notes: Reverse or full curve with T-style handle
Humeral head retractor

FIGURE 10-136
Size: 8.750
Quantity: 1
Uses: Used for shoulder procedures
Notes: Single-prong angled retractor
continues
Pelvic single-prong retractor
FIGURE 10-137
Uses: Used for shoulder procedures
Notes: Rounded, tapered, prong-angled retractor
FIGURE 10-138
Blount retractor
Size: 10.50; 7.00
Notes: Pronged right-angle retractors characterized by
variance in style; double prong, single prong, and knee-tapered single prong K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Fukuda shoulder retractor
FIGURE 10-139
Size: 81 mm
Notes: T-handled leverage retractor for shoulder procedures
Gelpi self-retaining retractor

Size: 7.50
Notes: Sharp prongs hold tissue apart; some styles
FIGURE 10-140
have ball stops near the tip to prevent retractor from
creating a button hole through the skin; ring handles
and ratchets
Weitlaner self-retaining retractor

Size: 6.50
FIGURE 10-141
Notes: Ring handles and ratchets; prongs can be sharp

or blunt
continues
MISCELLANEOUS BONE INSTRUMENTS
Bone hook
Size: 9.00
Uses: Sharp hook to hold bone
FIGURE 10-142
© 2019 Cengage®.
Bone chip packer
FIGURE 10-143
Size: 10.00
Uses: Blunt end used to press bone chips into
desired spaces
Notes: Single-ended instrument with various head configurations K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
Plug cutter
FIGURE 10-144
Size: 4.50
Notes: T-shaped circular cutter used to circumscribe a 3-mm surface
around K-wire
Bone tamp
FIGURE 10-145
Size: 6.00
Uses: Single-ended instrument used with a mallet for pushing
bone segments under pressure
Notes: Surface area 2 mm to 10 mm © 2019 Cengage®.
Castroviejo caliper
Size: 3.50
FIGURE 10-146
Notes: Measures up to 20 mm for hand

surgery
© 2019 Cengage®.
continues
MISCELLANEOUS BONE INSTRUMENTS continued
Townley caliper
Size: 4.00
FIGURE 10-147
Notes: Slide rule–style measure that measures inside
and outside up to 4 inches
Finger ring cutter
FIGURE 10-148
Size: 6.50
Uses: Used to remove the patient’s finger rings
Notes: Documentation of disposition of
all valuables is essential; do not discard
removed ring fragments
FIGURE 10-149
Metal ruler
Size: 6.00
Notes: Inch and millimeter measurements Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Kleinert-Kutz tendon retriever
FIGURE 10-150
Size: 8.00
Notes: Courtesy of CareFusion, a division of Becton, Dickinson
and Co.
Carroll tendon puller FIGURE 10-151
Size: 5.00
Notes: Ring handle with small, serrated jaw; angled shanks
continues
v
MISCELLANEOUS BONE INSTRUMENTS continued
Brand tendon puller

Size: 6.00; 7.50; 9.50
FIGURE 10-152
Notes: Ring handle with small jaw with horizontal serrations and
single tooth tip; shanks angled
Bunnell tendon stripper
FIGURE 10-153
Size: 6.00
Notes: Single-ended dissector; tip is three-
quarters circular in shape with a sharp edge
for gouging; six tip sizes ranging from 3 mm
to 7 mm K-Medic branded instrumentation courtesy of Teleflex Medical, Inc.
ARTHROSCOPIC INSTRUMENTS
30-degree
arthroscope
FIGURE 10-154
Size: 4mm diameter
160mm length
Notes: J- lock, 115-degree
field of view
© 2019 Cengage®.
Irrigation sheath
Size: 5.8mm dual
rotating cannula with
obturator
Notes: Dual rotating
cannula with FIGURE 10-155
obturator
© 2019 Cengage®.
continues
ARTHROSCOPIC INSTRUMENTS continued
Meniscus knives
FIGURE 10-156
Notes: Hook knife, banana knife
© 2019 Cengage®.
Inflow-outflow
sheath
Size: 4.5 mm
FIGURE 10-157
Notes: Cannula with
obturator
© 2019 Cengage®.
Meniscus hook
Size: 125 mm shaft length, 5.4 mm tip length
FIGURE 10-158
© 2019 Cengage®.
Meniscus
grasper
Size: 2.7mm
FIGURE 10-159
© 2019 Cengage®.
continues
Light source cord—Xenon

Notes: Should be handled
with care and folded
or bent. The internal
structure is glass tubular
filaments and will fracture
easily. Transmits light to
the arthroscope. Broken
glass filaments will not
FIGURE 10-160
transmit light
© 2019 Cengage®.
Camera head
Notes: Camera head with coupler
used for capturing images from
the arthroscope
FIGURE 10-161
© 2019 Cengage®.
continues
Arthroscopic shaver
Notes: Used for debriding meniscus
FIGURE 10-162
A.
© 2019 Cengage®.
B. © 2019 Cengage®.
SUMMARY
Surgical services that perform procedures involving found in this chapter. Additional specialties, such as
manipulation of bone that are not for specific ortho- plastics or neurology, that alter or manipulate bony
pedic purposes will utilize many of the instruments tissue are described in other chapters.
CHAPTER 11
HEAD AND NECK

PROCEDURE
INSTRUMENTATION
After reading this chapter the learner should be able to: Ear and Mastoid Instrumentation
1. Select instrumentation appropriate for ear and mastoid procedures. Ear Instrumentation
2. Select instrumentation appropriate for nasal procedures. Grasping Forceps
3. Select instrumentation appropriate for open neck dissection.
Debulking Instruments
Probes and Dilators
Head and neck procedures involving soft tissues of the face, neck, and Retraction and Exposure Instruments
low anterior throat commonly require the use of soft tissue sets appro- Mastoid Instrumentation
Grasping Forceps
priate in length for the surgical site. Short and medium foundation sets
provide adequate exposure and hemostasis for these procedures with the Debulking Instruments
addition of a few specialty dissectors, graspers, or debulking instruments. Retraction and Exposure
Specialty procedures such as ear, dental, and intraoral sites require Instruments
instruments that perform like their larger counterparts but have much Nose and Throat Instrumentation
smaller tips or jaws and specially designed shanks and jaws. The anatomic Intranasal and Pharyngeal
Instrumentation
structures involved are typically much smaller and may be obscured by Grasping Forceps
larger, more traditional instrument design when the operator’s hand enters Dissection Instruments
the field of view. Debulking Instruments
Probes and Dilators
Instruments
EAR AND MASTOID INSTRUMENTATION Retraction and Exposure Instruments
Ear instruments are highly specialized with small, short jaws and box-lock Specialty-Specific Instruments
angles. The handles are frequently offset with a bayonet or ringed pistol- Anterior Neck Instrumentation
Thyroidectomy and Neck Dissection
grip design so the user’s hands and fingers do not block the target tissue. Instrumentation
Instruments used in the intra-aural canal are similar in appearance, design, Probes and Dilators
and applications. As the names vary greatly by geographic region and manu- Retraction and Exposure
facturers, characteristics common to the majority of these specialized ear Instruments
forceps include: Tracheostomy-Tracheotomy
Instrumentation
●● 3.00 to 3.250 length Probes and Dilators
●● Ringed, pistol-grip handle design Instruments
●● Thin shafts Retraction and Exposure Instruments
●● Tips with serrations, grooves, or cups
285
Names of grasping ear instruments include: ●● Micro alligator

●● Schuknecht
●● Bellucci
●● Struempel
●● Dieter
●● Weingartner
●● Fisch
●● Wullstein
●● Fuller
●● Goodhill Microsurgical instruments are listed in Chapter 14.
●● Greven Individuals involved in the ordering and/or purchasing of
ear/nose/throat (ENT) instrumentation should communi-
●● Heermann
cate with the surgeons in that specialty to identify specific
●● Hoffman instrument brand/design/name preferences to prevent re-
●● McGee dundancy with respect to specific surgeon requests.
Ear Instrumentation
Ear Instrumentation—GRASPING FORCEPS
Lucae bayonet forceps

Size: 5.5″
FIGURE 11-1
Characteristics: Thumb forceps with bayonet-shaped
body and straight jaws with horizontal serrations and
blunt tips
Uses: Offset angle allows for an unobstructed view of
narrow structures such as the nares
Notes: Bayonet forceps with teeth are also available Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Adson bayonet forceps

Size: 7.5″
FIGURE 11-2
blunt tips
Uses: Offset angle allows for an unobstructed view of
narrow structures such as the nares
Notes: Bayonet forceps with teeth are also available;
choice of bayonet type is surgeon’s preference
Wilde (Troeltsch) ear forceps

Size: 5.0″
FIGURE 11-3
Characteristics: Thumb forceps with an 80-degree angulation;

horizontal serrations in the jaws and blunt tips
Uses: Commonly used for placement of packing and dressings in ear
and nasal procedures
Notes: Instrument selection over bayonet shaped forceps is surgeon’s
preference Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
continues
Chapter 11 Head and Neck Procedure Instrumentation 287
Ear Instrumentation—GRASPING FORCEPS continued
Quire foreign body instrument

Size: 4.0″
FIGURE 11-4
Characteristics: Long, thin shaft; spring-handled
grasper with looped handle and blunt tip
Uses: Used as a grasper for foreign objects in the
nose or ear
Notes: Check for ease of slide mechanism
Noyes alligator forceps

Size: 3.75″; 5.5″
Characteristics: Nonratcheted, pistol-grip–style ring-
FIGURE 11-5
handle; long, thin shaft with tapered, horizontally
serrated jaws with central groove; blunt and toothed
styles available
Uses: Used in ear and nose for placement or extraction of
objects
Notes: Resembles pituitary or Takahashi rongeur; however,
smaller and more delicate
Hartman-Herzfeld cup forceps

Size: 3.0″; 2-mm cup; 3-mm cup
Characteristics: Nonratcheted, pistol-grip–style ring-handle;
FIGURE 11-6
short, thin shaft with cup jaws
Uses: Useful for grasping of soft or compact tissues in small,
narrow spaces such as the nose or ear
Notes: Use caution when removing tiny specimens with gauze
sponges
Ear Instrumentation—DISSECTION INSTRUMENTS
Politzer tympanum perforator

Size: 7.0″
FIGURE 11-7
Characteristics: Angled handle with 80 mm from bend
to tip; tip is a spear-shaped knife
Uses: Reusable sharp dissector for placing a small
perforation in the tympanic membrane
Notes: Care should be taken with handling and
packaging
Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Wullstein ear scissors
FIGURE 11-8
Size: 3.0″
Characteristics: Ringed, pistol-grip handle with very thin shaft and
delicate, straight, sharp scissor tips
Uses: Sharp dissection of fine structures of the ear
Notes: Extra-delicate sharp tips must be protected to prevent
damage or sharps injury Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Bellucci ear scissors: micro

Size: 3.0″
FIGURE 11-9
Characteristics: Ringed, pistol-grip handle with thin shaft and straight, sharp
micro scissor tips; ebony finish
Uses: Sharp dissection of ear structures visualized under the microscope
Notes: Delicate micro ear scissors with ebony finish, which cuts down on glare
under the microscope; however, finish may wear off and require
repair or replacement Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Rosen round knife

Size: 6.0″
Characteristics: Long, very thin handle with 2-mm, FIGURE 11-10
round blade at tip
Uses: Used for sharp dissection of fine structures in
tympanoplasty
Notes: Care should be taken to protect knife edges
in packaging and personnel from injury in transfer Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Freer elevator
FIGURE 11-11
Size: 7.25″
Characteristics: Double-ended dissector with one sharp
5-mm end and a blunt end; cross-serrated hand-grip
Uses: Multiple uses, including blunt dissection and
elevation of periosteum
Notes: Freer elevators are also commonly used in orthopedics and neurosurgery © 2019 Cengage®.
Ear Instrumentation—DEBULKING INSTRUMENTS
Buck ear curettes
FIGURE 11-12
Size: 6.25″ length; curette diameter from 000 to #5
Characteristics: Beveled open loop curettes available in sharp
or blunt working edge in straight or angled handle configurations
Uses: Debulking ear instrument
Notes: May need to thoroughly clean open loop of cerumen after use
Shapleigh ear curette
FIGURE 11-13
Size: 6.25″; small and large
Characteristics: Thin handle with large or small
fenestrated, serrated tip; may be straight or slightly
angled forward at base of tip
Uses: Used for debulking in ear procedures
Notes: May need to thoroughly clean open loop of cerumen after use Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Billeau flexible ear curette
FIGURE 11-14
Size: 5.5″; small, medium, and large wire loops
Characteristics: Thin handle with small, medium, or
large teardrop-shaped, flexible wire loop tip
Uses: Used for removal of cerumen from ear canal
Notes: Flexible loop allows for variations in canal shape Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Endaural curette
Size: 8.25″ length; 5-0 (1.5 mm); 4-0 (2 mm); 3-0 (2.2
mm); 2-0 (2.5 mm) cup size
FIGURE 11-15
Characteristics: Hollow, vertical-groove handle with
tapering shaft and sharp, oval spoon-shaped cup
tip; available in 1.5 mm (5-0 or 00000), 2 mm (4-0 or
0000), 2.2 mm (3-0 or 000), and 2.5 mm (2-0 or 00) cup diameter
Uses: Sharp edges used for debulking of bone or other compact tissue
Notes: Heavier handle and shaft useful for digging into thick or dense tissues
House curette
Size: 7.0″ length; 1-mm/1.2-mm or 1.5-mm/1.8-mm double-ended tips
FIGURE 11-16
Characteristics: Flat-handled, double-ended with

tapering ends; small 1-mm/1.2-mm or large
1.5-mm/1.8-mm sharp or dull edge, spoon-shaped,
cup tips
Uses: Used for debulking of delicate microscopic ear structures
Notes: When being used under microscope, ask surgeon which size/end he or she needs
continues
Ear Instrumentation—DEBULKING INSTRUMENTS continued
Malleus nipper
FIGURE 11-17
Size: 3.0″
Characteristics: Nonratcheted, pistol-grip–style ring-handle with fine shaft and
up- or down-biting and right- or left-biting sliding cutting surface
Uses: For bone or other compact tissue debulking
Notes: Miniature rongeur style similar to a Kerrison rongeur
Piling branded instrumentation courtesy of Teleflex Medical.
Ear Instrumentation—PROBES AND DILATORS
Brown applicator
FIGURE 11-18
Size: 5.75″
Characteristics: Thin, malleable, triangular-tipped
applicator
Uses: Small bits of cotton can be wound onto the tip to swab the ear
Notes: Available in triangular or cross-serrated tip style
Buck applicator
FIGURE 11-19
Size: 7.5″
Characteristics: Long, thin, straight handle and shaft
with 1.5-mm spiral coarse serrations at tip
Uses: Small bits of cotton can be wound around tip to swab the ear
Notes: Serrated handle for secure hold while twisting instrument in ear Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Day ear hook
FIGURE 11-20
Size: 6.5″; small; large
Characteristics: Very thin handle with small or large
right-angle blunt tip
Uses: Used to explore depth and direction of ear canal
Notes: Protect fine right-angle tip during packaging Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Gross ear hook and spoon

Size: 5.0″
FIGURE 11-21
Characteristics: Straight shaft, double-ended instrument

with blunt right-angled hook on one end and blunt
edge, oval spoon on opposite end
Uses: For probing the ear canal and scoop for retrieval
of foreign material or cerumen
Notes: May be used with or without magnification Courtesy of Sklar Instruments.
continues
Ear Instrumentation—PROBES AND DILATORS continued
Hough stapedectomy foot plate pick
FIGURE 11-22
Size: 6.0″
Characteristics: Thin, straight handle with slight angle
of shaft and right-angle sharp tip
Uses: Used for manipulation of stapes bone in ear
Notes: Care must be taken to prevent dulling or
production of a barb at the sharp tip
Rosen pick
Size: 6.25″
FIGURE 11-23
Characteristics: Thin handle with slight curve at distal
end and sharp point tip
Uses: May be used to manipulate fine tissues or graft
material in the ear
Notes: For use in multiple ear procedures; care should
be taken to protect sharp tip from blunting Piling branded instrumentation courtesy of Teleflex Medical.
Rosen suction tube

Size: 2.5″; 14–26 g lumen
FIGURE 11-24
Characteristics: Hollow cannula tip available in multiple
diameters; flange at base for connection to Luer-Lok
syringes or suction control adapters
Uses: For suctioning or aspiration of blood or secretions in
small incisions
Notes: May come with thin wire stylets for dislodging debris
from internal cannula Piling branded instrumentation courtesy of Teleflex Medical.
Ear Instrumentation—EVACUATION AND INSTILLATION INSTRUMENTS
Frazier suction tip

Size: 7.5″ length; 6 Fr. to 12 Fr.
Characteristics: Angled, thin, hollow cannula with finger-
FIGURE 11-25
control opening; wire stylet included; ridged connection

for suction tubing
Uses: Used for suctioning of small or narrow structures
Notes: Intensity of suction pressure is reduced when finger
is removed from finger-control opening and increased when opening is
covered; various diameters of cannulas are available for use; wire stylet is
used to dislodge debris clogs
continues
Ear Instrumentation—EVACUATION AND INSTILLATION INSTRUMENTS continued
Baron suction tip

Size: 7.5″ length; 3 Fr.; 5 Fr.; 7 Fr.
Characteristics: Delicate, thin, angled suction tip
FIGURE 11-26
with thumb-controlled pressure opening; connects
to conventional suction source; flexible wire stylet
included
Uses: Suctioning of small or narrow structures
Notes: Suction pressure is reduced when finger is
removed from finger-control opening and increased
when opening is covered; finer diameters than most
Frazier tips with various diameters of cannulas available
for use; wire stylet is used to dislodge debris clogs Courtesy of Sklar Instruments.
House suction cut-off adapter
FIGURE 11-27
Size: 2.25″
Characteristics: Hollow cannulated adapter with finger cut-off opening
Uses: Luer cone and Luer hub connections for tubing and Rosen or Day type tips
Notes: Provides variability of suction tip sizes, and finger control of negative
suction pressure is needed Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Ear Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS
Boucheron ear specula
FIGURE 11-28
Size: 5 mm; 6 mm; 7 mm; 8 mm
Characteristics: Reusable metal specula with round
distal opening
Uses: For visualization of ear canal
Notes: Chrome plated to reflect microscope lighting Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Gruber ear specula

FIGURE 11-29
Size: 1.5″ length; small, medium, large, and

infant diameter openings
Characteristics: Reusable metal specula with
oval distal opening
Uses: Oval opening for visualization of ear
canal
Notes: Chrome plated to reflect microscope lighting Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
continues
Ear Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS continued
Farrior ear specula
FIGURE 11-30
Size: 4–6 mm
Characteristics: Oval, slightly slanted opening
Uses: Visualization of ear canal
Notes: Stainless steel with nonglare finish
Mastoid Instrumentation
Mastoid procedures are a combination of compact bone lists several types of instruments that are commonly
or cartilage and soft tissue surgery. The procedure used during a mastoidectomy. These few instruments
involves incising the epidermis and dermis with a are added to the previously listed ear procedure instru-
short foundation set, cutting through bony areas, and ments for a full complement of external and internal ear
debulking bony mastoid air cells. The following table procedural needs.
Mastoid Instrumentation—GRASPING FORCEPS
House Gelfoam pressure forceps
FIGURE 11-31
Size: 6.25″
Characteristics: Ratcheted, ring-handle forceps with square, flat plates at tips that
compress together tightly
Uses: Used for crushing Gelfoam (absorbable gelatin sponge) pieces for removal of
air and/or fluid
Notes: Similar structure to a clamp but not designed to be used as a hemostat Piling branded instrumentation courtesy of Teleflex Medical.
Hartmann alligator ear forceps
FIGURE 11-32
Size: 5.0″
Characteristics: Nonratcheted, ring-handled, angled forceps with 6-mm
serrated tips with central grooves
Uses: For debridement or extraction of foreign bodies from ear canal
Notes: Angled to maintain visual perspective in narrow areas
Noyes alligator ear forceps

FIGURE 11-33
Size: 3.25″; 5.5″; 6.5″ lengths for instrument shafts

Characteristics: Nonratcheted, pistol-grip–style ring-handles with fine,
tapered, serrated tips; available with 1 × 2 teeth at tip as well
Uses: Serrated up-biting jaws used for introduction or extraction of objects
in ear canal
Notes: Angle maintains visual perspective in narrow areas Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Mastoid Instrumentation—DISSECTION INSTRUMENTS
Freer elevator
FIGURE 11-34
Size: 7.25″
Characteristics: Double-ended dissector with one
5-mm end that is sharp and the other end that is
blunt; cross-serrated hand-grip
Uses: Blunt dissection and elevation of periosteum
Notes: Found in multiple specialty trays © 2019 Cengage®.
Freer chisel
FIGURE 11-35
Size: 6.5″
Characteristics: Straight handle and shank; slight up-curvature, 4-mm, sharp chisel tip
Uses: Fine cutting surface used to cut or scrape bone or other compact tissue in ear procedures
Notes: Small mallet may be used to impact chisel end in order to cut bone
Courtesy of Padgett Surgical Instruments, a division of Integra LifeSciences Corporation.
Mastoid Instrumentation—DEBULKING INSTRUMENTS
Hartman rongeur
FIGURE 11-36
Size: 5.75″
Characteristics: Straight rongeur with curved jaws and oval-shaped,
sharp-edged cupped tips
Uses: Used for debulking of bone in mastoidectomy
Notes: Rongeur has a single-action, spring handle for use on dense
tissue and bone Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Kerrison rongeur
Size: Various lengths; tip diameters: 1 mm, 2 mm, 3 mm,
FIGURE 11-37
4 mm, 5 mm
Characteristics: Pistol-grip–style spring handle with
slide mechanism in shaft; tips can be straight up- or
down-biting or angled up-biting; tip widths are 1, 2, 3,
4, or 5 mm
Uses: For removal of bone or other compact tissue
Notes: Narrow shaft allows access to small or narrow
areas without obscuring view © 2019 Cengage®.
continues
Mastoid Instrumentation—DEBULKING INSTRUMENTS continued
Beyer bone rongeur

Size: 7.0″
FIGURE 11-38
Characteristics: Double-action, curved-jaw rongeur with spring-
grip handle; 3 × 14-mm concave cup tips
Uses: Used for debulking of bone or other compact tissue
Notes: Double-action provides for increased closing pressure
Lempert rongeur
Size: 6.25″
FIGURE 11-39
Characteristics: Single-action, spring-handle rongeur with straight or
curved jaws; 2.5-mm cup tips
Uses: For debulking of bone or other compact tissue in a mastoidectomy
Notes: Delicate ball-and-socket handle
Freidman mini rongeur
FIGURE 11-40
Size: 5.5″
Characteristics: Delicate single-action, spring-handle rongeur
with straight or curved jaws; 1.3-mm cup bite at tips
Uses: Fine debulking rongeur for mastoid dissection
Notes: Short length good for superficial tissues or use in
pediatric procedures Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Mastoid Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS
House retractor
FIGURE 11-41
Size: 6.0″
Characteristics: Handheld, double-ended, smooth,
right-angle blades in opposite directions
Uses: For superficial tissue retraction
Notes: Handheld retractors often used in pairs for
bilateral retraction Piling branded instrumentation courtesy of Teleflex Medical.
continues
Mastoid Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS continued
Jansen retractor
FIGURE 11-42
Size: 4.5″
Characteristics: Small, self-retaining retractor with thumbscrew
opening width of 3.0″ with 3 × 3 10-mm deep, blunt prongs
Uses: Separation of wound edges without need for handheld
retractors, which might obscure visualization of the surgical site
Notes: Also available in 3 × 3 or 4 × 4 sharp or dull prongs, or
20-mm depth © 2019 Cengage®.
Jansen-Wagner mastoid retractor
FIGURE 11-43
Size: 5.0″
Characteristics: Self-retaining retractor with thumbscrew; sharp prongs 5 × 5 on
pivots for self-adjusting positioning
Uses: Retraction of thick tissue in mastoidectomy
Notes: Separation of wound edges without need for handheld retractors, which might
obscure visualization of the surgical site Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Alm retractor
FIGURE 11-44
Size: 2.75″; 3.75″; 4.0″
Characteristics: Small, self-retaining retractor with
thumbscrew and short 4 × 4 blunt prongs
Uses: Superficial retraction of small incisions
Notes: Also available with sharp prongs Courtesy of Sklar Instruments.
Heiss retractor
FIGURE 11-45
Size: 4.0″
Characteristics: Cross-bar action; small retraction with 4 × 4 or 4 × 5 prongs;
available in sharp or blunt styles
Uses: Retracts wound edges to expose surgical site
Notes: Used for very superficial tissues and small incisions Piling branded instrumentation courtesy of Teleflex Medical.
Weitlaner retractor
Size: 4.0″; 5.5″; 6.5″
FIGURE 11-46
Characteristics: Self-retaining straight or curved

retractor that locks with cam-ratchets; ring handles;
sharp or blunt prongs in 2 × 3 or 3 × 4 configurations
Uses: Mainly used for bilateral retraction of superficial
tissues
Notes: Multiple options for size of incision opening
continues
Mastoid Instrumentation—RETRACTION AND EXPOSURE INSTRUMENTS continued
Weitlaner-Beckman retractor
Size: 5.5″; 6.5″
Characteristics: Self-retaining straight retractor with hinged
FIGURE 11-47
articulating distal ends; locks with cam-ratchets; ring handles;
sharp or blunt prongs in 2 × 3 or 3 × 4 configurations
Uses: Retraction and exposure by positioning its articulating
sides over areas with high and low body contours such as the
rounded lateral and posterior skull
Notes: Similar in style to a Weitlaner, but has hinged blades to
allow for displacement of the ringed handles © 2019 Cengage®.
Perkins endaural retractor

Size: 5.25″
FIGURE 11-48
Characteristics: Curved, self-retaining cam-ratchet retractor with ring handles; one
serrated blade and 3 opposing sharp prongs
Uses: Retraction of wound edges without obscuring the operative site by assistant
holding hand-held retractors
Notes: Available in right-serrated blade or left-serrated blade options for protection of
delicate tissues Courtesy of CareFusion, a division of Becton, Dickinson and Co.
NOSE AND THROAT instruments have double-action hinges to minimize

visual obstruction during tissue removal. Many of
INSTRUMENTATION the instruments are angled to prevent the user’s
Nasal procedures include components of both inter- hands from blocking the view of the surgical field.
nal and external soft and compact tissue manipula- Scrub personnel should keep the suction imme-
tion or modification. External tissue modification diately available because of the vascular nature of
requires the use of a short foundation set. When nasal tissue and adjacent anatomic structures. The
external nasal procedures are combined with internal nasopharynx is a direct path to the airway and
procedures, the following instrumentation should be could collect clots and tissue around the balloon
added to complete the setup. of the endotracheal tube. If the sinuses are entered,
Internal nasal instruments commonly have ring the aspirated material could be contaminated from
handles, spring handles, or pistol-style grips. The purulent discharge present. The instrumentation in
working space limits the area available for instru- this section is designed for use in the nasopharynx.
ment jaw mobility; therefore, the shanks are narrow The exterior neck instrumentation is described later
and the jaws and tips are shorter. Some debulking in this chapter.
Intranasal and Pharyngeal Instrumentation

Intranasal and Pharyngeal Instrumentation—GRASPING FORCEPS
Collin tongue forceps

Size: 6.75″
FIGURE 11-49
Characteristics: Straight, ratcheted, ring-handled
forceps with oval, serrated fenestrated jaws;
intermediate weight
Uses: For traction of the slippery tongue
Notes: Fenestrated, ring tips reduce tissue trauma during
traction and manipulation
Young tongue forceps

Size: 6.5″
FIGURE 11-50
Characteristics: Side-angled ring-hand forceps with
oval, rubber, serrated jaw insets; ratchet locks;
intermediate weight
Uses: For traction of the slippery tongue
Notes: Silicon or rubberized pads reduce slippage and
tissue trauma during manipulation Courtesy of Sklar Instruments.
Cushing bayonet tissue forceps

Size: 7.5″
FIGURE 11-51
Characteristics: Bayonet-style thumb forceps available
with serrations or 1 × 2 teeth; tip of handle has a
scraper configuration; peg-stop between shanks
Uses: Grasping and holding of tissue or sponges
Notes: Peg-stop between shanks prevents excessive
compression of tissue in jaws; bayonet shape prevents
obscuring of view of target tissue Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Adson bayonet forceps

Size: 7.5″; 8.25″
FIGURE 11-52

blunt tips
Notes: Offset angle allows for an unobstructed view of
narrow structures such as the nares; bayonet forceps with
teeth are also available; choice of bayonet type is
surgeon’s preference Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
continues
Intranasal and Pharyngeal Instrumentation—GRASPING FORCEPS continued
Hartmann nasal forceps
FIGURE 11-53
Size: 6.0″; 7.0″; 7.25″
Characteristics: Ring-handled, laterally angled dressing forceps with long
shanks, oval tips, and serrated jaws; delicate weight available; no ratchets
Notes: Angled shape helpful in rhinoplasty procedures
Instruments provided by www.sonictecinstruments.com.
Noyes alligator forceps
FIGURE 11-54
Size: 3.75″; 5.5″
Characteristics: Nonratcheted, squeeze-handle; long, thin shaft with
tapered, horizontally serrated jaws with central groove
Uses: Used in ear and nose for placement or extraction of objects
Notes: Blunt and toothed styles available
Heymann-Knight nasal forceps
FIGURE 11-55
Size: 7.0″
Characteristics: Medium-length, serrated, oval or cupped
jaws with angled ring handles; no ratchets
Notes: Similar to Hartmann nasal forceps
Watson-Williams nasal cutting forceps
FIGURE 11-56
Size: 5.0″; 7.75″
Characteristics: Pistol-grip style with ring handles and rounded jaws available
in 6 or 9 mm diameter
Uses: Used to grasp and remove nasal polyps
Notes: Similar to a Takahashi or pituitary rongeur
Rubin septal morselizer

Size: 8.0″
FIGURE 11-57
Characteristics: Flat, heavily serrated jaws; forward-angled,

double-action hinges and angled spring handles
Uses: Used to crush and morselize septal cartilage
Notes: Forward-bending angle minimizes visual obstruction;
double-action hinge provides greater closing pressure
during firm grasping and crushing of tissue Courtesy of Padgett Surgical Instruments, a division of Integra LifeSciences Corporation.
continues
Intranasal and Pharyngeal Instrumentation—GRASPING FORCEPS continued
Ballenger tonsil forceps
FIGURE 11-58
Size: 8.5″
Characteristics: Long, curved jaws with 3 × 3 sharp teeth; one
open ring with ratchet locks
Uses: Used for firm grasping and traction on tonsils
Notes: Care must be taken to prevent sharps injury Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Tivnen tonsil forceps
FIGURE 11-59
Size: 7.5″
Characteristics: Lateral-bending, right-angle shanks with 3 × 3
sharp teeth; ratchets and one open ring handle
Notes: Care must be taken to prevent sharps injury
White tonsil forceps
FIGURE 11-60
Size: 7.5″; 9.0″
Characteristics: Ring-handled, curved grasper with Allis-
style teeth; curved or straight shanks with one open finger
ring; ratchet locks
Notes: Care must be taken to prevent sharps injury Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Intranasal and Pharyngeal Instrumentation—DISSECTION INSTRUMENTS
Joseph scissors
FIGURE 11-61
Size: 5.75″
Characteristics: Short, delicate, curved or straight
blades and sharp tips
Uses: Precision cutting of fine tissue
Notes: Sharp tips must be protected from blunting Courtesy of Sklar Instruments.
Cottle dorsal scissors

FIGURE 11-62
Size: 6.0″
Characteristics: Forward-angled, medium-heavy, blunt-tipped
scissors
Uses: Sharp dissection of medium to heavy tissue
Notes: Angled forward for access to nasal structures without
obstruction of view © 2019 Cengage®. Photo by Margaret Rodriguez.
continues
Intranasal and Pharyngeal Instrumentation—DISSECTION INSTRUMENTS continued
Knight scissors
FIGURE 11-63
Size: 6.25″
Characteristics: Side-angled medium-heavy, blunt-tipped scissors
Uses: Sharp dissection of heavier nasal tissues
Notes: Side-angled for access to nasal structures without obstruction
of view
Seiler turbinate scissors
FIGURE 11-64
Size: 6.25″
Characteristics: Angled to side, medium-heavy scissors
with longer blades and blunt tips
Uses: Sharp dissection of nasal turbinate tissues
Notes: Blunt tips prevent puncture or tearing of proximal
structures Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Freer septum knife
FIGURE 11-65
Size: 6.25″
Characteristics: Reusable, D-shaped knife blade on
one side of tip; flattened handle with grooves
Uses: Sharp dissection of nasal septal cartilage and mucosa
Notes: Cutting edges should be inspected for sharpness and
absence of edge damage Courtesy of Padgett Surgical Instruments, a division of Integra LifeSciences Corporation.
Freer elevator
FIGURE 11-66
Size: 7.25″
Characteristics: Double-ended dissector with one
5-mm end that is sharp and the other end that is
blunt; cross-serrated hand-grip
Uses: Blunt and somewhat sharp dissection and elevation of periosteum or nasal mucosa
Notes: Sharper end may need to be sent out to be resharpened if dull © 2019 Cengage®.
Freer chisel
Size: 6.5″
FIGURE 11-67
Characteristics: Straight handle and shank; slight

up-curvature; 4-mm, sharp chisel tip
Uses: Fine cutting surface used to cut or scrape bone or
other compact tissue in ear procedures
Notes: Small mallet may be used to impact chisel end in
order to cut bone Courtesy of Padgett Surgical Instruments, a division of Integra LifeSciences Corporation.
continues
Ballenger swivel knife A.
FIGURE 11-68
Size: 7.75″
Characteristics: Narrow, straight, or bayonet-shaped
shaft with reusable swivel blade at tip
B.
Uses: Sharp dissection of midline septal cartilage
Notes: Cutting surface rotates as pressure is exerted
against tissue A: Instruments provided by www.sonictecinstruments.com; B: Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Ballenger V-shaped chisel
FIGURE 11-69
Size: 6.0″
Characteristics: Straight chisel with inverted V-shaped tip
Uses: Used with lightweight mallet to shape the nasal bridge
Notes: Available in various tip widths Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Joseph double-edged nasal knife
FIGURE 11-70
Size: 6.0″
Characteristics: Reusable knife with sharp double edge
and tip; flattened handle; available in curved or straight styles
Uses: Used to sharply dissect nasal mucosa off of nasal cartilage or bone
Notes: Cutting edges should be inspected for sharpness and absence of edge damage
Joseph button knife
FIGURE 11-71
Size: 6.0″; 6.25″
Characteristics: Straight or curved reusable knife with
small, sharp, button-tip blade
Uses: Used in rhinoplasty or septoplasty to sharply
dissect nasal mucosa from septal bone or cartilage
Notes: Reinforced blunt button tip protects adjacent tissue as the sides
of the knife cut Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Cottle nasal knife

FIGURE 11-72
Size: 5.5″
Characteristics: Straight 4-mm blade with cutting
surface situated at the tapered tip; flat handle with
horizontal grooves
Uses: Used in rhinoplasty or septoplasty to sharply
dissect nasal mucosa from septal bone or cartilage
Notes: Cutting edges should be inspected for sharpness
and absence of edge damage Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
continues
Cottle septum elevator

Size: 9.0″
FIGURE 11-73
Characteristics: Double-ended blunt dissector with
flat middle handle, one rounded end and one more
flattened end
Uses: Blunt dissection of nasal mucosa from septal bone or cartilage
Notes: Graduations are marked in centimeters
Courtesy of Ruggles Surgical Instruments, a division of Integra LifeSciences Corporation.
Joseph nasal saw

Size: 7.5″
FIGURE 11-74
Characteristics: Reusable, serrated, side-cutting saw
blade available in angled, straight, or right-facing or
left-facing bayonet style
Uses: For use in rhinoplasty or septoplasty procedures
to cut septal cartilage or bone
Notes: Serrated saw blade should be inspected for broken
or bent points to prevent tissue damage
Fisher tonsil knife

Size: 8.5″
Characteristics: Reusable, straight-
handled knife with curved, semi-
sharp serrated blade
Uses: Used to scrape and sharply
dissect tonsils from pharyngeal
FIGURE 11-75
wall
Notes: Sometimes called ″hockey
stick″ knife
continues
Dean tonsil knife
FIGURE 11-76
Size: 7.5″
Characteristics: Reusable knife with straight double-
edge blade
Uses: Sharp dissection in tonsillectomy
Notes: Similar to Joseph button knife Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Hurd tonsil dissector
FIGURE 11-77
Size: 9.0″
Characteristics: Double-ended instrument; smooth,
rounded, blunt dissection blade with pillar retractor
blade lip on opposite end
Uses: For blunt tissue dissection or retraction in tonsillectomy
and other oral procedures
Notes: Rounded, pencil-style handle Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Gerzog mallet
FIGURE 11-78
Size: 7.5″
Characteristics: 14-ounce, lead-filled mallet
Uses: Used to impact instruments such as chisels or
osteotomes
Notes: Surgeon may ask assistant to gently “tap-tap”
the instrument end with the mallet Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Lucae mallet
FIGURE 11-79
Size: 8.0″
Characteristics: Small 8-ounce mallet
Uses: Used to impact instruments such as chisels or
osteotomes held by surgeon
Notes: Surgeon may ask assistant to gently “tap-tap” the
instrument end with the mallet Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Intranasal and Pharyngeal Instrumentation—DEBULKING INSTRUMENTS
Bruening septum forceps

FIGURE 11-80
Size: 7.5″
Characteristics: Heavy shanks with fenestrated cupped jaws; no
ratchets; angled ring handles
Uses: Used in septoplasty or rhinoplasty procedure for firm grasping
of nasal septum bone or cartilage
Notes: Available in small, medium, large, and extra-large cups Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
continues
Intranasal and Pharyngeal Instrumentation—DEBULKING INSTRUMENTS continued
Jansen-Middleton septum forceps

Size: 7.5″
FIGURE 11-81
Characteristics: Double-action, angled spring-handles; spoon-
shaped jaws or fenestrated, flat, oval cutting jaws
Uses: For sharp dissection of nasal septal bone or cartilage
Notes: Double-action hinge design provides increased closing
pressure
Takahashi ethmoid forceps

Size: 7.5″ instrument length; 5.0″ working length
FIGURE 11-82
Characteristics: Angled ring handles; no ratchets; elongated
2 mm × 10 mm cup jaws
Uses: Sharp dissection of ethmoid tissue
Notes: Resembles pituitary rongeur
Wilde rongeur
Size: 5.5″
FIGURE 11-83
Characteristics: Angled ring handles; no ratchets; pointed
fenestrated cutting, cupped jaws
Uses: Used for sharp dissection of ethmoid tissue
Notes: Available in four sizes
Kerrison rongeurs
Size: Various lengths; tip diameters: 1 mm, 2 mm, 3 mm,
4 mm, 5 mm
Characteristics: Pistol-grip–style spring handle with FIGURE 11-84
slide mechanism in shaft; tips can be straight up- or
down-biting or angled up-biting; tip widths are 1, 2, 3,
4, or 5 mm
Uses: Sharp dissection of bone or other compact tissue
Notes: Narrow shaft allows access to small areas for
removal of bone or other compact tissue without
obscuring view; used frequently in neurosurgery © 2019 Cengage®.
continues
Pratt ethmoid curette
FIGURE 11-85
Size: 8.25″
Characteristics: Double-ended, round curette with
fenestrated cup on angled tip and solid cup on straight tip
Uses: Used to scoop out or debulk tissue
Notes: May be used in septoplasty or ethmoidectomy procedures Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Faulkner ethmoid curette
FIGURE 11-86
Size: 8.75″
Characteristics: Double-ended, open-ring curette; one
end is 7 mm and the opposite end is 10 mm
Uses: Used for excision of tissue in the nasal antrum
Notes: Tissue may be wiped off of curette with moistened
sponge or swished in specimen cup with small amount of saline Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Joseph raspatory
FIGURE 11-87
Size: 6.25″
Characteristics: Single-ended, straight raspatory with
oval-shaped blade with cross-hatched serrations
Uses: Used to smooth and debulk delicate bone edges
Notes: Rasp surface should be inspected for any retained bone pieces
Courtesy of Joe Fortunato.
Cottle raspatory
Size: 8.0″
FIGURE 11-88
Characteristics: Single-ended instrument with
backwards-cutting horizontal serrations on jaw
Uses: For filing jagged edges or reshaping bone in nasal
procedures
Notes: Cutting serrations should be sent out for
re-sharpening if dull Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Maltz raspatory
FIGURE 11-89
Size: 7.0″
Characteristics: Three rows of serrations in jaw; flat
handle with vertical grooves
Uses: For filing or reshaping bone edges
Notes: Inspect serrations for sharpness or any retained bone fragments Courtesy of Padgett Surgical Instruments, a division of Integra LifeSciences Corporation.
continues
Aufricht glabella rasp
FIGURE 11-90
Size: 8.25″
Characteristics: Single-ended bone file with slightly
curved tip with reverse or forward horizontal serrations
Uses: Used to smooth bone edges
Notes: Inspect serrations for sharpness or any retained bone fragments
Fomon rasp
Size: 8.0″
FIGURE 11-91
Characteristics: Double-ended rasp with four serrated
convex sides for fine, flat, and backwards cutting
Uses: For shaping and smoothing of bone or other
compact tissues
Notes: May have tungsten-carbide tips indicated by gold handles
Weiner antrum rasp

Size: 7.0″
FIGURE 11-92
Characteristics: Angled, rounded trocar-tip rasp with
circumferential, downward cutting treads and blunt tip
Uses: Used to sharply debulk nasopharyngeal passages
to create an antrostomy
Notes: Available in three diameters
Barnhill adenoid curette

Size: 8.5″
FIGURE 11-93
Characteristics: Square fenestrated blade with
sharpened edge; available in curved shaft or straight
and multiple sizes of fenestrated blades
Uses: Used to debulk and strip adenoid and tonsil tissue from pharyngeal wall
Notes: Flat edge should be inspected for sharpness
continues
Shambaugh adenotome
Size: 9.25″
Characteristics: Curved box-chamber–type instrument
with sliding, sharp blade tip; three finger rings; sliding
FIGURE 11-94
action of cutting tissue
Uses: Uses a “guillotine” type of cutting action of
adenoidal tissue placed into box chamber, then
sliding blade cuts tissue off
Notes: Available in different curvatures and sizes of box
chamber to accommodate different sizes of patients; blade
must be pulled back to empty box of specimen
Meltzer adenoid punch

Size: 5.5″
Characteristics: Ring-handled grasper with round or triangular
FIGURE 11-95
debulking biting surface
Uses: Used for debulking adenoidal tissue
Notes: Similar in shape to a Takahashi or pituitary rongeur
Intranasal and Pharyngeal Instrumentation—PROBES AND DILATORS
Farrell applicator
FIGURE 11-96
Size: 5.5″
Characteristics: Straight probe
with irregular surface on tip
Uses: For use in the application of
intranasal medications
Notes: Cotton is wound around the tip
and used to swab the nasal mucosa Courtesy of Sklar Instruments.
Intranasal and Pharyngeal Instrumentation—EVACUATION AND INSTILLATION

INSTRUMENTS
Coakley antrum trocar

Size: 7.0″
FIGURE 11-97
Characteristics: Perforating device with curved
cannula, triangular cutting obturator, and irrigating
port; 3 mm diameter
Uses: Used for access to sinus cavities for irrigation and
drainage
Notes: Irrigation extension tip is available Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Lichtwicz antrum trocar
FIGURE 11-98
Size: 4.25″
Characteristics: Needle-style trocar with cross T handle; sharp obturator;
16-g tip with Luer-Lok connection
Uses: For evacuation of sinus contents by aspiration
Notes: Designed to connect to syringe after obturator is removed Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
Intranasal and Pharyngeal Instrumentation—RETRACTION AND EXPOSURE

INSTRUMENTS
Vienna nasal speculum
FIGURE 11-99
Size: 5.5″
Characteristics: Spring-handled nasal speculum that separates nasal
tissue
Uses: For direct visualization of the nares
Notes: Available in small, medium, and large Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Halle infant speculum
FIGURE 11-100
Size: 5.25″
Characteristics: Small, spring-handled, 18-mm nasal
speculum
Uses: For direct visualization of infant nasal passages
Notes: Limited opening size to protect infant tissues Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Beckman nasal speculum

FIGURE 11-101
Size: 5.75″
Characteristics: Nasal speculum with angled, double-
spring handle and strongly curved shaft
Uses: Visualization of nasal structures
Notes: Compound curve provides enhanced view of
nares Courtesy of CareFusion, a division of Becton, Dickinson and Co.
continues

Killian nasal speculum

Size: 6.0″ length; 3″ blades
FIGURE 11-102
Characteristics: Nasal speculum with spring handle and long
narrow blades; locks with screw
Notes: Longer blades allow for greater access to deeper
nasal structures
Cottle nasal speculum
FIGURE 11-103
Size: 5.5″; 6.0″
Characteristics: Spring-loaded nasal speculum with
screw lock
Notes: Available in laser-safe ebonized finish
Kleinert-Kutz hook
FIGURE 11-104
Size: 5.0″
Characteristics: Hook-style retractor with sharp tip
Uses: Used for very superficial, delicate skin retraction
Notes: Care must be taken to prevent sharps injury or blunting of the sharp tip
Joseph hook
Size: 6.25″
Characteristics: Hook-style skin
retractor with sharp
single or double tips
FIGURE 11-105
Uses: Superficial handheld retraction of

very thin, delicate skin
Notes: Available in double-hook tips of 2
mm to 12 mm separation
continues

Aufricht nasal retractor

Size: 7.25″
FIGURE 11-106
Characteristics: Solid or open 11 mm × 60 mm long blade
on angled handle
Notes: Angle provides for unobstructed view into nares
Brown uvula retractor
FIGURE 11-107
Size: 8.5″
Characteristics: Long, thin retractor with forward-curved,
wire-loop tip
Uses: Manual retraction of uvula
Notes: Fenestrated loop tip minimizes tissue trauma during retraction Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Love uvula retractor
FIGURE 11-108
Size: 18 mm
Characteristics: Flat, double-angled retractor with rounded lip; available in various
widths
Uses: Retraction of uvula for access to adenoid tissue
Notes: Hooked distal end prevents slippage during retraction
Wieder tongue depressor
FIGURE 11-109
Size: 28 mm; 36 mm
Characteristics: Manual right-angle tongue retractor; contact surface is clover leaf or
heart-shaped with traction serrations
Uses: For depression of pediatric or adult tongues
Notes: Available in small pediatric and large adult sizes Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Bosworth tongue depressor FIGURE 11-110
Size: 25 mm
Characteristics: Manual right-angle retractor with fenestrated blade; smooth surface
Uses: For depression of the tongue
Notes: May be used in combination with mouth gag such as Jennings
continues

Blair cleft palate retractor
FIGURE 11-111
Size: 7.75″; 8.0″
Characteristics: Long, thin, manual, blunt, right-angle
retractor
Uses: Used for gentle retraction of intraoral structures in cleft palate repair procedures
Notes: Longitudinal serrations in the handle prevent slippage during retraction
Columbia lip retractor

Size: 5.5″
Characteristics: Double-ended, manual, fenestrated, straight lip
FIGURE 11-112
retractor; 35-mm and 50-mm blade widths
Uses: Gentle retraction of the lip in dental, oral, or maxillofacial
procedures
Notes: Two widths available to accommodate patient size
University of Minnesota cheek retractor

Size: 5.5″
FIGURE 11-113
Characteristics: Manual, solid-blade cheek retractor; double
ended; 14-mm and 20-mm blade widths
Uses: Used in dental, oral, or maxillofacial procedures to retract
the cheeks
Notes: Two widths available to accommodate patient size
Cheek retractor with swivel blade

Size: 7.25″
FIGURE 11-114
Characteristics: Manual scoop-blade retractor with

swivel head; fenestrated loop handle
Uses: Used in dental, oral, or maxillofacial procedures to
retract the cheeks
Notes: Swivel head allows for repositioning of the
retractor handle without removing and replacing the retractor blade
continues

Davis mouth gag

Size: 6.25″
Characteristics: Self-retaining mouth retractor with side
opening; ratchet locks on vertical plane; padded teeth
FIGURE 11-115
protector
Uses: Used to maintain opening of the mouth for oral
procedures such as tonsillectomy
Notes: Available in right or left models; surgeon may
suspend distal hook end of the tongue blade from a
Mayo stand placed over the patient
Doyen-Jansen mouth gag

Size: 5.5″
FIGURE 11-116
Characteristics: Self-retaining mouth retractor with cam
ratchets; 4.5″ right-angle intraoral blades
Uses: Used to maintain opening of the mouth in oral procedures
such as tonsillectomy
Notes: May be used in conjunction with a tongue depressor
such as the Weider
McIvor mouth gag
FIGURE 11-117
Size: 5.75″
Characteristics: Self-retaining mouth retractor; ratchet locks on
vertical plane
Uses: Maintains opening of the mouth for oral procedures such as
tonsillectomy
Notes: Surgeon may suspend distal hook end of the tongue blade
from a Mayo stand placed over the patient
continues

Jennings mouth gag

Size: 6.0″; 4.75″; 3.75″
Characteristics: Self-retaining mouth retractor with side
FIGURE 11-118
ratchets; reversible for right or left locking
Uses: Used to maintain opening of the mouth for oral
procedures such as tonsillectomy
Notes: The central portion may be padded with gauze to
protect the teeth
Dingman mouth gag

Characteristics: Self-retaining, square mouth retractor with three
tongue retraction blades
FIGURE 11-119
Uses: Used to maintain opening of the mouth for oral procedures such
as tonsillectomy
Notes: Small side blades provide lateral cheek retraction
Intranasal and Pharyngeal Instrumentation—SPECIALTY-SPECIFIC INSTRUMENTS
Cottle cartilage crusher
FIGURE 11-120
Size: 16-mm anvil
Characteristics: Stainless-steel anvil with hinged crusher
Uses: For flattening and reshaping of graft cartilage
Notes: Cartilage is removed from anvil with forceps after being crushed flat
Eve tonsil snare

FIGURE 11-121
Size: 11.0″
Characteristics: Straight snare with three finger rings
Uses: Ligation and severing of tonsils
Notes: Uses disposable wire loop, which is pulled back
into the cannula to sever the tonsil Courtesy of Jarit Surgical Instruments, a division of Integra Life Sciences Corporation.
continues
Intranasal and Pharyngeal Instrumentation—SPECIALTY-SPECIFIC INSTRUMENTS continued
Tyding tonsil snare
FIGURE 11-122
Size: 9.25″
Characteristics: Pistol-grip snare with straight tip; slide bar with wire-insertion
holes
Uses: Ligation and severing of tonsils
Notes: Uses disposable wire loop, which is pulled back into the cannula to sever
the tonsil
Krause-Voss nasal polyp snare
FIGURE 11-123
Size: 10.5″
Characteristics: Instrument with three finger rings that is
armed with a disposable-wire grasping snare
Uses: Wire encircles and amputates a polyp or other tissue
segment
Notes: Similar action as Eve or Tyding tonsil snares Piling branded instrumentation courtesy of Teleflex Medical.
ANTERIOR NECK of the neck’s complex vascular and neurologic struc-

tures. The short and medium foundation instrument
INSTRUMENTATION sets are commonly used; however, the long foundation
Anterior neck instrumentation is used for superficial set could be required for deep esophageal dissection.
and subcutaneous structures associated with glandular, Anterior neck procedures are primarily soft tissue dis-
digestive, endocrine, and airway components. Neck section. Few additional specialty instruments could be
dissection can be tedious and time consuming because needed for dissection and exposure.
Thyroidectomy and Neck Dissection Instrumentation

Thyroidectomy and Neck Dissection Instrumentation—PROBES AND DILATORS
Cushing nerve hook
FIGURE 11-124
Size: 7.5″
Characteristics: Thin, single-ended instrument with
blunt hook
Uses: Used to isolate tissue layers surrounding nerves
and vascular structures
Notes: Frequently used in neurosurgery Courtesy of Sklar Instruments.
Frazier dural elevator

FIGURE 11-125
Size: 6.5″
Characteristics: Short, single-ended instrument with angled, tapered, blunt, flat tip
Uses: Used to isolate and carefully separate tissue layers surrounding nerves and vascular structures
Notes: Frequently used in neurosurgery Courtesy of Ruggles Surgical Instruments, a division of Integra LifeSciences Corporation.
continues
Thyroidectomy and Neck Dissection Instrumentation—PROBES AND DILATORS continued
Dandy nerve hook
FIGURE 11-126
Size: 9.0″
Characteristics: Long, thin, rounded handle and shaft with blunt, tapered, right-angle hook
Uses: Used to isolate and carefully separate tissue layers surrounding nerves and vascular structures
Notes: Frequently used in neurosurgery Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ.
Thyroidectomy and Neck Dissection Instrumentation—RETRACTION AND EXPOSURE

INSTRUMENTS
Lahey retractor
FIGURE 11-127
Size: 7.75″
Characteristics: Handheld, right-angle retractor with
narrow solid blade
Uses: Manual retraction for thyroid procedures
Notes: Rounded edges of retractor blade protects delicate adjacent nerves
and vessels Courtesy of Sklar Instruments.
Green retractor
FIGURE 11-128
Size: 8.5″
Characteristics: Handheld, retractor with curved fenestrated wire blade
Uses: Manual retraction for thyroid procedures
Notes: Rounded fenestrated retractor blade protects delicate adjacent nerves
and vessels from compression by solid blades
Senn retractor
FIGURE 11-129
Size: 6.25″
Characteristics: Handheld, double-ended retractor with a
solid right-angle blade at one end and a rake on the other end, facing opposite direction
Uses: Manual retraction of superficial tissues
Notes: Rake end may be either sharp or blunt; care must be taken to prevent sharps injury when
handling sharp Senn retractors Courtesy of Sklar Instruments.
Beckman-Weitlaner retractor
Size: 9.0″
FIGURE 11-130
Characteristics: Self-retaining retractor with sharp or blunt rake

blades; flexes with a hinge at midshank
Uses: Retraction and exposure by positioning its articulating
sides over areas with high and low body contours such as the
anterior neck and jaw line
Notes: Similar in style to a Weitlaner, but has hinged blades to allow
for displacement of the ringed handles © 2019 Cengage®.
Tracheostomy-Tracheotomy
Instrumentation
The short foundation set should contain sufficient in- airway maintenance instruments listed in this
struments for a tracheotomy. Additional exposure and collection are required.
Tracheostomy-Tracheotomy Instrumentation—PROBES AND DILATORS
Trousseau tracheal dilator
FIGURE 11-131
Size: 5.5″; 4.5″
Characteristics: Spring-loaded, double-bladed, blunt-tipped
tracheal dilator; manual with no ratchets
Uses: Used to expand tracheal cartilage opening for insertion of
tracheostomy tube
Notes: Opposite action of a hemostat, when finger rings are
closed, distal tips spread apart
LaBorde tracheal dilator

Size: 5.5″
Characteristics: Spring-loaded, triple-blade, blunt tipped
tracheal dilator; manual with no ratchets
FIGURE 11-132
Uses: Used to expand tracheal opening for insertion of
tracheostomy tube
Notes: Third blade provides greater tracheal dilation
Tracheostomy-Tracheotomy Instrumentation—EVACUATION AND INSTILLATION

INSTRUMENTS
Jackson laryngectomy tube

FIGURE 11-133
Size: Individually sized for each patient
Characteristics: Reusable three-part cannula system; wide diameter; components are the
sleeve, inner cannula, and insertion obturator made of sterling silver
Uses: For prolonged percutaneous airway support after laryngectomy
Notes: Plastic tracheal tubes may be preferred
Tracheostomy-Tracheotomy Instrumentation—RETRACTION AND EXPOSURE

INSTRUMENTS
News tracheotomy hook

Size: 6.0″
FIGURE 11-134
Characteristics: Flattened, taper-handled instrument
with sharp, curved hook at distal tip and rounded,
curved end at hand-held proximal end, facing opposite
direction
Uses: Provides traction of incised tracheal cartilage for insertion of tracheostomy tube
Jackson trachea hook

Size: 7.0″
FIGURE 11-135
Characteristics: Flattened, taper-handled instrument with sharp,
curved hook at distal tip and rounded, curved end at proximal,
hand-held end, in same direction
Uses: Used for traction of incised tracheal cartilage for insertion of
tracheostomy tube
© 2019 Cengage®.
SUMMARY Most procedures of the anterior neck can be per-

formed with the medium foundation set instrumen-
Surgery of the mouth and anterior neck commonly
tation along with the addition of minimal clamps,
includes exposing structural components of the upper
hooks, and dilation instrumentation used in and
airway. Safety considerations include avoiding the use
around the trachea.
of electrosurgery pencils in the presence of oxygen.
Intraoral instruments are longer, curved, or
An ignition spark could cause an upper airway fire
bayonet styled and have smaller jaws to enhance
that is disastrous and potentially fatal for the patient.
visualization while manipulating tissue within the
Anesthesia providers may adjust the anesthetic gas
confined space of the mouth and oropharynx.
ratios to include more room air than pure oxygen.
CHAPTER 12
NEUROSURGERY
INSTRUMENTATION

After reading this chapter the learner should be able to: Basic Neurosurgical
1. Select instrumentation appropriate for open cranial procedures. Instrumentation
2. Select instrumentation appropriate for spinal procedures. Clamps
3. Select instrumentation appropriate for cervical spine procedures. Specialty Neurosurgical
Hemostatic Clamps and Clips
Grasping Forceps
Specialty Graspers
INTRODUCTION
Specialty Sharp Dissection
Neurosurgery is unique because it involves working with every form of
Specialty Blunt Dissection
tissue and instrumentation from every category. Neurologic procedures
can be performed on any body part ranging from head to toe, literally. Instruments
Soft tissue dissection for peripheral nerves in the superficial regions of Retraction and Exposure
the body can be performed using short or medium foundation sets with Instruments
the addition of assorted nerve hooks and dissectors. Self-Retaining Retractors
The sections in this chapter include intracranial and spinal instru- Closure Instruments
mentation used in combination with medium and long foundation sets. Cranial Procedures
Spinal Procedures
BASIC NEUROSURGICAL INSTRUMENTATION

Instrumentation for neurosurgical surgery includes drills, saws, burrs, and
rongeurs for entering the skull and elevators for blunt dissection of the adher-
ent layers of periosteum and dura mater. Fine soft tissue is dissected with
delicate specialty devices and microscopic instrumentation. Instruments
used with microscopes are described in Chapter 14.
319
CLAMPS
Jacobson clamp
Size: 7.0″
Characteristics: Curved or straight hemostat; serrated full
FIGURE 12-1
length of jaw; fine, delicate tip
Notes: Used for small vessels during craniotomy
Dandy scalp clamp

Size: 5.5″
Characteristics: Lateral curve; serrated half the length of
the jaw
FIGURE 12-2
Notes: Used for small vessels during craniotomy. Also
known as Cairns clamp
Kelly clamp
Size: 5.5″
straight; jaw is one-third
size of the shank. Horizontal
serrations halfway down
the jaw
FIGURE 12-3
Notes: Also known as clamp,
tag, snap, hemostat, and
stat
Chapter 12 Neurosurgery Instrumentation 321
SPECIALTY NEUROSURGICAL HEMOSTATIC CLAMPS AND CLIPS
Heifetz clip applier

Size: 7.25″
FIGURE 12-4
Characteristics: Spring handle with locking jaw.
Flange on temporary clip seats into jaw for
application to vascular structure in brain.
Two styles of clip appliers: curved and straight
Notes: Used only with temporary clips
Heifetz clip, straight

Size: 8 mm or 12 mm
FIGURE 12-5
Characteristics: Black clips are light pressure
with delicate serrations. Gold clips are firm pressure.
Applied only with Heifetz clip applier
Notes: Temporary hemostasis
Heifetz clip, angled

Size: 8 mm or 12 mm
Characteristics: Black clips are light pressure with delicate
serrations. Gold clips are firm pressure. Applied only with
FIGURE 12-6
continues
SPECIALTY NEUROSURGICAL HEMOSTATIC CLAMPS AND CLIPS continued
Heifetz clip, curved

Size: 8 mm or 12 mm
Characteristics: Black clips are light pressure with delicate
serrations. Gold clips are firm pressure. Applied only with
FIGURE 12-7
Yasargil clip applier

Size: 8.0″
FIGURE 12-8
Characteristics: Spring-handled, locking, bayonet-
style forceps with cupped tips used only for
Yasargil clips. Titanium forceps are used for
titanium clips
Notes: Yasargil clips are available in temporary or
permanent styles
Yasargil clip, straight

Size: 6 mm
FIGURE 12-9
Characteristics: Double spring clip for cerebral vessels.
Applied with Yasargil clip forceps
Notes: Temporary or permanent styles available. Titanium
styles (nonmagnetic) are designed for permanence and
can be used in magnetic resonance imaging (MRI)
continues
SPECIALTY NEUROSURGICAL HEMOSTATIC CLAMPS AND CLIPS continued
Yasargil clip, curved

Size: 7 mm
FIGURE 12-10
Characteristics: Double spring clip for cerebral
vessels. Applied with Yasargil clip forceps
Notes: Temporary or permanent styles available.
Titanium styles (nonmagnetic) are designed
for permanence and can be used in magnetic
resonance imaging (MRI)
Raney scalp clip applier and clips

Size: 6.5″; standard clips
Notes: Ring-handled clip applier
with ratchets. Spring control
along shanks. Applier is locked
open until controlled release on
bleeding scalp tissue edges.
Clips are black, green, or blue
FIGURE 12-11
nonreflective finish; 3 3 3
edge grips; used only for edge
hemostasis; removed at the end
of the procedure and discarded.
Used to provide hemostasis
during craniotomy
GRASPING FORCEPS
Adson forceps
Size: 4.75″
FIGURE 12-12
Characteristics: Delicate tip with wide thumb

grasp area; straight or curved tip forceps. Can
be smooth, serrated, or 1 3 2 toothed tip
Notes: Several types, with and without teeth, used
for tissue approximation; extra fine teeth are
available. Used in pairs for skin closure
continues
Broli-Adson forceps
Size: 6.0″
FIGURE 12-13
Characteristics: Flat, wide handle with longer,
narrow tip. Resemble standard Adson forceps.
Straight or curved serrated tip. Available with
1 3 2 teeth
Notes: Used on delicate tissue in deeper plane
Dressing forceps
Size: 5″ to 12″
tissue
FIGURE 12-14
pairs in a set. Sometimes
referred to as thumb
forceps
Tissue forceps
Size: 5″ to 12″
Characteristics: Tips with 2 3 1
teeth for traction. Medium-
weight tissue
in a set. Sometimes referred FIGURE 12-15
forceps. Care is taken not to
penetrate through to epidermal
layers during use
continues
Dennis forceps
Size: 7.0″, 8.25″
FIGURE 12-16
Characteristics: Straight forceps with 1-mm micro
open-ring tips. Rounded finger grip with textured
surface. Tips are lined with diamond dust.
Counterbalanced for stability
Notes: Titanium
Brophy forceps
FIGURE 12-17
Size: 8.0″
Characteristics: Straight tissue forceps with tiny
1 3 2 teeth. Serrated finger grip
Notes: Peg-stop to prevent overcompensated
grasping
DeBakey forceps
Size: 6.0″; 7.75″; 8.0″; 9.0″
FIGURE 12-18
longitudinal fine teeth and matching grooves.
Used for most vascular and general surgery
procedures. Available in straight or bayonet
styles
Notes: Atraumatic forceps; the favorite tool of
many surgeons; the straight tips narrow toward
the distal end and interdigitate. Also known as
cartilage forceps. Available in titanium
Tumor forceps
Size: 8.75″
FIGURE 12-19
Characteristics: Bayonet forceps with serrated
finger grip. Tips are concave cups with tiny
circumferential serrations available in 3 mm or 5
mm diameter
Notes: Very fine grasping surface
SPECIALTY GRASPERS
Bipolar bayonet forceps

Size: 7.5″
Characteristics: Bayonet forceps with bipolar
FIGURE 12-20
electrosurgery power connection. Coated with
insulation to prevent stray current. Tissue does not
build up on tips because of a coating of nonstick
material. Active and inactive tips measuring 1 mm
or 2 mm transfer the current only through the
tissue in the grasp of the forceps
Notes: No return patient electrode required. Cords are supplied separately
Bipolar bayonet forceps with suction

Size: 7.5″
FIGURE 12-21
Characteristics: Bayonet forceps with bipolar
electrosurgery connection. Coated with insulation
to prevent stray current. Coated tips (1.4 mm,
2.0 mm) prevent tissue accumulation. Suction port
built into low-profile finger grip
Notes: No patient return electrode required. Cords are
supplied separately
Standard operating scissors

Size: 4.5″; 5.0″; 5.5″; 6.0″; 6.5″
scissors; sharp-blunt or sharp-
sharp tips can be straight or
curved
scissors or suture scissors; used FIGURE 12-22
on the back table by the scrub
person; not commonly handed
up to the main field
continues
Metzenbaum scissors
Size: 5.5″; 7.0″; 8.0″; 9.0″; 11.0″; 14.5″
FIGURE 12-23
Characteristics: Fine, lightweight scissors with blunt-
blunt tips; haws are half the length of the shanks;
available in curved and straight styles
Notes: Found on most instrument sets; the most
commonly used style is curved. Should not be used to
cut suture. Dissection of fine tissue Courtesy of Scanlan International.
Mayo scissors
Size: 6.25″
Characteristics: Heavy operating
scissors with blunt-blunt tips.
Can be straight or curved
Notes: Found in most instrument
FIGURE 12-24
sets in both curved and straight
styles; curved are used on
heavier patient galeal tissue
during craniotomy; straight are
used to cut suture
Harrington scissors
Size: 11.5″
scissors with curved
blunt-blunt tips; jaws are
one-quarter the length of
FIGURE 12-25
the shanks. Dissection of
intermediate to fine tissue
Notes: Resembles a slightly
longer, lighter Mayo scissor
continues
Taylor dural scissors

Size: 6.0″
FIGURE 12-26
Characteristics: Lightweight scissors with slightly curved
shanks and laterally angled tips. Upper blade is blunt, and
lower blade is probe-tipped for protection of underlying
structures
Notes: Probe tip
SPECIALTY SHARP DISSECTION
Gigli wire saw with guide and

A.
two handles B.
Size: 12.0″; 20.0″; 30.0″ wire
Characteristics: Two opposing handles, either loop
or T-shaped, that attach to a disposable length of
FIGURE 12-27
twisted barbed wire. In cranial surgery holes are
made by a drill for the insertion of the wire. The
D.
length of wire is placed beneath the surface of bone C.
to be cut, and each end is attached to a hook on the
edge of the handles
Notes: Used to cut through bone in a rapid hand-opposition sawing motion
A. Gigli wire saw

B. T-shaped handles (2)
C. Loop handles (2)
D. Bailey saw wire guide A, D: Courtesy of CareFusion, a division of Becton, Dickinson and Co.; B, C: © 2019 Cengage®.
Hudson brace set

A.
Size: 10.5″; 11.0″
Characteristics: Manual drill for making burr holes in the
cranium after the skin is incised. Currently, four Hudson
FIGURE 12-28
burrs—9 mm, 14 mm, 16 mm, and 22 mm—fit into the distal

end with a thumb screw (more sizes may become available
in the future). The burr is positioned, and the hand crank is
turned in a circular motion to penetrate the compact tissue.
Can be used to relieve intracranial pressure caused by
B.
bleeding
Notes: Can be used to make perforator holes for use of the
Gigli saw. Hudson cerebellar extension is available for longer
reach Courtesy of CareFusion, a division of Becton, Dickinson and Co.
continues
SPECIALTY SHARP DISSECTION continued
Liston Stille bone cutting forceps

Size: 5.5″; 6.75″; 7.5″; 8.5″
Characteristics: Double-action bone cutter with sharp-
FIGURE 12-29
sharp tips. Spring handle
Notes: Powerful cutting surface. Can be used to enlarge
the bony edges of a craniotomy incision
© 2019 Cengage®.
Cushing rongeur
Size: 8.0″
Characteristics: Spring handle bone cutter with a 6-mm
U-shaped cutting surface. Straight handle
FIGURE 12-30
Notes: Can be used to enlarge the bony edge during
craniotomy
Kerrison rongeur
Size: 7.0″
Characteristics: Pistol-spring handle with slide mount
FIGURE 12-31
3-mm, angled cutting surface. Other available slide
cutters are aligned in other directions. Commonly used
in spinal procedures
Notes: Image shown is an up-biter. Several sizes will be
included in a set
© 2019 Cengage®.
continues
Ferris Smith pituitary rongeur

Size: 7.0″
Characteristics: Pistol-spring handle with 2 mm 3
10 mm sharp cup biter with blunt tips. Good for tough
FIGURE 12-32
tissue in smaller spaces. Commonly used in spinal
procedures
Notes: Cup jaw rongeurs available in straight, curved-up,
and curved-down designs. Several sizes will be
included in a set
Spurling Kerrison rongeur

Size: 7.0″
Characteristics: Pistol-spring handle with slide mount
biter. Commonly used in spinal procedures
Notes: Available in up-bite and down-bite. Several sizes
FIGURE 12-33
will be included in a set
Gruenwald rongeur
Size: 10.0″
Characteristics: Ring-handled rongeur with FIGURE 12-34
10 mm 3 3 mm sharp biting cup
Notes: Commonly found in spinal instrumentation for
small sections of heavy tissue. Also referred to as Love
rongeurs
continues
Peapod rongeur
Size: 5.5″, 7.0″
Characteristics: Ring-handled rongeur in sharp
FIGURE 12-35
biting cup with sizes ranging from 2 mm 3
6 mm to 4 mm 3 6 mm. Commonly used on
tougher material in spinal procedures
Notes: Cupped up-biter
Wilde rongeur
Size: 7.0″
FIGURE 12-36
Characteristics: Ring handle with 4-mm, sharp,
fenestrated ovoid cups used for tough tissue in
spinal procedures
Notes: Available in straight and angled designs
Yasargil Bayonet dissector

Size: 7.25″
FIGURE 12-37
Characteristics: Bayonet handle with sharp
tip curved up or down. Round handle
with gripper surface
Notes: Delicate tissue dissection
SPECIALTY BLUNT DISSECTION
Yasargil dissector
Size: 7.25″
FIGURE 12-38
Characteristics: Lightweight, single-
ended shank with bayonet curve; used
to smooth delicate bone edge. Round
handle with gripper surface for secure
finger grasp
Notes: Tip is a fine rasp
Olivecrona dissector
Size: 9.5″
FIGURE 12-39
Characteristics: Double-ended blunt
dissector with or without ligature hole guide.
One end is slightly smaller. Finger grip in the
center. Used to dissect tissue from bone.
Can be used to tunnel under tissue
Notes: Available in heavy and light weights
Oschner dissector
Size: 7.25″
FIGURE 12-40
Characteristics: Double-ended dissector in two
tip set sizes (1 mm 3 2 mm and 3 mm 3 4 mm).
Central finger grip surface for stability. Used to
strip tissue from bone
Notes: Curved in opposite directions

Size: 7.5″; Sizes 6 to 12 Fr.
Characteristics: Used for fine-tip suction
FIGURE 12-41
during intricate surgical procedures; suction

is activated by covering the hole in the finger
grip with the thumb; has a clot-clearing stylet
Notes: Available in disposable models;
reusable styles must be processed with clot-
clearing stylet removed. Disposable styles
are preferred
continues
Adson suction tube

Size: 6.0″; 8.0″; Sizes 11 to 15 Fr.
Characteristics: Slightly curved tip. Used
FIGURE 12-42
for fine-tip suction during intricate surgical
procedures; suction is activated by
covering the hole in the finger grip with the
thumb; smaller than Frazier suction tips;
has a clot-clearing stylet
Notes: Reusable stylets must be processed
with stylet removed. Disposable styles are preferred
Baron suction tube

Size: 3.0″; Sizes 3, 5, 7 Fr.
Characteristics: Tip is angled at the thumb
FIGURE 12-43
control. Used for fine-tip suction during
intricate surgical procedures; suction is
activated by covering the hole in the finger
grip with the thumb; smaller than Frazier
suction tips; has a clot-clearing stylet
Notes: Reusable styles must be processed
with stylet removed. Disposable styles are
preferred Courtesy of Sklar Instruments.
RETRACTION AND EXPOSURE INSTRUMENTS
Memory nerve hook

Size: 10.0″
Characteristics: Unique
composition of nitinol and
stainless steel that has
shape memory. Can be bent
FIGURE 12-44
for use in complex areas.
When exposed to steam
processing, the instrument
returns to its original shape.
The tip is configured as a
blunt or flap hook
Notes: Do not bend more than
110 degrees, or the shape
may not be resumed during
processing. The handle is
stainless steel with a gripper surface
continues
RETRACTION AND EXPOSURE INSTRUMENTS continued
Nerve hook
Size: 9.5″
FIGURE 12-45
Characteristics: Rigid stainless-steel shaft with
blunt right-angle hook. Handle has a gripper
surface for secure hold. Used to retract and
bluntly dissect tissues around nerves and
vessels
Notes: Not flexible. Good for neurological and
many other procedures where delicate tissue
separation is necessary Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Adson dural hook
FIGURE 12-46
Size: 8.0″
Characteristics: Rigid shaft with a sharp,
curved, hooked, 5-mm tip. Handle is
hollow and smooth. Used to hold the
dura during dissection
Notes: Not flexible Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Meyerding retractor
Size: 7.0″
Characteristics: Single-ended
retractor available with right
angle, smooth rounded, blade or
rake-style tip. Finger loop at the
FIGURE 12-47
end of the handle
Notes: For more superficial tissue.
Ergomatic design
continues
Love nerve root retractor

Size: 8.5″
Characteristics: Right-angle retractor with curved,
FIGURE 12-48
rounded tip at the end of the 7-mm blade.
Smooth, flat handle. Can be used in many types of
neurological procedures, especially spine
Notes: May be used in pairs
© 2019 Cengage®.
SELF-RETAINING RETRACTORS
Markham-Meyerding self-retaining
retractor
Size: 7.5″
FIGURE 12-49
Characteristics: Ringed handled, self-retaining retractor
with single prong on the right-opposing, solid,
2.0″ 3 1.0″ Meyerding blade on the left. Ratchets
have thumb release. Handed up in closed position
Notes: May be used in pairs. Care is taken when
handling this retractor. The tip is very sharp and could
cause a puncture injury
INGE lamina spreader

Size: 6.5″
Characteristics: Spring handle with locking
ratchet at handle base. Available with or without
teeth for traction. Used to separate the lamina
FIGURE 12-50
during spinal procedures
Notes: Handed up in closed position
© 2019 Cengage®.
continues
Gelpi retractor
Size: 4.5″; 6.5″; 7.0″
Characteristics: Double sharp prongs with
ratchet thumb-release lock; arms are slightly
curved; with or without ball stops
FIGURE 12-51
Notes: Commonly found in general, spinal, and
orthopedic surgery. Handed up in closed
position. May be used in pairs at opposing
ends of the incision for spinal procedures.
Care is taken when handling this retractor.
The tips are very sharp and could cause a
puncture injury
Weitlaner retractor
Size: 4.0″; 5.5″; 6.5″; 8.0″; 9.5″
lock; tips have sharp or blunt 4 3 3 rake prongs
that interdigitate when closed. Used for small,
FIGURE 12-52
deep incisions in a variety of sizes. More than one
size may be included in a set
more than one can be used at opposing ends of
the incision; used by almost every surgical service.
The curved style is also known as a cerebellar
retractor. Handed up in closed position
Beckman retractor
Size: 6.75″ to 12.5″
Characteristics: Double-armed blades with
FIGURE 12-53
ratchet lock; tips are mounted on hinged arms

and have sharp 3 3 4 rake prongs. May be
used in pairs. Good for use during spinal or
other rounded surface; the arms fold down out
of the way
Notes: Used for small, deep incisions. Handed
up in closed position
© 2019 Cengage®.
continues
LEYLA self-retaining brain retractor

Size: Universal
Characteristics: Flexible, self-locking retractor base
attaches to side rail of operating bed; assembles in
FIGURE 12-54
two pieces that can hold up to five flexible arms; ball
joint adjustment
Notes: Each arm can hold individual retractor blades
of differing styles
Cushing brain spatula
FIGURE 12-55
Size: 8.25″
Characteristics: Tapered, flat, solid, double-ended blade
that tapers from 25 mm to 13 mm in width. Silver
plated. Used to retract brain tissue
Notes: Slightly flexible Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Davis brain spatula
FIGURE 12-56
Size: 8.0″
Characteristics: Tapered, flat, solid, double-ended blade
that is 10 mm on one end and 13 mm on the opposite
end. Used to retract brain tissue
Notes: Malleable
Loftus distractor
Size: Universal
Characteristics: Three-bladed device that separates
two levels of vertebrae during a cervical spine
procedure. Can be positioned from right or left side of
FIGURE 12-57
the surgical site
Notes: No need to reposition during multilevel cervical
spine procedure
CLOSURE INSTRUMENTS
Derf needle holder

Size: 4.75″
with short, linear, serrated jaws
with a central notch; delicate
weight. Shorter jaws than
Webster
FIGURE 12-58
Notes: Used for skin closure or
securing a drain

Size: 5.25″
holder
FIGURE 12-59
continues
CLOSURE INSTRUMENTS continued
Crile-Wood needle holder

Size: 6.0″; 7.0″
FIGURE 12-60
Mayo needle holder

Size: 6.25″; 7.0″; 8.0″; 12″
with heavy jaws; cross-serrated
with central notch
FIGURE 12-61
continues
Ryder needle holder

Size: 5.0″; 6.0″; 7.0″; 8.0″; 9.0″;
10.25″
with narrow, flat jaws; cross-
serrations in jaw
Notes: Used for lightweight suture
FIGURE 12-62
vascular, neurologic, and plastic
surgery
CRANIAL PROCEDURES the arena of the neurosurgeon, orthopedic sur-

geons perform spinal procedures. Both disciplines
Neurosurgical procedures require the use of instrumen- take precautionary measures to preserve delicate
tation for several types of tissue. A medium foundation tissues.
set is used to open and close the soft tissues of the scalp. A medium or long foundation set is used to enter
The scalp edges are handled with care because injury to the surgical site, and compact tissue instrumentation
hair follicles or follicular blood supply may cause bald- is used for bone and fibrous disc material. Incisions
ness in the area of the vascular distribution. Temporary for spinal surgery are very deep. The level of vertebral
occlusion Raney scalp clips are applied around the surgery is confirmed by x-ray before the bony part of
edges of the incision for hemostasis and are removed at the procedure is started. The surgeon will place a metal
the end of the procedure. This preserves the blood sup- spinal needle or instrument in the proposed vertebral
ply, yet keeps the field of vision clear during the surgical space and have a scout film taken as confirmation. Be
procedure without harming the blood vessels. sure to provide x-ray protection, such as lead screens or
After opening the skin, the cranium is opened using aprons, for the team. Implants (rods, screws, cages) can
bone instrumentation. The compact tissue of bone can be placed during procedures for stabilization or defor-
be carefully removed in small pieces using rongeurs mity correction.
with cutting edges. More specific bone instrumentation Cervical spine procedures may use many of the
is found in Chapter 10. typical lower spine instruments. Tissue depth will vary
according to the approach used to enter the surgical
SPINAL PROCEDURES site. The surgical methods involve prevention of injury
Spinal surgery involves soft and compact tissue to adjacent tissues such as vascular, neurological, and
handling. Although neurologic tissue is commonly lymphatic vessels.
SUMMARY nerves and nervous tissue. Nervous tissue is very

delicate and easily injured by inadvertent pres-
Neurologic surgical procedures can involve all types
sure or forceful displacement with retractors.
of tissues. Procedures may involve very delicate
Regeneration, or healing of injured nervous tis-
instrumentation used under a microscope or heavy
sue, is not consistent and may result in permanent
instrumentation used to debulk bone.
damage not only to the nerve itself, but also to
Regardless of the type of surrounding tissue
structures innervated distally, such as blood vessels
involved with the surgical procedure, consideration
and muscles.
must be given to the focus of the dissection—the
CHAPTER 13
CARDIOTHORACIC
AND VASCULAR
INSTRUMENTATION
Basic Cardiothoracic and After reading this chapter the learner should be able to:
Vascular Instrumentation 1. Select instrumentation appropriate for cardiac procedures.
Clamps 2. Select instrumentation appropriate for carotid procedures.
Grasping Forceps
Probes and Dilators
Measuring Instruments
INTRODUCTION
Evacuation and Instillation Cardiac, vascular, and thoracic surgical procedures involve working
Instruments with both soft and compact tissues, depending on the physiologic
Retraction and Exposure location of the structures that require surgical intervention. Incisional
Instruments access through the soft tissues of skin is accomplished by the use of one
Approximation and Closure of the foundation sets, depending on the depth of the target tissues.
Instruments After the skin and outer tissues are incised, the main part of the proce-
Specialty Instruments dure will require additional instrumentation.
Memory Instruments
Basic Cardiothoracic and
Vascular Procedures
BASIC CARDIOTHORACIC AND VASCULAR
INSTRUMENTATION
Most cardiovascular procedures are performed using similar instruments of
varying lengths and weight. Some of the instrumentation has unusual curves,
angles, or jaws designated right or left. Some of the curves are designed to
fit the circumference of the vessel. The jaw patterns differ by serrations, but
DeBakey and Cooley jaws are the most common design. Many of the clamps
are occlusive but not crushing. Occlusive clamps do not damage edges of the
vessel that will be anastomosed.
342
Chapter 13 Cardiothoracic and Vascular Instrumentation 343
CLAMPS

Size: 5.0”
FIGURE 13-1
Notes: Hemostasis; holding (tagging) suture
ends. Uses the small yellow suture boots. May
use alternating straight and curved clamps to
distinguish multiple individual sutures

Size: 5.0”
FIGURE 13-2
Characteristics: Straight or curved with short jaw; lighter
weight and more delicate than Halsted; serrated full
length of jaw
Notes: Hemostasis; holding (tagging) suture ends. Uses
the small yellow suture boots. May use alternating
straight and curved clamps to distinguish
multiple individual sutures
Kelly clamp
Size: 5.5”
straight; jaw is one-third of
shank. Horizontal serrations
halfway down the jaw
Notes: Hemostasis at the
FIGURE 13-3
superficial level; holding suture
ends. Found in most sets as
a standard hemostat. Clamp,
tag, snap, hemostat, and stat
are alternative nicknames for
this instrument
continues
CLAMPS continued
Crile clamp
Size: 5.50”; 6.25”
curved or straight; jaw is half
the length of the shank
Notes: Hemostasis at the
FIGURE 13-4
superficial level; holding suture
ends. Found in most sets as a
standard hemostat. Referred to
as tag, snap, and hemostat
Size: 5.50”; 6.25”; 7.25”; 8.0”; 9.0”; 10.25”; 12.0”
FIGURE 13-5
jaw; curved or straight; heavy-style instrument; jaw is
proportionate to shanks
Notes: Clamping larger segments of tissue for hemostasis.
Do not confuse this with a basic Pean as noted earlier;
serrations are different; shorter styles are
sometimes referred to as hemostat or Kelly; longer styles
are sometimes referred to as a long or extra-long Kelly Courtesy of Sklar Instruments.
Adson clamp
Size: 7.25”
FIGURE 13-6
length of the shanks; curved or

straight
Notes: Commonly used for
passing suture around or
under tissue. “Tie in a passer”
is a term for a ligature (suture
without a needle) placed in the
jaws of a curved or right-angle
clamp
continues
CLAMPS continued
Bridge clamp
Size: 11.0”
FIGURE 13-7
Characteristics: Long delicate clamp with short jaw;
serrated full length. Pointed tips
Notes: Deep surgery
Kantrowitz clamp
Size: 6.0”
Characteristics: Right-angle
clamp; intermediate weight.
Horizontal serrations half the
length of the jaw. Rounded tips
FIGURE 13-8
Notes: Similar to Mixter and other
right-angle clamps

Gemini Mixter clamp

Size: 5.5”; 7.0”; 8.0”; 9.0”; 11.0”
Characteristics: Delicate weight
with horizontal serrations the
full length of the jaw; the jaw is
one-third the length of the
shanks FIGURE 13-9
Notes: Grasp tissue around

pedicle attachments; used as a
passer for suture around a stalk
of tissue
© 2019 Cengage®.
continues
CLAMPS continued
Mixter
horizontal
clamp
Size: 6.25”
weight; horizontal serrations
the full length of the long jaw;
FIGURE 13-10
curved in a mild right angle or
a true right angle
Notes: Similar function to other
Mixter clamps with variations in
direction of serrations. Pedicle
hemostasis. Used as a passer for
© 2019 Cengage®.
Mixter longitudinal clamp

Size: 8.5”
FIGURE 13-11
Characteristics: Intermediate-weight, long jaw with
longitudinal serrations three-quarters the length of the
jaw; cross-serrated tips. Available in delicate weight
Notes: Grasp tissue around pedicle attachments
Bailey clamp
Size: 7.0”
Characteristics: Short jaw
is narrowed toward the tip.
Angled tip in three size ranges:
30 degrees–60 degrees–
FIGURE 13-12
90 degrees flexure
Notes: Delicate pedicle
hemostasis. Suture passer
CLAMPS continued
Finochietto clamp
Size: 9.75”
FIGURE 13-13
Characteristics: Long right-angle jaws with longitudinal
serrations. Jaw is same length as shanks. Perforated
tip
Notes: Commonly used in thoracic surgery
Zanger clamp
Size: 12.0”
FIGURE 13-14
Characteristics: Long, intermediate-weight clamp with
angled shanks. DeBakey jaws with slight curve
Notes: Common in aortic surgery
DeBakey clamp
Size: 9.25”
Characteristics: Tangential
DeBakey jaws with curved
shanks. Noncrushing occlusion
of vessels
FIGURE 13-15
Notes: Many varieties of jaw
curvatures. Commonly used in
vascular procedures
Instrument: Courtesy of Scanlan International.

continues
CLAMPS continued
Kocher
intestinal clamp
Size: 10.5”
Characteristics: Jaws are two-thirds the length of
the shanks with longitudinal serrations; the jaws
have mild flexibility and can be curved or straight
Notes: Used to grasp pedicles without crushing.
FIGURE 13-16
Differs from Kocher clamp because it is
atraumatic (toothless) and longer; occludes
without tissue destruction; closely resembles a
Doyen clamp. Noncrushing
Satinsky clamp
Size: 8.75”
Characteristics: Tangential
DeBakey jaws with size
ranges: 2.3 cm, 2.7 cm, and
3.5 cm curvature. Slightly
curved shanks
FIGURE 13-17
vascular procedures
continues
CLAMPS continued
Selman clamp
Size: 5.0”
Characteristics: Fully curved Cooley jaws with straight
shanks
FIGURE 13-18
Notes: Used for peripheral vessels
Cooley clamp
Size: 5.5”
Characteristics: Right-angle
Cooley jaws with slightly
angled shanks. Atraumatic
rounded tips
Notes: Available in pediatric sizes
FIGURE 13-19
Cooley Satinsky clamp

Size: 5.5”
Characteristics: Tangential Cooley jaws with slightly
curved shanks. Marked at 5 mm. Atraumatic rounded
FIGURE 13-20
tips
Notes: Available in pediatric sizes
continues
CLAMPS continued
Dennis Cooley clamp

Size: 6.75”
FIGURE 13-21
Characteristics: Tangential Cooley jaws with
angled shanks. Tip sizes range 1 cm, 1.5 cm,
and 2 cm
Notes: Used in vascular procedures
Dennis DeBakey clamp
FIGURE 13-22
Size: 6.25”, 6.75”, 7.0”
Characteristics: Angled shanks with 3-cm angled
DeBakey jaws. Intermediate weight with rounded tips
Notes: Used in vascular surgery
Straight DeBakey clamp
FIGURE 13-23
Size: 8.5”
Characteristics: Straight shanks with long,
straight DeBakey jaws
Hunter clamp
FIGURE 13-24
Size: 8.75”
Characteristics: Tangential 3.5-cm DeBakey jaws
with angled shanks. Rounded tips
Sarot bronchus clamp

Size: 9.0”
Characteristics: Right-angle 1.5” jaws with
FIGURE 13-25
longitudinal serrations with pin grips. Shanks

curved inward
Notes: Used in thoracic/lung procedures
continues
CLAMPS continued
Smith Leifer clamp

Size: 7.0”
FIGURE 13-26
Characteristics: Ring-shaped tip with slight curve.
Intermediate weight
Notes: Circumferential clamp. Used in vascular surgery.
Can be used for the vas deferens in vasectomy
Tube occluding clamp

Size: 6.5”
FIGURE 13-27
Characteristics: Smooth, curved jaws; intermediate to heavy weight
for firm control
Notes: Used to occlude moderate thickness of chest tubing.
Ratchets. Applies even occlusive pressure without damaging the
tubing
Tube occluding clamp with guard

Size: 6.0”
Characteristics: Smooth, straight jaws; heavy weight
FIGURE 13-28
Notes: Used to occlude moderate to heavy tubing such
as chest tubes. Applies even occlusive pressure without
damaging the tubing. Ratchets. Guard prevents the
tubing from being caught in the box locks
Bulldog applicator FIGURE 13-29

Size: 7.5”
Characteristics: Ring-handled, intermediate-weight instrument
used to apply bulldog temporary hemostatic clamps
Notes: Used only to apply bulldog clamps
© 2019 Cengage®.
continues
CLAMPS continued
Bulldog clamp, straight
FIGURE 13-30
Size: 2.75”
Characteristics: Temporary spring-action occlusion
hemostatic clamp with straight Cooley 1.25” jaw.
Rounded tips
Notes: Other jaw styles available
Bulldog clamp, curved
FIGURE 13-31
Size: 3.0”
Characteristics: Cross-action temporary clamp with
2-cm curved DeBakey jaws
Notes: Other jaw styles available
Bulldog clamp, angled
FIGURE 13-32
Size: 1.75”
Characteristics: Cross-action temporary clamp with
20-mm, angled, serrated jaw
Notes: Also known as Diethrich bulldog
Sweet clip applier

Size: 9.25”
Characteristics: Used to apply permanent McKenzie
FIGURE 13-33
hemostatic clips. This style of clip applier is available
for many styles and sizes of permanent stainless-
steel or titanium clips. Ring handled with spring
action. Nonlocking. Tips are pointed and shanks are
slightly curved. Available in straight or angled tips
Notes: Used in many types of procedures for hemostasis.
Care is taken to hold the loaded instrument at the box locks
and not to compress the shanks together. The clip can accidentally
discharge. Cartridges hold five loadable clips Courtesy of CareFusion, a division of Becton, Dickinson and Co.
GRASPING FORCEPS
Dressing
forceps
Size: 5” to 12”
FIGURE 13-34
tissue
Notes: Can be used to
manipulate tissue or dressing
material. Commonly found
in pairs in a set. Sometimes
referred to as thumb forceps
Tissue forceps
Size: 5” to 12”
tips with teeth for traction.
Medium-weight tissue
FIGURE 13-35
Notes: Can be used to
manipulate tissue. Commonly
found in pairs in a set.
Sometimes referred to as rat
tooth or mouse tooth forceps
DeBakey forceps
FIGURE 13-36
Size: 6.0”; 7.75”; 8.0”; 9.0”
longitudinal fine teeth and matching grooves
Notes: Atraumatic forceps; the favorite tool of many
surgeons; the straight tips narrow toward the
distal end and interdigitate. Also known as cartilage forceps Courtesy of Scanlan International.
continues
Gerald forceps
Size: 7.0”
Characteristics: Lightweight to
FIGURE 13-37
shanks have a stop-peg to
grasping of tissue
dissection
Instrument: Courtesy of Scanlan International.

Cooley forceps
Size: 6.0”; 8.0”
weight to fine-weight forceps
with longitudinal teeth and
FIGURE 13-38
matching grooves; the straight
tips narrow toward the distal
grooved end and interdigitate
Notes: Atraumatic forceps with
2-mm-wide tips. Similar to
DeBakey forceps, but with a
reverse jaw configuration
Cushing forceps FIGURE 13-39

Size: 7.0”; 7.25”
Characteristics: Lightweight to intermediate-
weight forceps with fine serrations at the tip;
the proximal end is beveled for use as a blunt
dissector; the handle is longitudinally grooved to
fit the bulk of the thumb and pad of the index finger
Notes: Frequently used during dissection; handles can
be straight or bayonet style; the handle grooves can vary Courtesy of Scanlan International.
continues
Kantrowitz forceps
FIGURE 13-40
Size: 7.75”
finely serrated angled jaws
Notes: Commonly used in cardiothoracic procedures
Wagensteen forceps
FIGURE 13-41
Size: 9.5”
Characteristics: Straight forceps with cross-serrated
rounded tips
Notes: Used in thoracic procedures
Duval forceps
Size: 8.0”
FIGURE 13-42
Characteristics: Straight, ring-handled grasping forceps
with fenestrated, triangular tips with cross-hatched
serrations along the distal base of the triangle
Notes: Used in thoracic procedures. Similar to Pennington
forceps
© 2019 Cengage®.
Lovelace forceps
Size: 7.5”
grasping forceps with 1.0”
fenestrated triangular tips with
horizontal serrations along the
body of the triangle. Angled at
FIGURE 13-43
the shanks
Notes: Used in lung procedures.
Similar to Pennington forceps
© 2019 Cengage®.
continues
Foerster
sponge forceps
Size: 7.0”; 9.5”
Characteristics: Ringed handles
with open, oval, serrated
or smooth grasping edges;
shanks are straight or mildly
FIGURE 13-44
curved at the box locks;
intermediate weight
with moderate traction;
commonly used for sponge
forceps and prepping. Also known
as sponge stick and ring forceps.
Folded radiopaque sponges can
be positioned in the jaws to create
sponge sticks
© 2019 Cengage®.
Hallman tunneling forceps

Size: 14.75”
FIGURE 13-45
Characteristics: Ring-handled, double-action
forceps with cross-serrated oval fenestrated tips.
Ratchets for secure grasp
Notes: Can be used to pass grafts and materials
through the subsurface layers of tissue
Metzenbaum scissors
Size: 5.5”; 7.0”; 8.0”; 9.0”; 11.0”; 14.5”
FIGURE 13-46
Characteristics: Fine, lightweight scissors with

blunt-blunt tips; jaws are half the length of the
shanks; available in curved and straight styles
Notes: Dissection of fine tissue. Found in most
instrument sets; the most commonly
used style is curved. Should not be used to cut suture Courtesy of Scanlan International.
continues
Mayo scissors
Size: 6.25”
curved
Notes: Found in most instrument
FIGURE 13-47
sets in both curved and
straight styles; curved are used
on moderate to heavy patient
tissue; straight are used to cut
suture
Harrington scissors
Size: 11.5”
scissors with blunt-blunt tips;
jaws are one-quarter the length
of the shanks
Notes: Dissection of intermediate
FIGURE 13-48
to fine tissue
continues
Doyen scissors
Size: 7.0”
Characteristics: Heavy blunt-
blunt scissors used for heavy
fascial tissues. Wider blades
than Mayo scissors
FIGURE 13-49
Notes: Straight only
Thompson scissors
FIGURE 13-50
Size: 8.5”; 10.0”
Characteristics: Long, intermediate-weight scissors
with short curved blades. One blade is serrated
Notes: Curved only. Common in cardiovascular
procedures
Laine Kendal scissors
FIGURE 13-51
Size: 7.20”
Characteristics: Short sharp-sharp jaw with a curve.
Slightly heavier than Joseph scissors. Available in
tenotomy wedge tip styles. Good for undermining
tissue
Strully scissors
FIGURE 13-52
Size: 8.75”
Characteristics: Lightweight dissecting scissors
with probe tip. Short, curved jaw
Notes: Can be used for undermining in peripheral
vascular procedures
continues
Potts Smith
scissors
Size: 7.0”; 7.5”
Characteristics: Lightweight,
side-angled scissors with
sharp-sharp tips. Blades are
available angled in 25-degree,
FIGURE 13-53
45-degree, 60-degree,
90-degree, and 125-degree
directions
Notes: Common in vascular
procedures
Sistrunk scissors
Size: 5.25”
FIGURE 13-54
Characteristics: Heavy, short scissors with blunt-blunt curved
blades
Notes: Similar to Doyen in weight, but curved
Mixter scissors
Size: 6.25”
weight scissors. Blunt-blunt
curved or straight blades are
half the length of the shanks
FIGURE 13-55
Notes: Tissue dissection
Thorek
scissors
Size: 7.25”; 10.0”
Characteristics: Long,
intermediate-weight scissors.
Sharp curve to jaw; blunt-blunt
tips
FIGURE 13-56
Notes: Dissection of intermediate
tissue
© 2019 Cengage®.
Satinsky scissors
FIGURE 13-57
Size: 9.75”
Characteristics: Longer, intermediate-weight scissors
with blunt-blunt, curved, 1.75” tips. Curved shanks
Notes: Common in cardiovascular procedures
Hegeman scissors
FIGURE 13-58
Size: 5.25”
Characteristics: Short, lightweight scissors with sharp-
sharp tips. Angled tips range in 25-degree, 45-degree,
60-degree, and 90-degree direction
Notes: Short jaw similar to Potts Smith scissors
Favaloro scissors
Size: 6.75”
FIGURE 13-59
Characteristics: Laterally curved shanks with 125-degree

angled sharp-sharp tips
Notes: Common in cardiovascular procedures
continues
Flemma scissors
FIGURE 13-60
Size: 12.0”
scissors with short curved blades. Flat tips
Notes: Common in mitral valve and venous valve
procedures
Size: 4.25”; 4.75”
one-quarter the length of the
shanks, and the jaws have one
serrated blade at a 45-degree
angle; available in angled
styles; tips are blunt-blunt
FIGURE 13-61
Notes: Used only for cutting wire
suture or intermediate pins
Gluck rib shears

Size: 7.75”
FIGURE 13-62
Characteristics: Heavy pliers grip with sharp, curved
blades
Notes: Used for cutting ribs
continues
Shoemaker rib shears

Size: 9.0”
Characteristics: Heavy, spring-handled shears with
FIGURE 13-63
sharp hook tip
Notes: Used for cutting ribs
Doyen rib stripper
FIGURE 13-64
Size: 7.0”
Characteristics: Intermediate-weight, elevator-style
rib stripper with fully 1.25” curved tip
Notes: Removes periosteum from ribs
Matson rib stripper
FIGURE 13-65
Size: 8.75”
Characteristics: Double-ended instrument for stripping
and raising periosteum. Double-pronged stripping end
is 2.5 cm, and rounded elevator end is 1.6 cm wide
Notes: Common in thoracic procedures
PROBES AND DILATORS
Garrett vascular dilators

Size: 5.5”; 8.25”
FIGURE 13-66
Characteristics: Flexible-memory nitinol vessel dilators

with blunt graduated tips. Sizes range from 0.5 mm to
2.5 mm tip circumference
Notes: Memory Instruments can be bent for use, but
return to original straight length during the steam
sterilization process
MEASURING INSTRUMENTS
Castroviejo caliper
Size: 7.0”
FIGURE 13-67
Characteristics: Combined measuring and marking
device; graduated in 0 to 20 mm. Straight precision
tips for accuracy. Screw hold to maintain position of
measurement. Satin finish to reduce glare
Notes: Used to measure diameters and widths
Tessier caliper
Size: 10.25”
FIGURE 13-68
Characteristics: Linear measuring graduated in 0 to
20 mm
Notes: Commonly used to measure width
Ring-handled caliper
FIGURE 13-69
Size: 11”
Characteristics: Long, ring-handled design for deeper
measurements in the 0 to 65 mm range. Measuring
bar locks and corresponds to the spread of the jaw
tips inside the chest. Low-glare finish
Notes: Measures deep surfaces
Courtesy of Scanlan International
Yankauer suction tube

with removable tip
Size: 12”
FIGURE 13-70
Characteristics: Long, angled tube with removable

screw tip; hand grip is ridged; stainless steel; some
are chrome-plated
Notes: Suction fluids and substances; good for
generalized suctioning
Notes: Disposable models are preferred; reusable Yankauer tips have a screw tip that must be removed for
cleaning and processing; the screw tip is a counted item; sometimes known as tonsil suction
continues
Wolf suction
FIGURE 13-71
Size: 17 cm; 22 cm
Characteristics: Yankauer-style curved suction
used in video-assisted thoroscopic surgery
(VATS) procedures
Notes: Available with and without a thumb suction control
D’Amico suction
Size: 32 cm
Characteristics: Yankauer
handle–style straight suction
used in video-assisted
FIGURE 13-72
thoroscopic surgery (VATS)
procedures. Side holes
along tip
Notes: Available with and without
a thumb suction control
Poole suction tube

Size: 12”
Characteristics: Medium-length, stainless-steel tube
FIGURE 13-73
with screw-on perforated cover to prevent suction
lesions of viscera during intraabdominal suctioning;
cover guard is used to perform deep suctioning
during irrigation. Disposable styles are preferred.
Outside diameter is 32 Fr. Primarily used in intracavitary
suctioning

Size: 13.0”; width 3/4” to 2.0”
FIGURE 13-74
Characteristics: Flat piece of chromium-plated copper
that is easily shaped to the desired retraction form
Notes: Used to secure and protect viscera during
abdominal procedures. Narrower and shorter ribbon
retractors can be used in other areas of the body.
Also known as Zalkind ribbon retractors
Notes: Size denotes width of blade
Allison retractor
Size: 12.25”
FIGURE 13-75
Characteristics: Solid handle with curved wire
retraction blade angled to 25 degrees
Notes: Used for lung retraction
Davidson retractor
Size: 8.5”
Characteristics: Sharply angled scapular retractor.
Ergonomic handle with finger grips
Notes: Primarily used for scapular exposure
FIGURE 13-76
continues
Leaflet retractor
Size: 8.25”
FIGURE 13-77
Characteristics: Double-ended retractor for cardiac
valve leaflets
Notes: Only used in cardiac procedures
Valve retractor
Size: 9.0”
FIGURE 13-78
Characteristics: Double-ended retractor for cardiac
valves
Notes: Used only in cardiac procedures
Cooley retractor
Size: 9.25”
Characteristics: Angled manual atrial retractor
with a rounded wire 7/8” × 3/4” blade
FIGURE 13-79
continues
Valve retractor set

Size: Universal
FIGURE 13-80
Characteristics: Multipiece, self-retaining mitral valve retractor
set with ratchets to hold position. Solid and fenestrated
adjustable blades
Favaloro retractor
Size: Universal
Characteristics: Bed-mounted, self-retaining retractor with adjustable rake-style blades
Notes: Used only in cardiothoracic procedures
FIGURE 13-81
Finochietto retractor
Size: Universal
Characteristics: Self-retaining retractor that separates ribs
FIGURE 13-82
approximately 3.0”. Hand crank turns on ratchets that lock in
position. Solid blades
Notes: Used in cardiothoracic procedures
continues
Bailey retractor
Size: Universal
FIGURE 13-83
Characteristics: Used in pairs to contract ribs during
closure
Notes: Used in cardiothoracic procedures
Lemmon retractor
Size: 7.25”
FIGURE 13-84
Characteristics: Used in pairs to approximate the
sternum for closure. Thumb screw–controlled ratchets
Notes: Used only in cardiothoracic procedures
APPROXIMATION AND CLOSURE INSTRUMENTS
Mayo-Hegar
needle holder
Size: 6.25”; 7.0”; 8.0”; 12”
FIGURE 13-85
continues
APPROXIMATION AND CLOSURE INSTRUMENTS continued
Crile-Wood
needle holder
Size: 6.0”; 7.0”
intermediate-weight suture.
FIGURE 13-86
Ryder needle holder

Size: 5.0”; 6.0”; 7.0”; 8.0”; 9.0”;
10.25”
with narrow flat jaws; cross-
serrations in jaw
Notes: Used for lightweight
FIGURE 13-87
suture. Commonly used in
vascular, neurologic, and
plastic surgery
continues
Stratte needle holder

Size: 9.0”
FIGURE 13-88
Characteristics: Long, intermediate-weight needle
holder with lateral curved shanks and curved
serrated jaws
Notes: For lightweight suture. Used in
cardiothoracic procedures
Wagensteen needle holder

Size: 10.5”
FIGURE 13-89
Characteristics: Long, intermediate-weight straight
needle holder with cross-serrated jaws
Notes: For lightweight suture
Sarot needle holder

Size: 5.0”; 7.0”; 10.25”
FIGURE 13-90
Characteristics: Ring handles with medially curved
shanks; fine jaws with cross-serrations; central
notch
Notes: Used for lightweight to intermediate-weight
suture. Commonly used in vascular surgery
Dennis needle holder

Size: 7.0”
Characteristics: Delicate straight needle holder
FIGURE 13-91
with small diamond-dust jaw

Notes: Best for 5-0 suture or smaller
continues
Finochietto
needle holder
Size: 10.5”
Characteristics: Long,
intermediate-weight needle
holder with angled, cross-
serrated jaws
FIGURE 13-92
Notes: Used in cardiothoracic
procedures
Deschamps ligature carrier

Size: 8.0”
Characteristics: Straight shaft with
medium-weight handle on one
end and curved, eyed needle
tip; available in right and left
curvature and sharp or
blunt tip
FIGURE 13-93
Notes: Circumferential suturing
with a free suture. Also known
as aneurysm needle
continues
Sternal wire
needle holder
Size: 7.0”
Characteristics: Short, snub-
nosed jaws with cross-
serrations for holding wire
suture
FIGURE 13-94
cardiothoracic surgery
SPECIALTY INSTRUMENTS
Vessel punch
Size: 5.75”; 7.5”
Characteristics: Used to create a round 2.7-mm ×
FIGURE 13-95
6.0-mm or elliptical 2.0 mm × 4.0 mm; 2.0 mm ×
6.0 mm opening in a major vessel during coronary
artery bypass procedures. Finger rings for control
Notes: Round or elliptical hole styles
Rummel tourniquet
Size: 13.0”
Characteristics: Adult-size, reusable temporary vessel
FIGURE 13-96
tourniquet with locking ratchet. Slightly angled,

3.2-mm tip with threading stylet
Notes: Used to circumferentially occlude an individual
blood vessel. A Rummel tourniquet can be made
by passing a sterile umbilical tape through a 16 Fr.
Robinson catheter to create a disposable version.
Lumen of reusable style can be difficult to adequately
clean
continues
SPECIALTY INSTRUMENTS continued
McIntosh suture holder

Size: 5.25”
Characteristics: Ring-handled instrument with ratchets
used to separate and hold 10 individual sutures in
FIGURE 13-97
line to prevent tangling before tying. Allis-style tips for
attaching to drape without puncture
Notes: Care is taken not to leave needles attached to
suture ends to prevent needle stick injury
MEMORY INSTRUMENTS
Memory Instruments
bending tool
Size: 7.0”
Characteristics: Spring-handled
pliers with a notched jaw used
to bend nitinol shaft of Memory
Instruments. Provides safety
when loading, disarming,
FIGURE 13-98
or bending the Memory
Instruments knife. Nitinol alloy
Memory Instruments can be
bent into the necessary angle
for use
Notes: Do not bend more than 110
degrees or the instrument may
not return to original shape during
steam autoclaving
continues
MEMORY INSTRUMENTS continued
Memory Instruments nerve hook

Size: 10.0”
FIGURE 13-99
Characteristics: Unique composition of nitinol and
stainless steel that has shape memory. Can be
bent for use in complex areas. When exposed
to steam processing, the instrument returns to
its original shape. The tip is configured as a blunt
(75-degree angle) or flat hook (40-degree angle)
The round handle is stainless steel with a gripper surface
Notes: Do not bend more than 110 degrees or the shape
may not be resumed during processing Courtesy of Scanlan International.
Memory Instruments mirror

Size: 25 cm
FIGURE 13-100
Characteristics: Bendable nitinol composition with
detachable 1.5 magnification mirror. Can be
used to visualize deeper structures and
minimize shadows with redirected light.
Rounded handle with gripper surface
Notes: Nitinol alloy Memory Instruments can be bent into the
necessary angle for use. Do not bend more than
110 degrees or the instrument may not return to
original shape during steam autoclaving Courtesy of Scanlan International.
Memory Instruments knife

Size: 9.25”
FIGURE 13-101
Characteristics: Bendable nitinol knife shaped
similar to a #7 scalpel. Uses standard #11 or
#15 blades. Bend this tool with the Memory
Instruments bending tool for safety. Rounded
handle with gripper surface
Notes: Nitinol alloy Memory Instruments can be
bent into the necessary angle for use. Do not bend more than
110 degrees or the instrument may not return to original
shape during steam autoclaving Courtesy of Scanlan International.
BASIC CARDIOTHORACIC AND only the inner lumen is sterile and the exterior is not.
The size is selected according to the clamp jaw width.
VASCULAR PROCEDURES The scrub person cuts the tubing on the sterile field and
The size and weight of the vascular instruments will be reports the number of cut segments to the circulator for
determined according to the texture and condition of addition to the surgical counts. The wide connecting
the tissues. Some clamps will have jaw covers, referred ends are passed off to the circulator. Care is taken to
to as shods, to cushion the hold and prevent slippage. determine if the patient is latex sensitive before select-
Small segments of tubular silicone (yellow = small; ing tubing to cut on the field.
pink = large) referred to as suture boots can be slipped Soft tissue foundation instrumentation is used to
onto the jaws of tiny mosquito hemostats for snug trac- incise the tissues over and around the carotid arter-
tion when holding suture. Clamps such as the Fogarty ies. The main instruments used in the endarterectomy
style have small holes along the jaws for snapping on portion of the procedure are clamps and dissectors.
special jaw liners. Shods, suture boots, and jaw liners are Some surgeons prefer to shunt the artery rather than
counted items and are closely contained. simply occlude the blood flow with a clamp. The
If the facility does not have shods or suture boots degree of plaque formation and volume of calcification
on hand, the scrub person can fashion shods for the are the determining factors as to which instrumenta-
jaws of clamps from sterile Robinson red rubber cath- tion is used. It is important to have an assortment of
eters sized 10 Fr. to 16 Fr. and suture boots from 3 Fr. to artery clamps and shunt clamps on hand. The shunts
5 Fr. infant feeding tubes. IV tubing is not used because are disposable.
SUMMARY If two chest tubes are used on the same side of

Cardiothoracic surgery is performed on patients the chest, the upper tube evacuates air and the lower
who are compromised with several conditions, such tube drains blood and other intrathoracic fluids. The
as inadequate circulation, diabetes, obesity, or other disposable collection chamber is delivered to the
comorbidity. Entering the chest of any patient inter- sterile field by the circulating nurse and prepared
rupts the integrity of the mediastinum and interferes by the scrub person with the correct amount of
with the performance of the lungs, regardless of the sterile water to create a water seal. Most manufactur-
surgical procedure performed. Medium and long ers incorporate a tint (usually blue) into the water
foundation sets are commonly used to enter the skin, chamber to make the fluid level easy to visualize
and specialty instrumentation is used for the internal from a distance. This process, referred to as water
organ procedure. seal drainage, permits the pleural cavity to expand,
Postoperatively, the goal of patient care manage- fully enabling the patient to resume normal respira-
ment is the restoration of the intrathoracic vacuum tion. Chest tube clamps should always be available;
required for respiration. As the patient’s chest is however, the chest tubes are never clamped unless
closed, one or two large-bore drainage tubes are the surgeon directs the procedure. Mediastinal shift
inserted into the chest either through the lateral chest can happen, causing the heart and lungs to move into
wall or through the median sternotomy incision. the wrong side of the chest.
CHAPTER 14
MICROSURGERY
INSTRUMENTATION

Basic Microsurgery After reading this chapter the learner should be able to:
Instrumentation 1. Select instrumentation appropriate for microsurgery.
Clamps 2. Select instrumentation appropriate for body size and location of the incision.
Grasping Forceps
Probes
Measuring Instruments
INTRODUCTION
Evacuation and Instillation Microscopic surgery is an application that can be extended to most
Instruments surgical specialties. All tissues can be surgically dissected using micro-
Retraction and Exposure scopic techniques. Performing microscopic procedures requires the
Instruments operator to have a steady hand and a high level of concentration. The
Closure Instruments scrub person is critical to this process because the surgeon will need to
maintain accommodation of vision through the microscopic lens and
trust that the correct instrument oriented in the correct position will
be placed in his or her extended hand. If the surgeon has to look away
from the microscope each time the instrumentation is passed, the visual
adjustment can cause misjudgment of distance or instrument place-
ment during tissue manipulation. Manual dexterity is critical for a safe
and effective microscopic procedure.
BASIC MICROSURGERY INSTRUMENTATION

Surgical procedures using a microscope require instruments with extremely
fine tips and handles that do not obscure the user’s vision during the proce-
dure. Sutures and devices manipulated by micro-instrumentation are equally
fine and delicate and cannot be handled with conventional instrumentation
without causing damage to the structure. The instrumentation described in
this section is selected according to the particular target tissue being manipu-
lated under microscopy.
The microscopic part of the procedure takes place after the outer tis-
sues have been incised. Opening the skin and gross dissection require the
376
CHAPTER 14 Microsurgery Instrumentation 377
use of the appropriate foundation set. The most com- the use of highly specialized instruments for handling
monly used sets for intraabdominal procedures are the the lens, the cornea, the sclera, and conjunctiva. The
medium and long foundation sets. Examples of micro- lacrimal structures and musculature are commonly
scopic procedures within the abdomen include vascular included in the realm of ophthalmic surgery and
attachments of transplantation and salpingoplasty. employ many probes and hooks. Procedure-specific
Ophthalmic surgeons use many of the basic micro- instruments would be packaged together as appropriate
instruments listed in the microscopic basic instrumen- sets. Foundation sets would not be included unless skin
tation list. The eye has many structures that require incisions are performed.
CLAMPS

Size: 3.50
serrations the full length of the jaw; shorter and heavier
FIGURE 14-1
than Halsted

Size: 5.00
FIGURE 14-2
serrated the full length of the jaw

Size: 5.00
FIGURE 14-3
Characteristics: Straight or curved with short jaw; lighter

weight and more delicate than Halsted; serrated full
length of jaw
Uses: Hemostasis; commonly used in plastic surgery
GRASPING FORCEPS
Bishop-Harmon forceps
FIGURE 14-4
Size: 3.50
Notes: Micro delicate forceps with fenestrated shanks;
1 3 2 fine teeth Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Gill (Chandler) iris forceps
FIGURE 14-5
Size: 3.00
Notes: Forceps with angled tips; cross-
serrated or toothed 1 3 2
Jeweler forceps
Size: 4.750
Notes: Stainless-steel forceps
with fine straight or angled
45-degree tip
FIGURE 14-6
FIGURE 14-7
Gerald micro forceps
Size: 7.00
Notes: Lightweight forceps with fine serrations at the tip; the tips are very narrow; the shanks
have a stop-peg to prevent overcompensated grasping of tissue Courtesy of Scanlan International.
continues
Gerald micro
ring forceps
Size: 7.00
Notes: Lightweight forceps with
a 1-mm ring at the tip; the
FIGURE 14-8
shanks have a stop-peg to
grasping of tissue
DeBakey micro forceps
FIGURE 14-9
Size: 6.00; 7.750
Notes: Atraumatic forceps; the straight tips narrow toward
the distal end and interdigitate
Cushing forceps
FIGURE 14-10
Size: 7.00; 7.250
Notes: Lightweight forceps with fine serrations at the tip; the handle is longitudinally
grooved to fit the bulk of the thumb and pad of the index finger. Handles can
be straight or bayonet style; the handle grooves can vary.
FIGURE 14-11
Gillies forceps
Size: 80
Notes: Delicate straight forceps with flat handles. Diamond-dust tips
continues
GRASPING FORCEPS
Dennis micro
forceps
Size: 6.00; 7.250
Notes: Counterbalanced round-
handled forceps with ring
FIGURE 14-12
tying platform, straight, or
curved jaws; diamond-
dust tips
FIGURE 14-13
Micro tip forceps
Size: 7.250
Notes: Lightweight, round-handled forceps with flat, diamond-dust jaws.
Straight, curved, or 45-degree angled tips Courtesy of Scanlan International.
FIGURE 14-14
Tumor grasping forceps
Size: 8.750
Notes: Bayonet-style forceps with cupped jaws;
diamond-dust tips Courtesy of Scanlan International.
Micro bayonet forceps

Size: 8.750
Notes: Delicate, titanium,
bayonet-style forceps with
many 0.5-mm to 1.0-mm
FIGURE 14-15
straight-tip styles. Available
with flat tying, ring, 1 3 2
teeth, or DeBakey tips
continues
Berke ptosis forceps
FIGURE 14-16
Size: 4.50
Notes: Angled grasping forceps
with longitudinal serrations along
27-mm jaw
FIGURE 14-17
Lambert chalazion forceps
Size: 3.50
Notes: Straight linear forceps with solid 1-cm lower plate and fenestrated upper plate Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Jabaley scissors
Size: 4.750
FIGURE 14-18
Notes: Intermediate-weight, sharp-sharp tips. Can be
curved or straight
Iris scissors
Size: 3.750; 4.00; 4.50
Notes: Fine scissors with sharp-sharp tips; jaws are
FIGURE 14-19
straight or curved and one-third to one-half the length
of the shanks; the ring handles are standard or flattened
into a ribbon style for a wider stabilizing grip. Available
in right-angle jaw. Standard ring handles; gold handle
has carbon blade inserts.
continues
Stevens tenotomy scissors
FIGURE 14-20
Size: 4.50
Notes: Lightweight scissors with wedge-shaped blades.
Can be curved or straight; tips are sharp-sharp; ring
handles are standard. Micro styles have spring handles.
Jaw shape allows scissors to spread and visualize channel as it is cut. Courtesy of Scanlan International.
Laine Kendal scissors
FIGURE 14-21
Size: 7.200
Notes: Short, sharp-sharp, wedge-shaped blades
with a curve
Wescott tenotomy scissors
FIGURE 14-22
Size: 4.250
Notes: Wedge-shaped sharp-sharp blades with flat
spring handles
Jacobson micro
scissors
Size: 6.50; 6.750
Notes: Spring-handled, sharp-
sharp, angled blades. Round
handles. Angles range from
25 degrees to curved 125
degrees. Round handles
FIGURE 14-23
continues
Jacobson fine
micro scissors
Size: 6.00; 8.00
Notes: Spring-handled, sharp-
sharp angled blades. Round
handles. Angles range from
FIGURE 14-24
25 degrees to circumflex
125 degrees. Round handles
Jacobson fine micro scissors
FIGURE 14-25
with bead tip
Size: 6.250; 6.50
Notes: Spring-handled scissors with one sharp
and one bead tip blade. Angles range from 25 degrees
to circumflex 125 degrees. Flat handles. Courtesy of Scanlan International.
Puskas Jacobson IMA scissors

Size: 8.00
FIGURE 14-26
Notes: Spring-handled scissors with angled shafts.
Sharp-sharp, 45-degree, angled fine blades available in
right or left directions. Flat handles.
IMA micro scissors, delicate

FIGURE 14-27
Size: 8.00
Notes: Spring-handled scissors with angled shafts.
Sharp-sharp, 45-degree, angled fine blades available in
right or left directions. Flat handles. Courtesy of Scanlan International.
continues
FIGURE 14-28
Jacobson Vannas scissors
Size: 7.00
Notes: Spring-handled scissors with straight shafts.
Sharp-sharp, 45-degree, forward-angled fine blades. Flat handles Courtesy of Scanlan International.
Castroviejo scissors
FIGURE 14-29
Size: 4.250; 4.50
Notes: Spring-handled scissors with straight shafts.
Sharp-sharp, 45-degree to 125-degree, forward-
angled fine blades. Round handles Courtesy of Scanlan International.
FIGURE 14-30
Micro bayonet flat-handle scissors
Size: 8.250; 9.00
Notes: Spring-handled bayonet scissors with sharp-sharp
straight or curved blades Courtesy of Scanlan International.
FIGURE 14-31
Micro bayonet round-handle scissors
Size: 8.250; 9.00
Notes: Spring-handled bayonet scissors with sharp-sharp
straight or curved blades Courtesy of Scanlan International.
Micro bayonet
circumflex scissors
Size: 8.00
Notes: Spring-handled
circumflex (125 degrees)
scissors. Sharp-sharp blades;
flat handle
FIGURE 14-32
continues
Micro scissors
with specialty
tips
Size: 8.250
Notes: Spring-handled,
bayonet-style scissors
FIGURE 14-33
available with sharp-sharp
straight, tenotomy, up-curved,
or down-curved fine blades
Micro bayonet
scissors, delicate
Size: 8.250; 9.00
bayonet-style scissors with
sharp-sharp straight or
FIGURE 14-34
curved blades. Longer than
the other types of bayonet
micro scissors
Barraquer DeWecker iris scissors

FIGURE 14-35
Size: 2.250
Notes: Delicate thumb-pressure scissors with 5-mm,
sharp-sharp, angled tips
continues
FIGURE 14-36
DeWecker iris scissors
Size: 4.250
Notes: Delicate, long, narrow, thumb-pressure scissors
with 11-mm, sharp-sharp angled tips Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Microsurgical knives
FIGURE 14-37
Size: Handle: 5.00; 8.00; 9.00 (bayonet), 11.00 (bayonet)
Notes: Micro knives available in straight, curved, angled,
and round blades. Individual blades seat in a straight or
bayonet handle
PROBES
Williams lacrimal probe

Size: Length 5.00; Sizes 4/0–3/0, 2/0–0, 1–2, 3–4, 5–6,
FIGURE 14-38
7–8
Notes: Sterling silver, double-ended, ball-tipped (two
sizes each probe); center of probe shank has flat finger
hold (referred to as a tongue tie) with slot and size
markings
Bowman lacrimal probe

Size: Length 5.50; Sizes 4/0–3/0, 2/0–0, 1–2, 3–4, 5–6,
7–8
Notes: Sterling silver, double-ended (two sizes each FIGURE 14-39
probe); center of probe shank has flat finger hold with
slot and size markings
continues
PROBES continued
Veirs probe–cannula set

Size: 18 ga; 15 ga
FIGURE 14-40
Notes: Probe–cannula set with blunt stylets. Curved and
straight styles
FIGURE 14-41
Heath punctum dilator
Size: 4.250
Notes: Sharp, single-ended dilator
FIGURE 14-42
Castroviejo punctum dilator
Size: 5.00
Notes: Double-end dilator. Sharp tips; two sizes
MEASURING INSTRUMENTS
FIGURE 14-43
Metal ruler
Size: 6.00
Notes: Stainless steel; graduated in inches, cm, and mm Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Castroviejo caliper
Size: 7.00
FIGURE 14-44
Notes: Combined measuring and
marking device; graduated in 0 to
20 mm. Straight precision tips for
accuracy. Screw hold to maintain
position of measurement. Satin
finish to reduce glare. Used to
measure diameters and widths
continues
MEASURING INSTRUMENTS continued
Jameson caliper
Size: 4.00
FIGURE 14-45
Notes: Accurate measurements of depths
(0 to 20 mm) with locking fine tips.
Measures in cm and mm
Thorpe caliper
FIGURE 14-46
Size: 4.250
Notes: Measures depths in inches to centimeters
with locking, fine-angled tips
Schiotz tonometer
Size: Universal
Notes: Device for measuring the pressure inside the eyeball by
FIGURE 14-47
the use of a series of small gram weights; sterilizing case
EVACUATION AND INSTILLATION INSTRUMENTS FIGURE 14-48
Jensen capsule polisher

Size: 25 ga
Notes: Bulb tip with Luer-Lok syringe connection
continues
FIGURE 14-49
Troutman cannula
Size: 25 ga
Notes: Bulb tip with Luer-Lok syringe connection. Angled shaft
FIGURE 14-50
Gill-Welsh cannula
Size: 25 ga
Notes: Flat, olive-shaped tip with Luer-Lok syringe connection. Right-angle tip Courtesy of CareFusion, a division of Becton, Dickinson and Co.
FIGURE 14-51
Bishop-Harmon cannula
Size: 1.750
Notes: Flat irrigating tip with Luer-Lok syringe connection. Silver-plated brass Courtesy of CareFusion, a division of Becton, Dickinson and Co.
FIGURE 14-52
Baron suction tube
Size: 5 Fr.; 7 Fr.
Notes: May be included as reusable with set, but disposable is preferred Courtesy of Sklar Instruments.
FIGURE 14-53
Size: 5 Fr.; 7 Fr.
Adson suction tube
FIGURE 14-54
Size: 5 Fr.; 7 Fr.
Barraquer lid speculum (open)

Size: 1.750
Notes: Spring-style, open blade; self-retaining retractor with simple
FIGURE 14-55
wire blades; available in small and large sizes
Barraquer lid speculum (solid)

Size: 1.750
Notes: Spring-style, solid blade; self-retaining retractor; available in
small and large sizes
FIGURE 14-56
Williams speculum
Size: 3.250; 2.750
FIGURE 14-57
Notes: Self-retaining retractor with screw-adjusted lock and
fenestrated blades; slightly angled; available in small and large
Guyton-Park speculum
Size: 3.50
Notes: Self-retaining retractor with three solid or fenestrated blades
FIGURE 14-58
and screw-adjusted lock; slightly angled; superior angle of blade

has vertical suture posts for tying traction suture
continues
FIGURE 14-59
Gill-Welsh lens loop
Size: 4.750
Notes: Double-ended lens loop. Olive probe tip on one end and
7 mm 3 5 mm lens loop on the opposite end Courtesy of CareFusion, a division of Becton, Dickinson and Co.
FIGURE 14-60
Krayenbuhl micro nerve hook
Size: 7.250
Notes: Delicate right-angled nerve hook for retraction
Jaeger lid plate
FIGURE 14-61
Size: 4.50
Notes: Double-ended lid elevator with rounded ends
McNeil-Goldman scleral lid retractor

Size: 24 mm outer diameter
Notes: Blepharostat lid retractor to elevate the eyelid
FIGURE 14-62
FIGURE 14-63
Wells enucleation spoon
Size: 5.750
Notes: Slotted globe elevator for removal of the eyeball;
21 mm diameter Courtesy of CareFusion, a division of Becton, Dickinson and Co.
CLOSURE INSTRUMENTS
Derf needle holder

Size: 4.750
FIGURE 14-64
Notes: Superficial suturing. Short serrated jaw for small
needles
Dennis micro needle holder
FIGURE 14-65
Size: 7.00
Notes: Ring-handled needle holder. Straight diamond-
dust jaws. Suture size 5-0 or smaller
Micro jaw needle holder
FIGURE 14-66
Size: 7.00
Notes: Ring-handled needle holder. Ratchets. Straight
diamond-dust jaws. Suture size 5-0 or smaller
Jacobson micro ring-handled needle

holder
FIGURE 14-67
Size: 7.250; 9.00
Notes: Ring-handled needle holder. Spring-action lock.
Straight, diamond-dust jaws. Suture size 5-0 or smaller
Glasser micro needle holder

FIGURE 14-68
Size: 5.00; 7.00

Notes: Pliers handle with inner spring lock. Straight or
curved diamond-dust jaws. Suture size 5-0 or smaller
continues
Kant needle holder
FIGURE 14-69
Size: 5.250
Notes: Thumb-control micro needle holder with tungsten
carbide insert straight jaws
Castroviejo needle
holder
Size: 4.750
straight-tip needle holder with
diamond-dust jaws. Suture
FIGURE 14-70
size 7-0 or smaller. Flat or
round handles
Micro bayonet needle

holder
Size: 7.00; 9.00
straight-tip needle holder with
diamond-dust jaws. Suture
FIGURE 14-71
size 7-0 or smaller. Flat or
round handles
continues
Micro
Jacobson
needle holder
Size: 7.250
Notes: Spring-handled straight-
or curved-tip needle holder
FIGURE 14-72
with diamond-dust jaws.
Suture size 5-0 or smaller. Flat
or round handles. Available
with and without locking
ratchet
SUMMARY
Many surgical procedures can be performed knowledge in the scrub person. The eye–hand
microscopically. Each procedure has its own inherent coordination and dexterity necessary for the scrub
intricacies and complexities. Microscopic surgery person to develop takes many months or sometimes
requires high levels of experience and anatomic years to master.
CHAPTER 15
ENDOSCOPIC
INSTRUMENTATION

After reading this chapter the learner should be able to: Essential Components of Endoscopic
Procedures
1. Select instrumentation appropriate for puncture/percutaneous endoscopy.
Percutaneous Endoscopy
2. Select instrumentation appropriate for open laparoscopy. Procedures
3. Select instrumentation appropriate for natural orifice endoscopy. Nonpuncture Endoscopy
Access and Creation of the Working
Space
INTRODUCTION Illumination and Viewing within the
Working Space
All endoscopic procedures have critical elements in common. The term Manipulation within the Working
Space
endoscopic means “looking inside.” The methods of looking inside the
Irrigation and Evacuation within and
body involve several steps that parallel each other even when a differ- from the Working Space
ent approach is used. Robotic-assisted procedures are most commonly Closure within the Working Space
performed using endoscopic techniques. Some open cardiac procedures Specialty Instrumentation
utilize robotics for delicate work. Essential Endoscopic Instrumentation
Failure to meet each endoscopic critical element can result in the Access and Creation of the Working
Space
need for conversion to an open conventional procedure. This is not Illumination and Viewing within the
always easy to accomplish in an efficient manner because the instru- Working Space
mentation for an open procedure is significantly different and the setup Manipulation within the Working
Space
requires different equipment and supplies. The patient may need to be
Irrigation and Evacuation of the
repositioned, reprepped, and redraped. Working Space
Patient safety is a serious issue when conversion to an open proce- Closure within the Working Space
dure takes place, because the electrosurgical patient return (dispersive) Ring-Handled Instruments
electrode can shift, causing electrical injury and lost instrumentation or Basic Endoscopic Procedures
sponges. In addition, the haste of the process may create an increased Laparoscopy
Robotic-Assisted Percutaneous
margin of error, which is well documented in the literature concerning Endoscopy
retained surgical instruments. Great care is taken to prevent injury to Arthroscopy
the patient and personnel. Neuroendoscopy
Thoracoscopy
Mediastinoscopy
Upper Airway Endoscopy
ESSENTIAL COMPONENTS OF ENDOSCOPIC Urologic Endoscopy
PROCEDURES
Two primary approaches to endoscopy involve penetrating through the skin
percutaneously or utilizing a natural body orifice. Both methods employ
an expansion medium (carbon dioxide [CO2] or fluid) to create a working
395
space, instruments for manipulation and capture, The surgeon will use a scalpel with a small #15 or
evacuation of the expansion medium, and closure of #11 blade to make an incision of 0.5 cm to place the
the surgical site. Veress needle. The Veress needle is a sharp, beveled can-
nula with a blunt, retractable obturator that cuts through
Percutaneous Endoscopy Procedures tissue layers as the surgeon presses it through the tissues
Percutaneous endoscopic procedures require the use in a blind puncture process. The obturator projects after
of a soft tissue foundation set to open the outer layers each tissue layer is passed to prevent a sharps injury to
of skin for the introduction of the Veress needle and/ nontarget tissue. The disposable insufflation tubing is
or trocars and the closure of the tissue layers at the attached to the Luer-Lok on the Veress needle, and gas is
completion of the procedure. insufflated to expand the peritoneal cavity.
The procedural process involves having several sizes The gas is turned off briefly when the space is suf-
of trocars inserted percutaneously through the skin to ficiently expanded to create the pneumoperitoneum.
allow for placement of telescopes and other working The surgeon will slightly enlarge the incision with the
instruments. The trocar is a two-part instrument that scalpel and introduce the sharp trocar assembly into the
incorporates an outer sleeve and inner obturator that patient’s abdomen. The gas tubing is disconnected from
can be sharp or blunt (Hasson). After placement of the the Veress needle and attached to the trocar inflow port.
trocar instrument, the inner obturator is removed and The gas is restarted and flows sufficiently enough to
placed on the Mayo stand and the outer sleeve remains maintain the desired volume of expansion for creation
in place to form a channel for insertion of various endo- of the working space. All of the trocars may be reusable
scopic viewing and working instruments. One or more or disposable
of the trocars maintain the expansion media through a In open laparoscopy, the surgeon makes a small
stopcock. Placement of the telescope through this tro- incision and places a blunt Hasson trocar percutane-
car sleeve can result in a fogged lens because the CO2 is ously. The CO2 is insufflated via the Hasson. No Veress
cold and the interior body is warm. needle is used for a blind puncture.
The CO2 is not harmful in a chemical sense because
Nonpuncture Endoscopy the body is well equipped to diffuse the gas across the
Nonpuncture endoscopy requires the use of an illumi- peritoneal membrane and dispose of it through the
nated viewing instrument with an incorporated working lungs. Pressures of the insufflated gas are monitored by
channel for graspers and dissectors. In colon resection special sensors in the insufflation machine to prevent
open and percutaneous procedures, the surgeon may overdistention of the peritoneal cavity. If a disturbance
use an additional nonpuncture sigmoidoscope inserted of the gas flow occurs, the machine will alarm to alert
through the rectum to assess the anastomosis. The open the circulating nurse to adjust the pressure or trouble-
abdomen is filled with irrigation solution, and a small shoot the cause. The gas should be evacuated through
pump bulb is used to insufflate the bowel with room air. the suction port at the end of the case. The CO2 is
If the anastomosis is not secure, bubbles will rise to the considered a biologic contaminant and should not be
surface indicating a leak. No bubbles will surface when released into the room air. Aerosolization could cause
the anastomosis is intact. biologic material to come in contact with the skin or
mucous membranes of the team.
ACCESS AND CREATION OF Percutaneous puncture endoscopy through a joint
capsule such as in arthroscopy requires the creation of a
THE WORKING SPACE working space with infused fluid. The fluid is evacuated
Endoscopic procedures require a proportionate work- through an exit portal on the trocar to prevent overdis-
ing space wherein to accomplish the surgical tasks. tention of the capsule.
Percutaneous punctures of the abdomen create a work- Endoscopy through a natural body orifice requires
ing space with insufflated carbon dioxide (CO2) with a a working space as well. The oropharyngeal, nasal,
spring-loaded Luer-Lok Veress needle. This procedure aural, and bronchotracheal cavities are framed in native
is referred to as laparoscopy. The Veress needle may be cartilaginous scaffolds and do not require an additional
reusable or disposable. substrate or gas to create room to work. Other entrance
Chapter 15 Endoscopic Instrumentation 397
areas such as the esophagus or rectum require the sur- when the power is on. Some light sources are consid-
geon to use an insufflation bulb to separate collapsible ered “cooler” and pose less of a fire hazard.
tissue walls. This creates a working space by pumping in
small amounts of ambient air, which is readily removed MANIPULATION WITHIN
by suction.
Intrauterine and bladder working space is created THE WORKING SPACE
by the instillation of solution. Exit portals permit the Assorted clamps, graspers, dissectors, and other tis-
constant controlled evacuation of the expanded cav- sue manipulators can be introduced into the patient
ity to prevent overdistention or abnormal absorption. through additional trocars or working channels in the
Volume instillation and evacuation ratios are continu- main trocar. The specimen can be extracted through
ously measured and recorded by the circulating nurse. the trocar. Most of the manipulation instrumentation
Rectal endoscopy uses room air delivered by bulb is powered by the electrosurgical unit (monopolar or
hand pumps or an insufflation-suction machine to bipolar). The instrumentation may be reusable or dis-
create the working space by separating the walls of the posable. All electrically powered instruments have an
bowel. Size-appropriate rigid or flexible working instru- insulation coating to protect the patient and team from
mentation are passed through channels in the body of stray current. Reusable insulated instruments should be
the scope for manipulation of tissue. carefully inspected for breaches in the insulation.
ILLUMINATION AND VIEWING IRRIGATION AND EVACUATION

WITHIN THE WORKING SPACE WITHIN AND FROM THE
When the endoscopic access and working space are WORKING SPACE
established, the surgeon will need to illuminate the
During the procedure, the surgeon may aspirate fluids
expanded cavity with a light source and utilize a view-
or irrigate the target tissue. The irrigation-aspiration
ing telescope with a rigid or flexible telescopic lens or by
instruments are placed into the abdomen through a
direct vision. Some endoscopes utilize eyepiece couplers
secondary trocar that is separate from the main trocar
that attach to a camera video system that displays the
where the telescope and camera are located. Some of
surgical site on a high-resolution monitor. This allows
the irrigation-aspiration instruments are powered by
all members of the team to observe the procedure.
the electrosurgical unit. Many of these are disposable.
An external electrical light source supplies illumina-
tion through a reusable fiber-optic cable attached to the
telescope or through a metal light pipe inserted through CLOSURE WITHIN THE
the side of a rigid hollow scope. Fiber-optic cables have WORKING SPACE
a series of glass tubes that deliver light to the field. Care
is taken not to tightly flex the tubing because the fibers Internal suturing is performed with endoscopic needle
will break, preventing the transfer of light to the scope. holders. Disposable styles are preloaded with suture
The cable can be tested under sterile conditions during and endoscopic needles. Special probes with notched
the sterile setup procedure by holding one end of the tips are used to aid the knot-tying process. Other inter-
cable up in the direction of the room light and simulta- nal organ closure methods include the use of disposable
neously looking at the glow from the opposite end. The linear or circular stapling devices.
glowing end will look peppered with black spots if glass
fibers are broken within the cable. Excessive black spots SPECIALTY INSTRUMENTATION
indicate that the cable may not deliver enough light to
perform the procedure adequately. Other forms of endoscopic instrumentation utilize
The illuminated fiber-optic cable can radiate ring-handled instruments with long shanks and shorter
enough heat during the procedure to cause the drapes jaws. The instrumentation can be inserted percutane-
to smolder or burn if permitted to lie unattended. The ously and manipulated by the surgeon using the ring
cable should be attached to the telescope at all times handles under endoscopic guidance.
ESSENTIAL ENDOSCOPIC INSTRUMENTATION

Essential Endoscopic Instrumentation—ACCESS AND CREATION OF
THE WORKING SPACE
Veress needle
Size: 80 mm; 120 mm; 150 mm
Notes: Spring-loaded needle with blunt inner obturator
FIGURE 15-1
and sharp, beveled, 2-mm outer cannula; inner blunt
obturator retracts as tissue is penetrated by outer
sharp beveled edge; Luer-Lok end with stopcock for
connection and control of carbon dioxide (CO2) gas
insufflation tubing; reusable styles are disassembled
and steam sterilized. Disposable styles are
commercially available and preferred for use Courtesy of Sklar Instruments.
Endoscopic trocar (sharp)

Size: 5 mm, 7 mm, 12 mm
Notes: Sharp pyramidal trocar and sheath with insufflation
maintenance stopcock. Used after CO2 insufflation with
FIGURE 15-2
a Veress needle as the primary trocar for laparoscope
and camera insertion. Single trumpet valve. Available
as secondary trocar without insufflation stopcock.
Caps are available to reduce larger trocar openings for
use with smaller-diameter instrumentation. Reusable.
Disposable models are available and preferred. Sharp
trocar assemblies with inflow stopcocks are available for
percutaneous entrance into other body areas, such as
joint spaces (arthroscopy) Courtesy of Sklar Instruments.
“S” retractors
Size: Universal
FIGURE 15-3
Notes: Used to facilitate insertion of blunt Hasson insufflation
trocar and sleeve assembly
Endoscopic Hasson trocar (blunt)

Size: 11 mm
FIGURE 15-4
Notes: Blunt, rounded trocar and sheath with

insufflation maintenance stopcock. Single trumpet
valve. Used for primary CO2 insufflation without a
Veress needle (open laparoscopy). Suture point
anchors. Reusable. Disposable models are available
and preferred
continues
Essential Endoscopic Instrumentation—ACCESS AND CREATION OF

THE WORKING SPACE continued
Thread sleeve
Size: 6 to 13 mm
Notes: A threaded outer cannula placed over the trocar
FIGURE 15-5
and sleeve assembly before placement into the patient’s
abdomen secures and anchors the sleeve. Commonly
used with sharp and blunt trocars
Insufflation tubing
Size: Universal
Notes: Double-ended, clear plastic disposable tubing
with Luer-Lock ends. The tubing has an inline
FIGURE 15-6
hydrophobic filter to prevent particulate from the
CO2 tank entering the patient’s body. The filter is
located at the tubing end that connects to the
machine. The other end attaches to the Veress
needle or Hasson trocar for insufflation of the
peritoneum (referred to as pneumoperitoneum)
Balloon dissector
Size: N/A
Notes: Balloon dissectors are not used to enter
the peritoneal space. They are used to separate
extraperitoneal tissue planes by percutaneous
insertion of a transparent PVC balloon mounted
on a trocar sleeve with a blunt obturator. As the
trocar is advanced and seated in the position of the
desired tissue separation, the balloon is expanded
FIGURE 15-7
to create the working space by instilling sterile
saline or by pumping air through the filling channel
with a sterile hand pump. The model depicted here
is for placement of breast implants. Filling volume
depends on the size of the balloon at the rate of
1 pump of air equals 10 to 20 mL saline. Either
expansion media may be used. Other styles of
balloon dissectors for other purposes (hernia repair,
vessel dissection, etc.) may be shaped as ovals,
cylinders, or oblong. When the balloon is expanded
to the desired working space size, the obturator
is removed and a telescope of corresponding
diameter is inserted Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Essential Endoscopic Instrumentation—ILLUMINATION AND VIEWING WITHIN

THE WORKING SPACE
Telescope (laparoscope and all rigid scopes)

Size: 2 mm; 5 mm; 10 mm
Notes: Telescope with fiber-optic light transmission
incorporated; uses trocar sized one number size larger
FIGURE 15-8
for insertion; single eyepiece that attaches to camera
assembly for robotic and video-assisted laparoscopy.
Available in viewing angles 0 degrees, 30 degrees, and
45 degrees. Specialty telescopes are available in various
lengths and diameters for cystoscopy, arthroscopy, and
endoscopic viewing within other body spaces
Fiber-optic light cable

Size: Universal
Notes: Glass fibers are encased in a flexible, nonlatex
sheath. Flexible transmission of light from a light source
machine. Attaches to the telescope through a side
connector. Care is taken not to fold or over bend the
FIGURE 15-9
cable. The glass fibers can break and diminish the quality
of the light passage. Never place a lighted cable directly
on the patient’s drapes. This is a potential fire hazard
Camera head
Size: Universal
Notes: The camera head is attached to the eyepiece of the
telescope to transmit images from the viewing angle to
a high-definition video monitor. The camera is attached
FIGURE 15-10
to a cable that is connected to the camera box. The

images are in true color, and this is enhanced by “white
balance” adjustments performed by the scrub person
while pointing the lens at a white surface, such as a
sponge. White balancing helps minimize odd colorization
of tissues. Most cameras have video and still image
recording capabilities
Essential Endoscopic Instrumentation—MANIPULATION WITHIN

THE WORKING SPACE
Monopolar cord
Size: Universal
Notes: Double-ended electrical cable that connects a
powered electrosurgical device for use on the sterile
FIGURE 15-11
field. Monopolar instrumentation use requires a patient
return electrode to return the electrical energy back to
the generator. Both ends have a single connection port.
One end connects to the instrument, and the other end is
plugged into the electrosurgical machine
Bipolar cord
Size: Universal
Notes: Double-ended electrical cable that connects a
powered electrosurgical device for use on the sterile
FIGURE 15-12
field. Bipolar instrumentation use does not require a
patient return electrode. The energy passes from the
instrument, through the tissues, and back into the
instrument for return to the generator. One end of
the cord has a single connection port for attachment
to the instrument. The other end connects to the
generator with two plugs
Wave clamp
Size: 33 cm
FIGURE 15-13
Notes: Horizontal, wave-shaped serrations with
locking ratchets. Blunt-blunt straight tip. Atraumatic.
Insulated for use with electrosurgery. Rotation knob
near handle
DeBakey clamp
Size: 33 cm
FIGURE 15-14
Notes: DeBakey jaws with locking ratchets.

Blunt-blunt straight tip. Atraumatic. Insulated for use
with electrosurgery. Rotation knob near handle
continues

Kelly clamp
Size: 33 cm
FIGURE 15-15
Notes: Horizontal, serrated, curved jaws for hemostasis. No
locking ratchets. Double action for firm grip. Insulated for
use with electrosurgery. Rotation knob near handle
Dolphin forceps
Size: 33 cm
Notes: Straight forceps with serrations along half of the
FIGURE 15-16
jaw with spoon-type jaw that runs halfway along the
proximal jaw. Insulated for use with electrosurgery.
Rotation knob near handle
Kocher intestinal forceps

Size: 33 cm
Notes: Atraumatic, 60-mm, axial, serrated,
FIGURE 15-17
grasping jaws. No ratchets. Insulated for use with
electrosurgery. Rotation knob near handle
Alligator forceps
Size: 32 cm
Notes: Straight, heavily serrated, double-action
FIGURE 15-18
grasper. Locking ratchets. Insulated for use with

electrosurgery. Rotation knob near handle
continues

Maryland dissector
Size: 33 cm
Notes: Nonlocking grasper used to separate tissues.
FIGURE 15-19
Horizontal serrations full length of curved jaw. Blunt-
blunt tip. Insulated for use with electrosurgery. Many
endoscopic surgeons favor this grasper. Rotation knob
near handle
Spoon forceps
Size: 33 cm
Notes: Straight, 10-mm spoon grasper. Locking ratchets.
FIGURE 15-20
near handle
Allis forceps
Size: 45 cm
Notes: Straight atraumatic grasper. Locking ratchets.
FIGURE 15-21
near handle
Babcock forceps
Size: 33 cm
Notes: Circumferential grasping forceps. Horizontal
FIGURE 15-22
serrations along the tip edge. Atraumatic. Locking

ratchets. Insulated for use with electrosurgery. Rotation
knob near handle
continues

A.
Endoscopic scissors
Size: 33 cm to 45 cm
Notes: Endoscopic scissors are insulated for use with
electrosurgical generators (bipolar and monopolar).
Handle styles are pistol grip, nonlocking. Blade
styles include curved Metzenbaum, hook, and micro
FIGURE 15-23
surfaces. Reusable styles are available, but dull
easily with repeated sterilization. Disposable models
are preferred
A. Universal handle
B. Hook-blade scissors B.
C. Curved-blade scissors
D. Micro-blade scissors
D.
C.
Fan retractor
FIGURE 15-24
Size: 19.50
Notes: Available in straight, rigid or 5-mm to 10-mm articulating
styles. May have three to five retraction blades up to 45 mm
to 95 mm spread. The instrument is inserted as a closed unit
and rotated open to retract internal organs. Reusable styles are
processed completely open by steam sterilization Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Hook ESU
Size: 32 cm
FIGURE 15-25
Notes: Straight electrosurgical instrument with lumen for suction.
Tip is 5 mm long and J shaped. Used to encircle tissue and
coagulate for hemostasis. The shaft is insulated. Inspect the
shaft for defects in the insulation before use Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Probe and tips

Size: 32 cm
Notes: Straight, rigid probe
available with open-end
FIGURE 15-26
knot pusher (5-0 or larger

suture), curved, rounded, or
dissector tips. Not used for
electrosurgical applications.
Not insulated. No lumen
continues

Measuring probe
Size: 32 cm
FIGURE 15-27
Notes: Straight, rigid, solid probe with blunt, 5-mm tip.
Used for manipulating tissue within the working space
during endoscopy. No lumen
Spatula ESU
Size: 32 cm
FIGURE 15-28
Notes: Straight, rigid instrument with insulation for
electrosurgical dissection. The 5-mm tip is spatula
shaped. Has a lumen for suction
Essential Endoscopic Instrumentation—IRRIGATION AND EVACUATION OF

THE WORKING SPACE
Aspiration needle
Size: 45 cm
FIGURE 15-29
Notes: Straight hollow instrument with a 2-mm beveled
needle tip for aspiration of cystic structures. Not for
use with electrosurgical procedures. Not insulated.
Luer-Lock end for use with a syringe during aspiration
or instillation of medication
Suction ESU
Size: 33 cm
FIGURE 15-30
Notes: Rigid, insulated, straight suction tip for use with

electrosurgical instrumentation. The 5-mm metallic
tip is used to provide hemostasis during coagulation.
Used to keep the field of vision clear during
endoscopic procedures
continues
Essential Endoscopic Instrumentation—IRRIGATION AND EVACUATION OF

Suction irrigation
FIGURE 15-31
Size: 33 cm
Notes: Straight, rigid suction tube with trumpet
valve controls for alternating suction and irrigation
during endoscopic procedures. Not insulated for
electrosurgical applications. Disposable models are
preferred Courtesy of CareFusion, a division of Becton, Dickinson and Co.
Essential Endoscopic Instrumentation—CLOSURE WITHIN THE WORKING SPACE
Needle holder
FIGURE 15-32
Size: 33 cm
Notes: 10-mm cross-serrated jaws. Locking ratchets.
near handle
Specialty Endoscopic Instrumentation—RING-HANDLED INSTRUMENTS
Reliance bulldog applier and bulldogs

Size: 23 cm; 44 cm
Notes: Straight jaws with secure hold on temporary bulldog
clamps for hemostasis. Noninsulated, ring-handled
locking applier in two lengths. Bulldog jaws are DeBakey
lined. Atraumatic. Loaded instrument is placed through
an endoscopic port for use A.
A. Curved bulldog secured in applier
B. Straight bulldog, 25 mm FIGURE 15-33
C. Curved bulldog, 25 mm
D. Short straight bulldog, 7 mm
B.
C. D.
continues
v
Specialty Endoscopic Instrumentation—RING-HANDLED INSTRUMENTS continued
Chitwood DeBakey clamp

Size: 12.250
FIGURE 15-34
Notes: Noninsulated, ring-handled, locking, curved
clamp with long, straight shanks. Jaw is blunt and
DeBakey lined. Instrument is placed through an
endoscopic port for use
D’Amico DeBakey clamp

Size: 37 cm
FIGURE 15-35
clamp with long, straight shanks. Jaw (11 cm)
is blunt and DeBakey lined. Longer jaw than
Chitwood. Instrument is placed through an
Dennis clamp
Size: 33.5 cm
FIGURE 15-36
DeBakey lined. Commonly used for dissection.
Instrument is placed through an endoscopic port
for use
Cooley clamp
Size: 34 cm
FIGURE 15-37
Notes: Noninsulated, ring-handled, locking,
90-degree clamp with long, straight shanks. Jaw
is blunt and Cooley lined. Instrument is placed
through an endoscopic port for use
Harken Semb clamp

Size: 34 cm
FIGURE 15-38

DeBakey lined. Instrument is placed through an
continues
Allis clamp
Size: 33.5 cm
FIGURE 15-39
grasper with long, straight shanks. Jaw is 6 mm
wide. Instrument is placed through an endoscopic
port for use
Duval clamp
Size: 34 cm
FIGURE 15-40
clamp with long, straight shanks. Jaw is triangular
and serrated. Instrument is placed through an
Node grasper
Size: 33 cm
FIGURE 15-41
Notes: Noninsulated, ring-handled, locking grasper
with long, straight shanks. Jaw is oblong and
11 mm wide. Instrument is placed through an
Chitwood scissors
Size: 29 cm
FIGURE 15-42
Notes: Noninsulated, ring-handled scissors with
3-cm, curved, blunt-blunt blades. Used for
dissection. Instrument is placed through an
Scanlan needle holder

Size: 34 cm
FIGURE 15-43
Notes: Non-insulated, straight, ring-handled, locking

needle holder with short jaws designed for use
with 4-0 suture or smaller. Instrument is placed
through an endoscopic port for use
continues
Chitwood knot pusher

Size: 40 cm
FIGURE 15-44
Notes: Noninsulated, long, straight instrument with
double blunt hooks used to push the throws of an
endoscopic knot in suture 2-0 or smaller. Instrument
is placed through an endoscopic port for use
Chitwood suture cutter

Size: 33 cm
FIGURE 15-45
Notes: Noninsulated, straight, ring-handled suture
cutter for 2-0 or smaller suture. Not used for
cutting tissue. Instrument is placed through an
BASIC ENDOSCOPIC PROCEDURES Other robotic devices had a remote control

computerized component that permits the surgeon
Laparoscopy to use a voice-imprinted card to recognize verbal
commands. Some of the robotic features could be used
Laparoscopy refers to the percutaneous entry into the
to control the room environment.
abdominal or pelvic cavity. The procedural steps are
Current robotic models have three or four num-
performed within the peritoneal cavity. Percutaneous
bered articulated “hands and arms” that respond to
procedures of the trunk involving the extraperitoneal or
motions made on a console by a surgeon-operated
retroperitoneal spaces utilize similar instrumentation
joystick (Fig 15-46). These robotic-assisted endoscopic
described in this chapter.
units can perform maneuvers too small for human
hands to perform with precision. The application of
Robotic-Assisted Percutaneous robotics to endoscopy has advanced the concept of
Endoscopy minimally invasive surgery to new levels for the 21st
Robotics can be used to enhance percutaneous endo- century and beyond.
scopic procedures to achieve finesse unmatched by Robotic technology incorporates all of the essential
mere human capabilities. The original robotic compo- elements of endoscopy and requires both sterile and
nents were hinged arms that attached to the rails of the nonsterile personnel in attendance (Fig 15-47). The
operating bed. These flexible-locking arms could be sterile personnel insert the trocars and establish the
positioned by the surgeon to facilitate the procedure. working space. When the pneumoperitoneum is ade-
The robotic-steady position of the camera or grasper quate, the draped robotic unit and its articulated arms
replaced the fatigable first assistant who could cause are positioned and locked over the field. The sterile
vision within the field to shift, making the image on the team connects the robotic-endoscopic instrumentation
video monitor difficult to accurately visualize. and inserts the working elements into the trocars.
One robotic arm is designated as the camera/ (Fig 15-49). The difference is where the instrument
telescope holder and remains in the position as con- attaches to the robotic arm. Each instrument has a
trolled by the surgeon (Fig 15-48). The camera remains microchip memory that documents each use. After
stable, unlike when a person holds the device dur- ten uses, the instrument is replaced with a new one to
ing laparoscopy and experiences fatigue or tremors. assure peak performance.
The other robotic arms are connected to the working The sterile team remains at the field for the entire
instruments, such as clamps, graspers, and dissectors. procedure as the nonsterile surgeon performs the sur-
The instrumentation has the same working tips as gery from a console several feet away from the patient
conventional endoscopic tools depicted in this chapter (Fig 15-50). The console is operated by a forehead
pressure bar, joysticks, and foot pedals. The forehead
pressure bar is depressed by the seated nonsterile sur-
geon to activate the system. Any release of the pressure
causes the robot to go into a standby mode as a safety
feature.
© 2019 Intuitive Surgical, Inc.

Figure 15-46 Robot
Figure 15-48 Camera/Endoscope
Figure 15-47 Robotic team Figure 15-49 Instruments

Figure 15-50 Surgeon console Figure 15-51 Video equip
The surgeon operates the working instruments via

joysticks. Each motion is calculated and precise. The
field of vision is 3-D stereo as if the surgeon is inside
the patient. The magnification permits vision up to
12 times the vision of standard percutaneous endos-
copy. The team can view the procedure through the
video monitor (Fig 15-51). The joysticks provide supe-
rior wrist motion above what the human hands can
perform (Fig 15-52). Specific terms are used to describe
each wrist motion with the surgeon’s controls:
Insertion: back and forth motion
Grip: grasp and release motion

Pitch: up and down linear motion
Yaw: side to side linear motion
Roll: clockwise and counterclockwise circular
motion
Figure 15-52 Wrist action
At the conclusion of the surgical procedure, the
sterile team closes the tiny incisions as with any percu-
taneous endoscopy. Fascial incisions of 10 mm in adults
should be sutured to minimize the risk of herniation. If the procedure must convert to an open operation,
Fascial incisions of 5 mm in children should also be the sterile team has a series of sterile wrenches to disen-
closed for the same reason. The skin can be closed with gage the robotic arms for removal without contamina-
suture or wound glue. Some surgeons use Steri-Strips or tion. The surgeon scrubs in to perform the remainder
Band-Aids as well. of the surgery. Instrumentation such as medium and
long foundation sets should be immediately available. Upper Airway Endoscopy

Some facilities routinely set up a laparotomy table as a Bronchoscopy is performed through the mouth or
backup. through a tracheostomy. The bronchus and bronchi-
oles are visualized using a rigid or flexible fiber-optic
Arthroscopy endoscope. Working elements, such as graspers, biopsy
Arthroscopy is performed by percutaneously inserting forceps, and other devices, can be passed through the
trocars and working instrumentation into a joint space. endoscope to perform surgical procedures. There is no
Common sites for arthroscopy include the knee, wrist, need to use any additional instrumentation for access
shoulder, and hip. The surgeon creates the working to the surgical site.
space by instillation of sterile normal saline or lactated
Ringer’s by gravity or by infusion pump. Infusion pump Urologic Endoscopy
instillation allows more control of bleeding and mea- Most urologic endoscopic instrumentation is used
sured administration of the fluid. Snug trocars prevent through the urethral orifice of either the male or the
slippage of the sleeve and leakage of the fluid from the female during cystoscopic surgery. A sheath with an
joint capsule into adjacent tissues. obturator is introduced through the urethra, and the
working space is created with sterile water instillation.
Neuroendoscopy The obturator is removed, and a telescope is inserted.
Rigid and flexible endoscopes are used to visualize the The sheath has a working channel for instrumenta-
brain and neural tissue. Ventricles can be unblocked, tion. The surgeon controls the instillation and evacu-
thereby avoiding the use of a shunt. One advantage of ation of the fluid expansion medium. Electrosurgical
neuroendoscopy over basic microscopy is the ability to procedures can safely be performed inside the bladder
look around corners and in retrograde mode for greater and prostate through the cystoscope. Cystoscopy can
field of vision. be performed with the patient under general or local
anesthesia. If a gel-type local anesthetic is placed in the
male urethra, a gentle spring-loaded clamp is placed
Thoracoscopy across the penis to prevent oozing of the gel before it
Percutaneous access through the chest wall is per- can take effect.
formed for procedures involving the lungs, structural An exception to the procedures performed through
aspects of the upper airway, and surface access to great the urethra is nephroscopy. The scopes used to view the
vessels and nodes. Standard laparoscopes and video- outside of the kidney via a percutaneous access portal
scopes can be inserted through the trocars for video- are introduced through the patient’s skin at the level of
assisted thoracoscopic surgery (VATS). the organ. The process is not the same as laparoscopy
because the peritoneal cavity is not entered.
Mediastinoscopy
Mediastinoscopy is performed to stage a disease entity
such as cancer. The extent of the spread of the nodal
advancement of disease is predictive of the patient’s SUMMARY
chances of survival. The procedure involves an incision Endoscopic procedures have revolutionized how
just above the suprasternal notch followed by the inser- surgery is performed. In most cases, the process
tion of a mediastinoscope alongside the trachea and has decreased surgical anesthesia time for the
biopsy of mediastinal nodes. Nodes accessible through patient. The tiny skin incisions decrease recovery
this route are the left and right paratracheal nodes, periods, permitting patients to return to work
pretracheal nodes, and anterior subcarinal nodes. Fine sooner. The addition of robotics has advanced the
needle aspiration biopsy can be performed through precision of delicate procedures.
mediastinoscopy.
CHAPTER 16
DECONTAMINATION
AND STERILIZATION

After reading this chapter the learner should be able to: Decontamination
1. Explain the decontamination process, including mechanical and manual cleaning Instructions for Use (IFUs)
and PPE. Cleaning
2. Describe the process of instrument inspection and packaging. Inspection/Packaging
3. Classify patient care items as critical, semi-critical, or noncritical. Processing
4. Describe the details of each sterilization method and the types of validation for Disinfection
each method.
Sterilization
5. Explain packaging materials, folding techniques, and packaging labels.
Sterile Storage and Packaging
Microbiological Concerns
Reprocessing Flexible
Endoscopes
INTRODUCTION
The decontamination and cleaning process begins at the point of use.
Figure 16-1 illustrates the steps of the decontamination and cleaning
process. These steps include:
1. Cleaning/decontamination
2. Inspection/packaging
3. Processing (sterilization and high-level, intermediate-level, and
low-level disinfection)
4. Storage
5. Use
6. Transportation back to sterile processing
413
ACQUISITION
1. Purchase
Cleaning
2. Loan
The process of instrumenta-
tion cleaning begins at the
point of use (the sterile field)
and continues within the ster-
CLEANING
ile processing department.
TRANSPORT
Cleaning is the process by
DISINFECTION
which bioburden (blood, body
fluids, and gross debris) is
removed from an instrument.
USE
This can be accomplished
At all stages manually or mechanically.
Location
Facilities INSPECTION Health care personnel
Equipment who handle contaminated
Management
Policies/Procedures instruments and devices are
required to wear personal pro-
STORAGE
tective equipment (PPE) to
protect from soil and debris,
PACKAGING blood and body fluids, and
splashes from liquid chemical
TRANSPORT DISPOSAL cleaning agents (Table 16-1).
1. Scrap
STERILIZATION 2. Return to lender PPE should include:
© 2019 Cengage®. ●● Hair cover
●● Shoe cover
●● Eye protection
Figure 16-1 Surgical Processing and Disinfection Cycle
DECONTAMINATION
Decontamination is the disinfection and cleaning pro-
cess that takes place in the decontamination section
of the sterile processing department. Contaminated
instrumentation should be transported to the central
supply department in a closed containment system or
case cart (Figure 16-2). These contaminated instru-
ments are then cleaned, disinfected, and sterilized in the
decontamination room (Figure 16-3).
Instructions for Use (IFUs)

Health care workers must follow manufacturers’ IFUs
throughout the decontamination and sterilization pro-
© 2019 Cengage®.
cess. Manufacturers must provide IFUs for all instru-

mentation, equipment, chemicals, and supplies within
the central supply department. These IFUs must be kept
on file within the central processing department. Figure 16-2 Case Cart
Chapter 16 Decontamination and Sterilization 415
TABLE 16-1 Chemical Cleaning Agents

Chemical
Cleaning Agents Characteristics
Sterile water • The scrubbed person within the sterile
field is responsible for wiping down
used instrumentation to keep organic
debris from drying
Enzymatic • Substance used as a soaking solution
© 2019 Cengage®.
© 2019 Cengage®.
• Aids in the breakdown of organic
material.
Figure 16-3 Decontamination Room

surgical instrumentation. The three-sink method is
used for the manual cleaning process:
●● Fluid-resistant face masks
●● Sink 1: Clean the instrumentation by brushing
●● Fluid-resistant gown
with tap water and detergent.
●● Gloves ●● Sink 2: Rinse the instrumentation with tap
In addition to wearing PPE, health care water.
personnel must follow these guidelines when cleaning ●● Sink 3: Rinse the instrumentation with distilled
instrumentation: and de-ionized water.
●● A hand wash must be per-
formed when the PPE is
Use
removed to prevent cross-
contamination and nosoco-
mial infections.
●● NaCl is never used in
the cleaning process on
surgical instrumentation Store
because it causes instrument

pitting. Sort and
disassemble
●● Powered surgical instru-
mentation can never be Sterilize
immersed.
●● All surgical instrumentation
should be disassembled and
unlocked prior to beginning Assemble
the cleaning process. and wrap Clean
(ultrasonic
The mechanical and manual cleaner)
cleaning process does not render
instrumentation safe for use on
patients (Figure 16-4) (Table 16-2).
Decontaminate
Manual cleaning is sometimes (washer-sterilizer)
© 2019 Cengage®.
Inspect
used in place of mechanical cleaning.
Manual cleaning is recommended
for delicate surgical instrumentation
such as lensed, powered, or micro- Figure 16-4 Instrument Processing Cycle
TABLE 16-2 Mechanical Cleaning Process Equipment

Mechanical Cleaning Process Equipment Characteristics
Washer decontaminator/washer sterilizer (Figure 16-5) • Both of these machines decontaminate/sterilize by steam.
• Used to make instrumentation safe to be handled by the
reprocessing team in the prep and pack section of the sterile
processing department.
© 2019 Cengage®.
Figure 16-5 Washer-Sterilizer
Ultrasonic Washer (Figure 16-6) • Mechanical machine that uses cavitation to clean soiled
instrumentation.
• Especially useful for instrumentation with lumens.
© 2019 Cengage®.
© 2019 Cengage®.
Figure 16-6 Ultrasonic Cleaner
Brushes used in manual cleaning must be the cor-

rect size to clean lumens. Clean and decontaminate
reusable brushes daily and discard when showing wear.
Once the cleaning process is complete, the instru-
mentation or equipment travels to the clean processing
area of central supply (Figure 16-7).
INSPECTION/PACKAGING
Inspection and packaging takes place within the
© 2019 Cengage®.
clean processing area of central supply (Figure 16-8)

(Table 16-3).
Figure 16-7 Clean Processing Area

PROCESSING
Processing takes place within the clean processing area
of the central supply department.
Tips The Centers for Disease Control (CDC) classifica-

tion of patient care items include:
●● Critical—items that are sterile; includes implants,
Jaws
catheters, and surgical instrumentation
●● Semi-critical—items that are high-level disin-
fected; includes endoscopes, cystoscopes, respi-
Box lock ratory equipment, and anesthesia equipment
●● Noncritical—items that are low-level disinfected;
includes bedpans, blood pressure cuffs, and
crutches
Shank
Disinfection
Finger ring
Disinfection is the process by which most microorgan-
isms on non-living surfaces are removed or destroyed.
© 2019 Cengage®.
Ratchets Levels of disinfection:

●● High-level disinfection—kills all microorgan-
Figure 16-8 Instrument Anatomy isms except spores (Figure 16-9)
●● Intermediate-level disinfection—kills most
microorganisms, including bacteria and viruses
●● Low-level disinfection—kills some fungi,
viruses, and bacteria
TABLE 16-3 Instrument Inspection
Instrument inspection • Functionality (not broken or damaged)
• Integrity (clean)
Instrumentation reassembled • Count sheet for instrumentation trays
• Instrument trays prepared for packaging
Packaging material selected—material used to wrap item • Peel packs
that is being processed • Woven textiles
• Nonwoven materials
• Rigid instrument containers
Indicator that is both chemical and biologic placed inside item to be • Autoclave tape
packaged. Chemical indicator is used outside as part of the tape. • Indicator
Labeling—item is labeled • Package contents
• Shelf-life
• Date of sterilization
• Sterilizer number
• Cycle number
• Initials of individual who processed item
Item is ready for sterilization – method is chosen in accordance Factors of sterilization:

with item IFU • Time
• Temperature
• Contact
© 2019 Cengage®.
• Moisture
• Pressure
Sterilization
Sterilization is the destruction of all microorganisms and
spores in or about an object with steam (Figure 16-10),
chemical agents, high-velocity electrons, or ultraviolet
rays. Table 16-4 describes various sterilization methods,
and Table 16-5 describes validation types.
●● Geobacillus sterothermophilus is the micro
organisms used to challenge steam sterilization
in biological testing.
●● Bacillus atrophaeus is the microorganism
used to challenge ETO sterilization in biological
testing.
© 2019 Cengage®.
Figure 16-9 Flexible colonoscope processed through high-

level disinfection
© 2019 Cengage®.
Figure 16-10 Steam sterilization area
TABLE 16-4 Sterilization Method (Note: Prior to processing, manufacturer’s IFUs must be followed)
Sterilization Method Description
Steam autoclave • Most frequently used method of sterilization
• Cheapest and safest method
• Gravity steam temperature 250°F to 270°F
• Pre-vacuum steam temperature 270°F to 275°F
© 2019 Cengage®.
Figure 16-11 Table top steam autoclave

© 2019 Cengage®.
Figure 16-12 Table top steam autoclave

TABLE 16-4 (Continued)
Sterilization Method Description
Sterrad • Hydrogen peroxide gas plasma
• Not effective on narrow-lumen items
© 2019 Cengage®.
Figure 16-13 Hydrogen peroxide sterilizer from Sterrad
STERIS • Peracetic acid

• Items sterilized with this method cannot be stored
© 2019 Cengage®.
Figure 16-14 Peracetic acid STERIS sterilizer

Ethylene oxide (ETO) • Not safe
• Most dangerous method.
• Requires 10-hour aeration post-sterilization
• Best method for electronic equipment
Glutaraldehyde (CIDEX) • High-level disinfectant; 20-minute immersion
• Sterilant 10-hour immersion
• Items immersed must be rinsed with sterile water
Immediate-use steam sterilization (IUSS) or (FLASH) • Temperature 270°F
• Minimum 3 minutes
• Emergency use only
© 2019 Cengage®.
• Ten minutes for lumen or complex instruments
• Check IFUs for powered instrumentation
STERILE STORAGE AND PACKAGING Two basic fold techniques for muslin, woven, and
nonwoven materials are the:
Sterile packaging is designed with tamper-evident seals
●● Square fold—parallel fold used for larger trays
to allow users to determine if items have been compro-
mised. Packaging materials should: ●● Envelope fold (Figure 16-16)—used for small
packs and trays
●● Allow penetration of sterilant
The packaging label should include:
●● Be designed to be opened using aseptic
technique ●● Name of device or item
●● Maintain sterility of contents until use ●● Initials of assembler
TABLE 16-5 Validation of Sterility

Validation Types Description
Mechanical—print out Permanent records or logs kept of each load and cycle for all
items processed.
Chemical indicators (Figure 16-15) Indicate exposure of item to sterilization process.
© 2019 Cengage®.
Figure 16-15 Indicator tape showing color

change appropriate for exposure to the steam
sterilization process
© 2019 Cengage®.
Biological Device that contains microorganism spore that is killed during the
sterilization process. Biological testing in all sterilization methods
is considered a guarantee of sterility.
A. B. ●● Sterilizer number and load number

●● Date of sterilization
Sterilization packaging materials come in both
reusable (Table 16-6) and disposable (Table 16-7) forms.
Sealing of packages (closure) is designed to secure
contents and maintain sterility until use. Packages can
C. D. be sealed with autoclave tape, heat seals, self-adhesive
seals, or rigid container seals (Table 16-8).
Do not seal packages with:
●● Safety pins
●● Staples
●● Paperclips
E. ●● Nonsterilization tapes
Sterility Plans:
●● Event-related sterility—concept that
© 2019 Cengage®.
items remain sterile until an event (use

or contamination)
●● Time-related sterility—concept that sterility is
Figure 16-16 Packaging (envelope fold): (A) Placement of related to a date of expiration
item on wrapper and addition of chemical indicator, (B) first fold
with tab, (C) second fold with tab, (D) final fold tucked, (E) pack- ●● Transportation of sterile item—items need to be
age secured with chemical indicator tape in a covered or enclosed cart (Table 16-9)
TABLE 16-6 Reusable Sterilization Packaging Materials

Material Description Advantages Disadvantages
Woven textiles Muslin—two-ply woven • Reusable • Must be checked for:
cotton fabric • Low cost ∘ Holes
• Reduced waste ∘ Punctures
• Has to be delinted prior to use
Rigid containers Reusable aluminum or • Excellent barrier • Susceptible to wet pack syndrome; need
high-impact plastic boxlike • No wrapper tears adequate time to dry
© 2019 Cengage®.
cases with removable lids • Need extra space for storage
• Easy to use
and filters
• Filter can become displaced
TABLE 16-7 Disposable Sterilization Packaging Materials

Material Description Advantage Disadvantage
Peel packs/pouches Made from paper, plastic, • Excellent barrier protection • Used for small single items
or Tyvek • Disposable after use • Susceptible to strike-through
or broken seal
Nonwoven wrap SMS—a nonwoven flat paper • FDA approved • Tears easily
© 2019 Cengage®.
wrap • Disposable • Susceptible to holes
• Excellent barrier
TABLE 16-8 Packaging Sealing Methods

Sealing Methods Types
Autoclave tape—chemical indicator • ETO
• Steam
• Sterrad
Heat seal—used to create plastic seal Need a heat sealer to complete the process
Self-adhesive seal—paper or plastic pouches that do not Care should be taken to avoid gaps in seal; gaps can compromise
require heat package integrity; always process on side, not flat, for complete
penetration
© 2019 Cengage®.
Rigid container seals—used on rigid container systems; designed Plastic locks that are placed on container (also a chemical indica-
to break for use or when integrity is compromised tor) prior to sterilization
Microbiological Concerns substances being introduced into the eye during the
Contaminated instrumentation can lead to microbio- procedure and can cause the patient to incur severe
logical issues such as toxic anterior segment syndrome permanent injury to the intraocular tissue and pos-
(TASS) and Creutzfeldt-Jakob disease (CJD). sible loss of vision.
Contaminated ophthalmic surgical instrumen- Contaminated neurological surgical instrumenta-
tation or inadequate decontamination and sterilization can lead to CJD, a prion disease affecting the
tion of ophthalmic instrumentation could result in central nervous system. Instrumentation that has been
TASS, an acute inflammatory condition of the ante- exposed to CJD should be destroyed and not be reused
rior chamber of the eye and a potential postoperative (Table 16-10). Many surgeons have moved to disposable
complication of cataract surgery. TASS is a result of instruments where a risk of CJD is suspected.
TABLE 16-9 Storage of Items

Storage Concerns Issue Prevention
Inventory control • Stock rotation is first-in, first-out to prevent out-dates and “neglected pack syndrome”
Moisture/fluid damage • Room temperature should be maintained between 72°F and 75°F to prevent
condensation on the packs
• Humidity should be between 20% and 70%
Dirt, dust, and debris • Prevent contamination (dustcover)
Physical damage • Prevent holes, tears, broken seals, and punctures
Ventilation • Positive air pressure to prevent airborne contamination
• Six air exchanges (including two fresh) per hour under positive pressure
Storage • Store sterile items 8 to 10 inches above the floor and no closer than 18 inches below
sprinkler heads on the ceiling
© 2019 Cengage®.
• Arrange items to prevent crushing
• Storage area should be a low-traffic area
TABLE 16-10 Microbiological Concerns

Ophthalmic Surgical Instrumentation
TASS Toxic anterior segment syndrome is an acute inflammatory condition of the anterior chamber of the eye and is a poten-
tial postoperative complication of cataract surgery. TASS is a result of substances being introduced into the eye during
the procedure and can cause the patient to incur severe permanent injury to the intraocular tissue and possible loss of
vision. TASS is linked to inadequate decontamination and sterilization of ophthalmic instrumentation.
Neurological Surgical instrumentation
© 2019 Cengage®.
CJD Creutzfeldt-Jakob disease (CJD) is a prion disease affecting the central nervous system. Transmission is associated with
the use of contaminated instrumentation. Instrumentation that has been exposed to CJD should be destroyed and not be
reused.
REPROCESSING FLEXIBLE
ENDOSCOPES
Cleaning of flexible endoscopes begins at the point
of use while the scope is attached to the monitor.
Precleaning is the removal of gross debris from the
endoscope’s external surfaces and internal channels.
Appropriate personal protective equipment (PPE)
must be worn during the entire reprocessing process.
© 2019 Cengage®.
Personnel reprocessing flexible endoscopes must con-

sult the manufacturer’s instructions for use (IFU),
and all instructions must be followed throughout the
Figure 16-17 A colonoscope is a type of endoscope requir-
entire process (Figure 16-17). ing high-level disinfection.
Point-of-use reprocessing:
1. Wipe down insertion tube with enzymatic deter- 2. Immerse distal tip of the flexible scope into the
gent solution formulated for endoscopes applied container of detergent solution, and depress the
by a soft lint-free cloth. suction valve to aspirate for 30 seconds.
3. Remove the distal tip from the detergent solution, 2. Completely immerse the endoscope in the
and depress the suction valve to aspirate air for detergent solution. Use a brush or lint-free cloth
10 seconds. to thoroughly clean all external surfaces.
4. Turn off the suction pump and light source. 3. For JF/TJF model duodenoscopes and other endo-
5. Attach air/water channel cleaning adapter, and set scope models with an elevator wire channel, brush
the light source air flow to high. around the forceps elevator.
6. Immerse the distal tip into the container of clean 4. Use endoscope model-specific brushes to brush
water. channels/cylinders/ports until no visible debris
remains.
7. Depress air/water channel cleaning adapter, and
feed water for 30 seconds. a. Brush the suction channel insertion tube.
8. Release the air/water channel cleaning adapter for b. Brush the suction channel in the universal cord.
10 seconds or more to let air through the channel. c. Brush the suction cylinder.
Turn off the light source. d. Brush the instrument channel port.
9. Disconnect all removable and reusable parts from the 5. Attach the suction cleaning adapter to the instru-
endoscope. Confirm the water-resistant cap is dry ment channel port. Connect the suction tube
and free of debris, and attach the water-resistant cap. from the suction pump to the suction connector
10. Transport to reprocessing area in a covered on the endoscope. Immerse the distal end and
container. weighted end of the suction cleaning adapter in
Leak testing: detergent. Cover the suction cylinder and aspi-
rate detergent solution for approximately 30 sec-
1. Fill a basin with clean water. onds. Turn off the suction source, and disconnect
2. Confirm that there is no water within the leakage the suction tube. Disconnect the suction tube and
tester’s connect cap. the suction cleaning adapter and reprocess them
3. Connect leakage tester to air source, and confirm as well.
that air is being emitted. 6. For JF/TJF model duodenoscopes and other
4. Connect leakage tester to the endoscope, and con- model endoscopes with an elevator wire chan-
firm bending section is inflating. nel, immerse the distal tip in the detergent solu-
5. Completely immerse the endoscope in water. tion, and raise and lower the forceps elevator
three times; with the forceps elevator raised,
6. Observe for 30 seconds while angulating the bend-
use a 30-cc syringe to flush the interior of the
ing section.
forceps elevator with detergent solution and
7. Remove the endoscope from the water and turn attach the channel plug. At this point the CST
off the air source. will follow the steps to manually flush with a
8. Disconnect the leakage tester from the air source. syringe or the steps to use the endoscope
9. Wait 30 seconds or until the bending section con- flushing pump.
tracts to its pre-expansion size.
10. Disconnect the leakage tester connector cap from Manually flushing with a syringe:
the venting connector. 1. Attach the injection tube, and immerse the suc-
11. If the endoscope has passed the leak test, repro- tion port of the injection tube into the detergent
cessing can proceed. solution prepared as recommended by the manu-
facturer. Attach a 30-cc syringe to the injection
Manual cleaning:
tube. Inject 90 cc detergent solution into each side
1. Fill a basin with a detergent solution prepared as of the injection tube. For endoscopes with auxil-
recommended by the manufacturer. Detach all iary water feeding channels, use a 30-cc syringe
removable parts; soak and scrub, or brush them to to flush 90 cc detergent solution into the auxiliary
remove all debris. water channel.
2. For JF/TJF model duodenoscopes and other High-level disinfection:

model endoscopes with an elevator wire channel,
1. High-level disinfection can be accomplished man-
attach the washing tube to the elevator channel
ually or through an automated endoscope repro-
plug. Use a 5-cc syringe to inject 15 cc of detergent
cessor (AER).
solution into the elevator wire channel. Disconnect
the washing tube from the endoscope and im- 2. IFUs must be consulted and followed throughout
merse in the detergent solution. the process.
3. Detach cleaning equipment. Soak in detergent Automated endoscope reprocessors:

solution with the endoscope for the time and 1. Test the potency of the disinfectant solution
temperature specified by the detergent manufac- according to the manufacturer’s instructions.
turer. Wipe down the scope with a lint-free cloth Inspect the connections according to the AER
while the endoscope is immersed in the detergent. manufacturer’s instructions. Verify that the proper
Remove the endoscope and equipment from the connector is being used for the endoscope being
detergent solution. reprocessed. Attach the endoscope connectors/
4. Immerse the endoscope and equipment in clean adapters to the AER and endoscope as per the
water and gently agitate to rinse. Reconnect the AER manufacturer’s instructions.
connector plug and injection tube. Use a 30-cc sy- 2. Operate the AER according to the AER’s manu-
ringe to inject 90 cc of water through each side of facturer’s instructions. Ensure the endoscope is
the injection tube. Then use 30-cc syringe to inject soaked in disinfectant solution according to the
90 cc of air through the injection tube. liquid chemical germicide manufacturer’s recom-
5. For other endoscope models with auxiliary water mendations for time and temperature. Remove
feeding channels, attach a 30-cc syringe to the the endoscope after the AER cycle is completed.
auxiliary water tube and inject 90 cc of clean wa- Proceed to alcohol flush and storage.
ter. Then use a 30-cc syringe to inject 90 cc of air
Manual high-level disinfection:
through the auxiliary water tube.
6. For JF/TJF model duodenoscopes and other 1. Fill a basin with disinfectant solution. Test the
model endoscopes with an elevator wire chan- potency of the disinfection solution according to
nel, attach a 5-cc syringe to the washing tube and the manufacturer’s guidelines. Attach the chan-
flush the elevator wire channel with 5 cc of clean nel plug and injection tube to the endoscope.
water. Then use a 5-cc syringe to flush 10 cc of air Completely immerse the endoscope and equip-
through the elevator wire channel. ment in disinfectant solution.
7. Disconnect and reprocess the cleaning equipment. 2. Use a 30-cc syringe to inject 90 cc of disinfectant
into each side of the injection tube. Confirm that
Use of the endoscope flushing pump: no bubbles exit the distal tip.
1. Fill a 2-liter container with detergent solution 3. For all other models of endoscopes with auxiliary
prepared as recommended by the manufacturer. water feeding channels, attach the auxiliary wa-
Connect the inlet hose, connect the main channel ter tube and use a 30-cc syringe to inject 90 cc of
assembly, and press the start button. disinfectant solution through the auxiliary water
2. For scopes with an elevator wire or auxiliary water tube.
channel, connect the special channel assembly and 4. For duodenoscopes and other model endoscopes
press start. Discard used detergent. with an elevator wire, attach the washing tube.
3. Rinse and fill containers and the endoscope basin Use a 5-cc syringe to flush 10 cc of disinfectant
with clean water. Press the start button, and place the solution through the elevator wire channel via the
screened end of the inlet hose in the empty container. washing tube. Confirm that no bubbles exit the
Press the stop button, and use a clean, lint-free cloth distal tip. While immersed in disinfectant solution,
to thoroughly wipe and dry the external surfaces of raise the forceps elevator and flush with disinfec-
the endoscope and reprocessing equipment. tant using a 5-cc syringe.
5. Disconnect all equipment from the endoscope. to flush 15 cc of air through the elevator wire
Remove any bubbles that adhere to the surfaces channel.
with a clean, lint-free cloth. Soak the endoscope 7. Disconnect all equipment from the endoscope,
and equipment for the time and at the tempera- and wipe all external surfaces with a lint-free
ture recommended by the disinfectant manufac- cloth.
turer. Reconnect the channel plug and injection
tube to the endoscope, and attach a 30-cc syringe Alcohol flush:
to each port on the injection tube and inject 1. Attach a reprocessed channel plug and injection
90 cc of air. tube to the endoscope. Immerse the suction port
6. For other models of endoscopes with auxiliary wa- of the injection tube in 70% isopropyl or ethyl
ter feeding channels, reattach the auxiliary water alcohol. Attach a 30-cc syringe to each port of the
tube and use a 30-cc syringe to inject 90 cc of air injection tube and inject 90 cc of alcohol. Remove
through the auxiliary water tube. the suction port from the alcohol.
7. For duodenoscopes and other models of scopes 2. For endoscopes with auxiliary water feeding
with an elevator wire, reattach the washing tube channels, attach a reprocessed auxiliary water
and use a 5-cc syringe to flush 10 cc of air through tube and use a 30-cc syringe to inject 90 cc of
the elevator wire channel. alcohol.
8. Remove the endoscope and equipment from the 3. For duodenoscopes and other model endoscopes
disinfectant, and disconnect the equipment from with elevator wire channels, attach a reprocessed
the endoscope. Proceed to the rinsing step. washing tube and use a 5-cc syringe to flush
10 cc of alcohol through the elevator wire
Rinsing:
channel.
1. Fill a basin with sterile water. Completely
4. Use a 30-cc syringe to inject 90 cc of air through
immerse the endoscope and equipment in the
each side of the injection tube.
water. Wipe all external surfaces with a lint-free
cloth. Attach the channel plug and injection 5. For endoscopes with auxiliary water feeding chan-
tube to the endoscope. Use a 30-cc syringe to nels, attach a reprocessed auxiliary water tube and
inject 90 cc of water through each side of the use a 30-cc syringe to flush 90 cc of air.
injection tube. 6. For duodenoscopes and other model endoscopes
2. For endoscope models with auxiliary water feed- with an elevator wire channel, attach a reprocessed
ing channels, attach the auxiliary water tube and washing tube and use a 5-cc syringe to flush 15 cc
use a 30-cc syringe to inject 90 cc of water. of air through the elevator wire channel.
3. For duodenoscopes and other model endoscopes 7. Disconnect all equipment from the endoscope,
with an elevator wire channel, attach the washing and use sterile cotton swabs to dry the inside of
tube and use a 5-cc syringe to flush 15 cc of water the air/water and suction cylinders and instrument
through the elevator wire channel. channel ports.
4. Remove the endoscope and equipment from the Endoscope storage:
water. Cover the distal tip with a lint-free cloth, 1. Remove all valves and removable parts from the
and use a 30-cc syringe to inject 90 cc of air endoscope. Ensure that the angulation locks are
through each side of the injection tube. in the free position. For endoscopes with a flex-
5. For endoscopes with auxiliary water feeding ible adjustment mechanism, set the insertion tube
channels, attach the auxiliary water tube and use to maximum flexibility. Store the endoscope in a
a 30-cc syringe to inject 90 cc of air. well-ventilated cabinet, and hang so that the uni-
6. For duodenoscopes and other models of versal cord and insertion tube are hanging verti-
endoscope s with an elevator wire channel, cally and the distal tip of insertion tube is
attach the washing tube and use a 5-cc syringe hanging freely.
REFERENCES Association of Surgical Technologists (AST). (2014).

AST standards of practice for packaging mate-
American Society for Healthcare Engineering (ASHE) rial and preparing items for sterilization. Retrieved
(2014). Guidelines for the Design and Construction from http://www.ast.org/uploadedFiles/Main_Site
of Healthcare Facilities. Retrieved from http://www /Content/About_Us/Standard_Packaging_Materials
.ashe.org/advocacy/orgs/fgi.shtml _Preparing_Items.pdf
Association of Surgical Technologists (AST). (2014). Centers for Disease Control and Prevention (CDC).
Standards of practice for the decontamination of (2009). Guidelines for disinfection and sterilization
surgical instruments. Retrieved from http://www in healthcare facilities, 2008 Retrieved from http://
.ast.org/uploadedFiles/Main_Site/Content/About www.cdc.gov/hicpac/Disinfection_Sterilization
_Us/Standard_Decontamination_%20Surgical /2_approach.html
_Instruments_.pdf
INDEX
A Baron suction tube, 154, 333, 389 Brown applicator, 290

Barr anal self-retaining retractor, 193 Brown uvula retractor, 311
Adson bayonet forceps, 286, 298
Barr fistula probe, 222 Brown-Adson tissue forceps, 101, 115, 144
Adson clamp, 31, 99, 141, 197, 344
Barraquer DeWecker iris scissors, 385 Bruening septum forceps, 304
Adson dural hook, 334
Barraquer lid speculum, 390 Brun curette, 266
Adson forceps, 101, 114, 127, 143, 202, 323
Baumgartner needle holder, 160 Brunner intestinal clamp, 186
Adson suction tube, 153, 333, 389
Bear claw retractor, 156 Buck applicator, 290
Aesculap sterile container, 91
Beaver handle, 146 Buck ear curettes, 289
Ahrya, 1
Beckman nasal speculum, 309 Buie fistula probe, 191
Alexander periosteotome, 264
Beckman retractor, 273, 297, 316, 336 Buie pile clamp, 189
Allen clamp, 33, 185
Bellucci, 286 Buie suction tip, 191
Allerdyce elevator, 262
Bellucci ear scissors, micro, 288 Bulldog applicator, 351
Allis Adair forceps, 142, 206
Bennett bone elevator-retractor, 276 Bulldog clamp, angled, 352
Allis forceps, 100, 113, 125, 142, 206
Benson pylorus dilator, 183 Bulldog clamp, curved, 352
Allison retractor, 365
Berke ptosis forceps, 381 Bulldog clamp, straight, 352
Alm self-retaining retractor, 158, 274, 296
Beyer bone rongeur, 295 Bunnell drill, 250
Anterior neck instrumentation,
Bihrle needle holder/dorsal clamp, 231 Bunnell tendon stripper, 281
315–316
Bill traction handle, 211 Busch scissors, 187
Army-navy retractors, 106, 119, 132, 155
Billeau flexible ear curette, 289
Arthroscope, 30-degree, 281
Billroth tumor forceps, 208
Arthroscopic instruments, 281–283 C
Bipolar bayonet forceps, 326
Arthroscopic shaver, 284
Bipolar bayonet forceps with Camera head, 283
Association for the advancement
suction, 326 Camera/endoscope, 410
of medical instrumentation
Bishop-Harmon cannula, 389 Capsule retractor, 277
(AAMI), 93
Bishop-Harmon forceps, 378 Carroll tendon puller, 280
Aufranc cobra retractor, 276
Blair cleft palate retractor, 312 Case Cart, 414
Aufrecht scissors, 150
Blount retractor, 278 Castroviejo caliper, 279, 363, 387
Aufricht glabella rasp, 307
Blumenthal rongeur, 267 Castroviejo needle holder, 393
Aufricht nasal retractor, 311
Bodenhammer rectal speculum, 193 Castroviejo punctum dilator, 387
Auvard weighted speculum, 219
Bone awl, 266 Castroviejo scissors, 384
Awls, 261–266
Bone chip packer, 279 Centers for disease control (CDC)
Aztec civilization, 3
Bone cutters, 267–272 critical, 417
Bone hook, 279 noncritical, 417
B Bone reduction forceps, 258 semi-critical, 417
Babcock forceps, 114, 126, 204 Bone tamp, 279 Chandler elevator, 263
Babylonians, 3 Bone-holding forceps, 259 Chedya, 1
Backhaus towel clamp, 38, 240 Bookwalter table-mounted retractor, Cheek retractor with swivel blade, 312
Bailey clamp, 346 183, 234 Chelsea-Eaton anal speculum, 193
Bailey retractor, 368 Bosworth tongue depressor, 311 Chemical cleaning agents, 415
Bainbridge clamp, 35 Boucheron ear specula, 292 Circumcision, 242
Bainbridge forceps, 187 Bowman lacrimal probes, 242, 386 clamps, 242
Balfour self-retaining retractor, 133, 221 Bozeman forceps, 204 Clamping, 12–14
Ballenger swivel knife, 302 Brand tendon puller, 281 Clamps, 14, 16, 20
Ballenger tonsil forceps, 300 Braun single tooth tenaculum, 207 Clean processing area, 416
Ballenger V-shaped chisel, 302 Bridge clamp, 239, 345 Cleaning, 414–416
Banjo curette, 216 Bristow Bankhart soft tissue retractor, 277 Closed rigid containers, 90–91
Barnhill adenoid curette, 307 Broli-Adson forceps, 144, 324 Coakley antrum trocar, 309
Baron suction tip, 292 Brophy forceps, 325 Cobb curette, 266
427
428 Index
Cobb elevators, 16, 261. See also Periosteal Dennis micro needle holder, 392 Fehland intestinal clamp, 186
elevators Dennis needle holder, 370 Fergusen angiotribe clamp, 189
Collin (Judd-DeMartel) gallbladder Derf needle holder, 107, 159, 338, 392 Ferguson gallstone scoop, 181
forceps, 180 Deschamps ligature carrier, 226, 371 Ferguson scissors, 187
Collin Segund tenaculum, 209 Desjardin (Rochester) gallstone forceps, 181 Fergusson bone-holding forceps, 259
Collin tongue forceps, 298 Desjardin gallstone scoop, 181 Ferris Smith Kerrison rongeur, 267
Colonoscope, 422 DeVilbiss speculum, 221 Ferris Smith pituitary rongeur, 330
Columbia lip retractor, 312 DeWecker iris scissors, 386 Fiber-optic cable, 397
Cooley clamp, 349 Diamond pin and wire cutter, 268 Finger ring cutter, 280
Cooley forceps, 354 Dieter, 286 Finochietto clamp, 347
Cooley retractor, 366 Dingman bone-holding forceps, 255 Finochietto needle holder, 237, 371
Cooley Satinsky clamp, 349 Dingman mouth gag, 314 Finochietto retractor, 367
Cottle cartilage crusher, 314 Disinfection, 417 Fisher tonsil knife, 303
Cottle dorsal scissors, 300 Packaging materials, 421 Flat nose cutter pliers, 269
Cottle nasal knife, 302 nonwoven wrap, 421 Flat nose pliers, 269
Cottle nasal speculum, 310 peel packs/pouches, 421 Flat nose pliers (heavy), 270
Cottle raspatory, 306 Dittel urethral sounds, 64, 240 Flemma scissors, 361
Cottle septum elevator, 303 Double-action parallel pliers and wire Flexible colonoscope, 418
Counter sink, 254 cutter, 268 Foerster sponge forceps, 34, 126, 205, 356
Cranial procedures, 340 Double-action wire cutter, 272 Foerster straight and curved sponge
Creutzfeldt-Jakob disease (CJD), 421 Doyen abdominal scissors, 184 forceps, 15
Crile clamp, 26, 97–98, 123, 139, 196, 344 Doyen clamp, 35, 185 Foman scissors, 150
Crile needle holder, 225 Doyen rib stripper, 362 Fomon rasp, 307
Crile retractor, 155 Doyen scissors, 358 Foss anterior resection clamp, 186
Crile-Wood needle holder, 108, 121, 134, 162, Doyen tumor screw, 210 Foss intestinal clamp, 186
236, 339, 369 Doyen-Jansen mouth gag, 313 Foss retractor, 235
Cruciform screwdriver with screw-holding Dressing forceps, 102, 115, 128, 143, Fracture fixation instrumentation, 244
tip, 246 202, 324, 353 pins and wires, 245
Curettes, 261–266 Drill bit, 247 Frazier dural elevator, 315
Cushing bayonet tissue forceps, 298 Drills and power equipment, 250 Frazier suction tube, 105, 118, 153, 291,
Cushing brain spatula, 337 drills and devices, 250–254 332, 389
Cushing elevator, 263 Dubois scissors, 187 Freeman nipple-marking template, 163
Cushing forceps, 354, 379 Duval forceps, 355 Freeman retractor, 156
Cushing nerve hook, 315 Freer chisel, 294, 301
Cushing rongeur, 329 Freer elevators, 16, 261, 288, 294, 301
E Freer septum knife, 301
Edwin Smith (papyrus), 2 Freidman mini rongeur, 295
D Elliott obstetrical forceps, 211 French rod shaper, 247
D’Amico suction, 364 El Zahrawi (940–1013 AD), 3 Front and side pin cutter, 270
Dandy nerve hook, 316 Endaural curette, 289 Fukuda shoulder retractor, 278
Dandy scalp clamp, 320 End-to-end anastomosis stapler (EEA), 188
Darrach elevator, 263 Esophageal dilator, 183
Davidson retractor, 365 Endoscopic instrumentation, 398–409 G
Davis brain spatula, 337 access and creation of the working space, Garrett vascular dilators, 362
Davis mouth gag, 313 398–399 Garrigue weighted speculum, 219
Day ear hook, 290 closure within the working space, 406 Gastrointestinal anastomosis stapler
Dean tonsil knife, 304 illumination and viewing within the (GIA), 188
Deaver retractor, 132 working space, 400 Gaylor punch, 217
DeBakey and Cooley jaws, 17 irrigation and evacuation of the working Gelpi self-retaining retractor, 120, 278, 336
DeBakey bayonet forceps, 4, 325 space, 405–406 Gemini mixter clamp, 30, 345
DeBakey clamp, 347 manipulation within the working space, Geobacillus sterothermophilus, 418
DeBakey micro forceps, 379 401–405 George Ebers, 2
DeBakey peripheral vessel clamp, 230 Ethylene oxide (ETO), 419 Gerald forceps, 127, 145, 354
DeBakey forceps, 101, 115, 127, 144, 353 Eve tonsil snare, 314 Gerald micro forceps, 378
Decontamination, 414 Gerald micro ring forceps, 379
Decontamination room, 415 Gerzog mallet, 273, 304
DeLee retractor, 70, 222 F Gigli wire saw with guide and two
Delicate wire cutter, 271 Fansler-Ives anoscope, 192 handles, 328
Demel wire guide, 272 Farabeuf bone-holding forceps, 261 Gill (Chandler) iris forceps, 378
Dennis clamp, 185 Farrell applicator, 308 Gilles skin hook, 157
Dennis Cooley clamp, 350 Farrior ear specula, 293 Gillies forceps, 379
Dennis DeBakey clamp, 350 Faulkner ethmoid curette, 306 Gill-Welsh cannula, 389
Dennis forceps, 325 Favaloro retractor, 367 Gill-Welsh lens loop, 391
Dennis micro forceps, 380 Favaloro scissors, 360 Glasser micro needle holder, 392
Index 429
Glassman visceral retainer, 227 Hudson brace set, 328 Jacobson microvascular needle holder, 385
Gluck rib shears, 361 Hulka tenaculum with uterine elevator, 211 Jacobson mosquito clamp, 24, 138, 343, 377
Glutaraldehyde (CIDEX), 419 Humeral head retractor, 277 Jacobson Vannas scissors, 384
Goelet retractor, 276 Hunter clamp, 350 Jaeger lid plate, 391
Goldman-Fox scissors, 191 Hurd tonsil dissector, 304 Jameson caliper, 388
Gomco circumcision clamp, 242 Hysterectomy clamp, 200 Jansen forceps, 145
Goodell dilator, 224 Jansen retractor, 158, 296
Gorney scissors, 151 Jansen-Middleton septum forceps, 305
Gosset self-retaining retractor, 193 I Jansen-Wagner mastoid retractor, 296
Graves vaginal speculum, 87, 221 IMA micro scissors, delicate, 383 Jarcho cannula, 218
Green retractor, 316 Immediate-use steam sterilization (IUSS), 419 Jennings mouth gag, 314
Gross ear hook and spoon, 290 Infection control, 92 Jensen capsule polisher, 388
Gruber ear specula, 292 Inflow-outflow sheath, 282 Jeweler forceps, 378
Gruenwald rongeur, 330 Infusion pump instillation, 412 Jones clamp, 27
Gutman speculum, 221 INGE lamina spreader, 272, 335 Jones towel clamp, 37
Guyon-Pean vessel clamp, 230 Inspection/packaging, 416 Jorgenson scissors, 215, 232
Guyton-Park speculum, 390 Instrument anatomy, 417 Joseph bone saw, 264
Instrument categories, 92t Joseph button knife, 302
Instrument cleaning process equipment, 416 Joseph double-edged nasal knife, 302
H washer-sterilizer, 416 Joseph hook, 310
Halle infant speculum, 309 ultrasonic cleaner, 416 Joseph nasal saw, 303
Hallman tunneling forceps, 356 Instrument containers and trays, 89–91 Joseph rasp, 265
Halsey needle holder, 79, 160 closed rigid containers, 90–91 Joseph raspatory, 306
Halsted mosquito clamp, 6, 24, 96, 98, 110, perforated trays, 89–90 Joseph scissors, 149, 300
137, 343, 377 specialty trays, 90, 91 Joseph skin hook, 156
Hank dilators, 223 Instrument inspection, 417 Judd-Masson bladder retractor, 234
Harrington retractor, 235 Instrument planning, essentials, 87–88
Harrington scissors, 214, 327, 357 evacuation, 87
Harrington-Mayo scissors, 232 hemostasis and occlusion, 87 K
Hartman mosquito clamp, 24, 137, 238, 377 methods and access, 87 Kahn cannula, 218
Hartman rongeur, 267, 294 retained foreign items prevention, 88 Kant needle holder, 393
Hartman-Herzfeld cup forceps, 287 retraction and exposure, 87 Kantrowitz clamp, 345
Hartmann alligator ear forceps, 293 tissue approximation, 88 Kantrowitz forceps, 239, 355
Hartmann nasal forceps, 299 tissue dissection, 87 Kaye needle holder, 161
Hayes hand and foot retractor, 275 tissue manipulation, 87 Keilland obstetrical forceps, 212
Heaney clamp, 200 visualization, 87 Kelly clamp, 25, 97, 110, 123, 138, 320, 343
Heaney hysterectomy clamp, 201 Instrument processing cycle, 415 Kelly fistula scissors, 190
Heaney needle holder, 224, 237, 241 Instrument sets, assembly of, 91 Kelly forceps, 203
Heaney retractor, 220 counts and accountability, 92–93 Kelly retractor, 234
Heaney-Ballentine clamp, 201 determining contents, 91–92 Kern bone-holding forceps, 257, 260
Heath punctum dilator, 387 Intermediate-level disinfection, 417 Kerrison rongeurs, 294, 305, 329
Hegar dilators, 223 Intraluminal stapler (ILS), 188 Kevorkian endocervical curette, 216
Hegeman scissors, 360 Intramedullary nail extraction Key periosteal elevator, 16, 262. See also
Heifetz clip applier, 321 instrumentation, 249 Periosteal elevators
Heifetz clip, angled, 321 Inventory control, 92 Killian nasal speculum, 310
Heifetz clip, curved, 322 Iris scissors, 148, 381 Kirk mallet, 273
Heifetz clip, straight, 321 Irrigation sheath, 281 Kirschner drill, 253
Heiss retractor, 296 Israel rake retractor, 272 Kleinert skin hook, 157
Herrick pedicle clamp, 230 Kleinert-Kutz hook, 310
Hexagonal screwdriver with screw-holding Kleinert-Kutz tendon retriever, 280
tip, 246 J Knight scissors, 301
Heymann-Knight nasal forceps, 299 Jabaley scissors, 151, 381 Kocher clamp, 31, 100, 141, 199
Hibbs retractor, 275 Jackson intervertebral disc rongeur, 334 Kocher intestinal clamp, 35, 348
High-level disinfection, 417 Jackson laryngectomy tube, 317 Krause-Voss nasal polyp snare, 315
Hill-Ferguson manual retractor, 192 Jackson retractor, 219 Krayenbuhl micro nerve hook, 391
Hirschman anoscope, 192 Jackson trachea hook, 318 Kuntscher diamond awl, 266
Hirschman proctoscope, 192 Jacob tenaculum, 207 K-wire pliers, 270
Hoff towel clamp, 37 Jacobson clamp, 320
Hoke osteotome, 264 Jacobson fine micro scissors, 383
Hough stapedectomy foot plate pick, 291 Jacobson fine micro scissors with L
House curette, 289 bead tip, 383 LaBorde tracheal dilator, 317
House Gelfoam pressure forceps, 293 Jacobson micro ring-handled needle LaGrange scissors, 190
House retractor, 295 holder, 392 Lahey clamp, 26
House suction cut-off adapter, 292 Jacobson micro scissors, 382 Lahey retractor, 316
430 Index
Lahey traction forceps, 209 Maxwell nipple-marking template, 163 Moore drill, 252
Laine Kendal scissors, 149, 358, 382 Mayo and Metzenbaum scissors, 104 Mosquito styles, 24
Lambert chalazion forceps, 381 Mayo common bile duct probe, 181 Mouth gags, 87
Lambotte bone-holding forceps, 260 Mayo common duct scoop, 182 Moynihan clamp, 29, 112, 124, 140, 198
Lane bone-holding forceps, 260 Mayo gallstone scoop, 181 Murphy bone skid, 276
Langenbeck bone-holding forceps, 259 Mayo needle holder, 225, 339. See also Murphy retractor, 155
Langenbeck metacarpal saw, 265 Mayo-Hegar needle holder Muslin, 90
Large bone instruments, 254–255 Mayo retractor, 222, 235 Mycotic nail nipper, 268
Large bone reduction forceps, 258 Mayo scissors, 103, 117, 130, 147, 213, 327, 357
Lateral side retractor, 220 Mayo-Adams self-retaining retractor, 194
Lead hand, 158, 275 Mayo-Hegar needle holder, 109, 122, 134, N
Leaflet retractor, 366 162, 236, 368 Nail nipper, 268
LEEP square electrod, 208 Mayo-Nobel scissors, 184, 214 Needle holders, 20
LeFort urethral sounds, 241 Mayo-Robson forceps, 183, 186 Needle nose pliers, 269
Lemmon retractor, 368 McCrea urethral sounds, 241 Nerve hook, 334
Lempert rongeur, 295 McGivney hemorrhoid grasping forceps, 189 News tracheotomy hook, 318
Lewin bone-holding forceps, 256 McGivney hemorrhoid ligator, 189 Nonwoven polypropylene (Tyvek), 90
Lexer chisel, 264 McGlamry elevator, 262 Nose and throat instrumentation, 297–315
LEYLA self-retaining brain retractor, 337 McIntosh suture holder, 373 Novak endometrial suction curette, 218
Lichtwicz antrum trocar, 309 McIvor mouth gag, 313 Noyes alligator forceps, 287, 293, 299
Light source cord—Xenon, 283 McKenty elevator, 261
Lightweight mallet, 274 McKissock keyhole pattern breast-marking
Lister bandage scissors, 104, 104, 117, template, 163 O
152, 215 McNeil-Goldman scleral lid retractor, 391 O’Sullivan-O’Connor retractor, 87, 222
Liston bone cutter, 267 Medium foundation set, 109–122 Olivecrona dissector, 332
Liston Stille bone cutting forceps, 329 Meltzer adenoid punch, 308 Ollier rake retractor, 276
Littler scissors, 149 Membrane forceps, 210 Olsen-Hegar needle holder, 108, 161
Locke phalangeal forceps, 256 Memory instruments bending tool, 373 Orthopedic instrument set count sheet,
Locking pliers, 270 Memory instruments knife, 374 254–255
Locklin scissors, 190 Memory instruments mirror, 374 Orthopedic mallet, 274
Loftus distractor, 337 Memory instruments nerve hook, 374 Orthopedic retractors and mallets, 272–278
Long foundation set, 122–134 Memory nerve hook, 333 Oschner clamp, 32
Lorna towel clamp, 38 Meniscus grasper, 282 Oschner dissector, 332
Love nerve root retractor, 273, 335 Meniscus hook, 282 Oschner trocar (modified Philadelphia
Love uvula retractor, 311 Meniscus knives, 282 style), 182
Lovelace clamp, 34 Metal ruler, 163, 280, 387 Osteotomes, 261–266
Lovelace forceps, 355 Metzenbaum scissors, 103, 117, 130, 147, 214,
Lovelace gallbladder forceps, 180 233, 327, 356
Low-level disinfection, 417 Meyerding retractor, 275, 334 P
Lowmann bone-holding forceps, 258 Micro alligator, 286 Packaging sealing methods, 421
Lucae bayonet forceps, 286 Micro bayonet scissors, delicate, 385 autoclave tape, 421
Lucae mallet, 304 Micro bayonet circumflex scissors, 384 heat seal, 421
Luer-Lok three-ring syringe, 105, 118, 131 Micro bayonet flat-handle scissors, 384 rigid container seals, 421
Luikart obstetrical forceps, 212 Micro bayonet forceps, 380 self-adhesive seal, 421
Micro bayonet needle holder, 393 Parham-Martin bone-holding forceps, 260
Micro bayonet round-handle scissors, 384 Payr clamp, 187
M Micro Friedman rongeur, 267 Pean clamp, 27
Magnetic resonance imaging (MRI), 17 Micro Jacobson needle holder, 394 Peapod rongeur, 331
Major laparotomy tray, 168–179 Micro jaw needle holder, 392 Pederson speculum, 220
Malleable looped endometrial curettes, 16 Micro scissors with specialty tips, 385 Peel packages, 89
Malleable ribbon retractor, 132, 365 Micro tip forceps, 380 Peers towel clamp, 39
Malleus nipper, 290 Microbiological Concerns, 421–422 Pelvic reduction forceps, 259
Maltz raspatory, 306 Microsurgical knives, 386 Pelvic single-prong retractor, 278
Manual cleaning, 415 Millen capsule forceps, 232 Penfield elevators, 16, 262
Manual/handheld retractors, 87 Miller rectal scissors, 190 Pennington clamp, 33, 205
Markham-Meyerding self-retaining Miltex pin puller, 270 Perforated trays, 89–90
retractor, 335 Mini fragment set, 248 Periosteal elevators, 16
Martin drill, 252 Mini Lambotte osteotomes, 263 Perkins endaural retractor, 297
Martin scissors, 148 Mini-Hohman retractor, 275 Personal protective equipment (PPE), 414
Martini bone curette, 265 Mixter clamp, 98, 125 eye protection, 414
Mastin muscle clamp, 35 Mixter gallstone forceps, 181 hair cover, 414
Mathieu retractor, 154 Mixter horizontal clamp, 29, 346 shoe cover, 414
Matson rib stripper and elevator, 263 Mixter longitudinal clamp, 30, 346 Phaneuf clamp, 32, 199
Matson rib stripper, 362 Mixter scissors, 359 Pillar retractor/dissector, 16
Index 431
Pin cutter, 267–272 Rosen suction tube, 291 Stainless-steel sterilization tray, 89
Pin puller, 270 Rosser crypt hook, 191 Standard operating scissors, 146, 213, 326
Pins and wires, 245 Rubin septal morselizer, 299 Steam autoclave, 418
Piper obstetrical forceps, 212 Rummel tourniquet, 372 Steam sterilization area, 418
Pistol grip handles, 7 Rush awl, 266 Steinmann pin chuck, 248
Pituitary and Kerrison rongeurs, 16 Ruskin-Liston bone cutter, 267 Sterile packaging, 419
Plate forceps, 257 Russian forceps, 128, 203 Sterile storage and packaging, 419–421
Plate-bending iron, 246 Ryder needle holder, 340, 369 Sterilization method, 418
Plate-bending pliers, 246 Sternal wire needle holder, 372
Plate-bending pliers with interchangeable Sterrad, 419
anvils, 247 S Stevens tenotomy scissors, 148, 382
Plate-bending press, 247 Sarot bronchus clamp, 350 Stille drill, 252
Plates and screws, 244–245 Sarot needle holder, 236, 370 Stille-Sherman drill, 251
Platypus nail remover forceps, 268 Satinsky clamp, 348 Storage of Items, 422
Pliers, 267–272 Satinsky scissors, 233, 360 Straight DeBakey clamp, 350
Plug cutter, 279 Sawyer retractor, 192 Stratte needle holder, 238, 370
Politzer tympanum perforator, 288 Scalpel, 145, 146 Stringers, 88
Poole suction tubes, 92, 131, 218, 364 Scalpel handle, 102–103, 116, 129–130 Strully scissors, 358
Potts Smith scissors, 359 Schiotz tonometer, 388 Stryker battery power drill, saw, reamer
Powered equipment, 253 Schmedberger drill, 254 combo, 253
Pratt ethmoid curette, 306 Schnidt clamp, 30, 99, 112, 124, 140, 197 Surgeon console, 411
Pratt rectal probe, 191 Schroeder tenaculum, 208 Surgical processing and disinfection cycle, 414
Pratt rectal speculum, 87, 193 Schuknecht, 286 Surgical team, 92
Pratt T clamp, 207 Scott retractor, 87 Sweet clip applier, 352
Pratt T-shaped forceps, 239 Screw depth gauge, 248
Pratt uterine dilators, 223 Screw-holding forceps, 247
processing, 416 Scudder intestinal clamp, 184 T
disinfection, 417 Sedillot periosteal elevator, 263 Table top steam autoclaves, 418
sterilization, 418 Seiler turbinate scissors, 301 Takahashi ethmoid forceps, 305
Puskas Jacobson IMA scissors, 383 Selman clamp, 349 Tauber retractor, 220
Senn retractors, 87, 106, 119, 154, 274, 316 Taylor dural scissors, 328
Sesamoidectomy clamp, 256 Telescopic hand drill, 252
Q Shambaugh adenotome, 308 Terminal end stapler (TA), 188
Quimby scissors, 191 Shapleigh ear curette, 289 Tessier caliper, 363
Quire foreign body instrument, 287 Shoemaker rib shears, 362 Thimble hook retractor, 157
Shushruta (circa 800 BC), 1 Thomas curette, 216
Simpson obstetrical forceps, 212 Thompson scissors, 358
R Simpson-Luikart obstetrical forceps, 212 Thorek scissors, 233, 360
Ragnell retractors, 106, 119, 154, 274 Sims double retractor, 219 Thorpe caliper, 388
Ragnell scissors, 151 Sims rectal speculum, 87, 193 Tip guards, 89
Ralks drill, 251 Sims retractor, 219 Tischler punch, 217
Randall stone forceps, 182, 211, 232 Sims scissors, 190 Tissue forceps with teeth, 102, 116, 129
Raney scalp clip applier and clips, 323 Sims uterine curette, 216 Tissue forceps, 143, 202, 324, 353
Rankin clamp, 25, 138 Sims uterine sound, 222 Tivnen tonsil forceps, 300
Rasp duo purpose, 265 Singley forceps, 203 Total hip prosthesis, 250
Rasps, 261–266 Sistrunk scissors, 359 Townley caliper, 280
Rasp with cross-serrations, 265 Small bone reduction forceps, 258 Toxic anterior segment syndrome (TASS), 421
Rasp with straight serrations, 265 Smillie knee retractor, 277 Trocars, 396
Reprocessing flexible endoscopes, 422–425 Smillie knife, 264 Trousseau tracheal dilator, 317
Retractors, 20–21 Smith (Buie) anal retractor, 194 Troutman cannula, 389
Richardson retractor, 120, 133 Smith Leifer clamp, 351 Tube occluding clamp with guard, 36, 351
Richardson-Eastman retractors, 119, 132 Smith-Peterson gouge, 264 Tumor forceps, 325
Rigid sigmoidoscope, 192 Smith-Peterson osteotome, 264 Tumor grasping forceps, 380
Ring-handled caliper, 363 Smithwyick hook and elevator, 262 Tyding tonsil snare, 315
Robot, 410 Soft tissue foundation sets, 96–109
Rochester Carmalt clamp, 28 Somer uterine elevator, 210
Rochester Oschner clamp, 32, 113 Spaulding U
Rochester Pean clamp, 27, 98, 111, 124, 139, critical, 417 Ulrich bone-holding forceps, 261
196, 344 noncritical, 417 Ultrasonic cleansing, 21
Rochester Pean forceps, 231 semi-critical, 417 Umbilical scissors, 215
Roeder towel clamp, 38 Spencer stitch scissors, 153 Universal drill, 251
Rongeurs, 267–272 Spurling Kerrison rongeur, 330 University of Minnesota cheek
Rosen pick, 291 Stainless steel, 300 series, 18 retractor, 312
Rosen round knife, 288 Stainless steel, 400 series, 18 Utility scissors, 152
432 Index
V Water-soluble lubricants, 21 Wire-cutting scissors, 152, 271, 361

Watson-Williams nasal cutting Wishbone retractor, 183
Valve retractor, 366
forceps, 299 Wolf suction, 364
Valve retractor set, 367
Webster needle holder, 107, 121, 133, 159, Woven wrappers, 421
Van Buren sounds, 233, 240
226, 338 Wrench, 246
Veirs probe–cannula set, 387
Weiner antrum rasp, 307 Wullstein ear scissors, 288
Verbrugge bone-holding forceps, 257
Weingartner, 286
Veress needle, 396
Weitlaner self-retaining retractor,
Vessel punch, 372 Y
120, 106, 158, 278, 296, 336
Video- assisted thoracoscopic surgery
Wells enucleation spoon, 391 Yankauer suction tube, 105, 118, 131, 217, 363
(VATS), 412
Wertheim pedicle clamp, Yasargil Bayonet dissector, 331
Video equip, 411
28, 198, 231 Yasargil clip applier, 322
Vienna nasal speculum, 309
Wescott tenotomy scissors, 382 Yasargil clip, curved, 323
Vogen sesamoid clamp, 256
White tonsil forceps, 300 Yasargil clip, straight, 322
Volkman rake retractor, 274
Wieder tongue depressor, 311 Yasargil dissector, 332
Volkman retractor, 155
Wilde (Troeltsch) ear forceps, 286 Yeoman biopsy forceps, 191
Volkmann hook, 275
Wilde forceps, 145 Young renal pedicle clamp, 230
Vsraya, 1
Wilde rongeur, 305, 331 Young tongue forceps, 298
Williams lacrimal probe, 386
W Williams speculum, 390
Wangensteen forceps, 355 Williger bone curette, 265 Z
Wangensteen needle holder, 238, 370 Wire twister, 269 Zanger clamp, 347

Surgical Instrumentation 2nd Ed

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Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.

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Notice to the Reader

Printed in the United States of America

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii CHAPTER 3 CATEGORIES OF SURGICAL

Excisional Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER 10 BASIC BONE AND JOINT

Manipulation within the Working Space . . . . . . . . . 397 CHAPTER 16 DECONTAMINATION

Robert Torres, BA, CRCST, CHL David Braun, CST, CRCST

CONTRIBUTORS Julia Hinkle, RN, MHS, CNOR

Rosemary Nagler Mecklin Soules, CST, AAS

Mary Seely, CST, AS

Cook Medical, Inc. Sklar Instruments

OBJECTIVES CHAPTER OUTLINE

HISTORIC SURGICAL INSTRUMENTATION

RITUAL AND MAGIC the internal anatomy sacred. Archeologists discovered

Courtesy of the National Library of Medicine

SUMMARY knowledge base concerning human anatomy and

REFERENCES Phillips, N. M. (2016). Berry and Kohn’s operating room

Figure 2-1 Basic anatomy of a surgical instrument (Halsted mosquito clamp).

Figure 2-2 Ring handles and compression handle grips.

D. Bar and locking nut

Figure 2-3 Spring handles and locking handle grips.

A. Ratchet lock D. Single spring

B. Thumb screw E. Double spring

F. Double spring with ball and socket joint

Figure 2-4 Locking and opposition handle system.

Figure 2-5 Rongeurs handles.

B. Scissor or lap joint

A–B: Courtesy of Sklar Instruments. C: © 2019 Cengage®. Photo by Margaret Rodriguez.

Figure 2-6 Joint types.

G. Angled with tip guard

Figure 2-7 Sharp dissection tip styles: curvatures and angles.

A, C–E: © 2019 Cengage®. Photo by Margaret Rodriguez. B: © 2019 Cengage®.

Figure 2-8 Sharp dissection tip styles.

are designed to mechanically occlude the lumens of

© 2019 Cengage®. Photo by Margaret Rodriguez.

A. Kocher clamp D. Lahey/Gemini/right angle longitudinal

A: © 2019 Cengage®. B–G: © 2019 Cengage®. Photo by Margaret Rodriguez.

B. Right angle/Mixter and Adson/Schnidt

C. Rochester Pean G. Doyen noncrushing intestinal clamp

Figure 2-10 Hemostatic clamps: jaw and tip variations.

C. Cross-hatched (diamond jaw) needle holder with tungsten

D. Micro “alligator” grasping forceps

A. Curved Allis and straight Judd-Allis

E. Foerster straight and curved sponge forceps

Figure 2-11 Grasping: tip variations

D. Boies nasal fracture elevator

Figure 2-12 Blunt dissection: tip variations

CATEGORIES OF SURGICAL tenaculum. Graspers can have locking or

Silver ●● Chrome plating: Chrome electrically bonded

and generalized appearance prior to placement in pro-

D. Boies nasal fracture elevator