Basics of instrument and tissue handling

1. Principles of superficial and subcutaneous tissues incision and closure

2.Safe use of surgical diathermy

Dr. RUTAYISIRE François Xavier

PGY1
Basic Surgical Skills Course
University of Rwanda
Introduction

• Surgical instrument
A specially designed tool or device for performing specific actions of carrying out desired
effects during a surgery
• 1. Modifying biological tissue
2. Provide access for viewing
Nomenclature

1. Action it performs
• scalpel, hemostat
• 2. Inventor(s) name
• Kocher forceps
• 3. Compound scientific name related to type of surgery
• Osteotome - tool used to perform osteotomy
Actions: Hemostatic Forceps
e.g: Clamps, artery forceps, hemostats
• Purpose - to achieve hemostasis
• Available in different lengths, curved and straight, serrated jaws or toothed ends
• Examples - Mosquito, Kelly, Kocher
Parts of Hemostats
Actions: Soft Tissue Forceps
Similar to hemostats
• Purpose – holding and retracting soft tissue for longer periods
• Characteristics include fine teeth or ridges on the jaws to provide a more delicate grip without trauma
to tissue
• Examples –Allis Intestinal, Babcock Intestinal, Kocher Artery, Right Angle, Forester sponge forceps
Actions: Thumb Forceps

• Do not have box locks or ring handles but rather have spring handles
• Held closed by the thumb and finger pressure
FORCEPS IS HOLD LIKE A PEN
Thumb Forceps
Toothed Forceps Non-toothed forceps

• Toothed forceps are useful for atraumatic tissue
handling.
• USUALLY FOR HANDLING SKIN.
• NOT SUITABLE FOR GRIPPING NEEDLES.
• Only a small area of tissue is held in the jaws
• Tissue must be handled very gently to avoid
unwanted damage
• THEY HAVE SERRATIONS TO HELP GRIP
NEEDLES, SUTURE MATERIALS AND
ALIKE.
• Non-toothed forceps spread the force of the grip
over a larger area
• They are used when handling delicate tissue such
as bowel or vessels
Actions: Needle Holders

• Similar to hemostats but with smaller, shorter and thicker jaws

• Available in a variety of lengths and styles and may be curved or straight
• Needle holders have inserts in the jaw to prevent excessive wear of the instrument
tungsten carbide granules in a cobalt or other metallic paste
Needle holders with tungsten carbide inserts have gold plated handles
• The inserts can be replaced which prolongs the life of the needle holder and reduce the
replacement
Instrument handling

• After opening the suture pack, the needle is presented ready for mounting in the
needle holder.
• Grasp the needle with the tip of the needle holder, two thirds along the shaft
from the needle tip.
• When removing the suture from the pack, it is often useful to use your little
finger to take up the slack in the suture.
Instrument Handling

• It is important that the needle is grasped at the tip of the jaws of the
needle holder
• The needle can either be held two thirds away from the tip and
perpendicular to the needle holder or, when using a half curved
needle, it can be held half way along the shaft at a slight angle.
• Use forceps to manipulate the needle in the holder
Instrument Handling

• When grasping the needle, only one click is required on the ratchet.
• Putting too much force on the handles will damage the hinged area of the needle holder.
Instrument Handling

• It is important that the needle is not handled at the tip or the swaged area.
Actions:Scissors

• Curved scissors – used to cut and dissect tissue

• Straight scissors - used for cutting sutures and any tissue when a smooth, straight cut is desired,
such as a damaged nerve or blood vessel
• Scissors can be used for probing, dissecting, and spreading tissue
• Should never be used to cut paper or tubing - bandage scissors may be utilized for this purpose
Scissors may also have tungsten carbide cutting edges which provide finer cutting with longer
lasting wear
• Scissors with tungsten carbide inserts are identified by gold plated ring handles
• Examples - Mayo scissors, Metzenbaum (Metz) scissors, Iris (dissecting) scissors
Instrument Handling

• The tips of the scissors should be used for dissection and division of structures.
Instrument Handling

• When using instruments with finger loop handles, it is important to use the correct grip
Actions: Retractors

• Purpose - used for holding the incision open to provide exposure to the surgical site
• The use of specific retractors depend on the type of surgical procedure being performed
• Smaller types - held by fingers or hand retract skin and subcutaneous tissue in shallow
surgical areas
• Larger, heavier types - retract muscle tissue and organs in deeper surgical sites
• Some retractors are held in place by an assistant
• Self-retaining retractors require no assistant - held open by their own action and may be
used in conjunction with the hand held retractors
Actions: Others

• Suction tubes
• Biopsy needles
• Knife handles
Scalpel instrument handling
The scalpel pack should be opened carefully The needle holder must always be used to pick up the
blade, never the fingers.
Instrument handling
The blade must be slid carefully into place, lining up the central
opening with the notch on the handle.
The blade is removed by gently lifting the proximal end and then
withdrawing the scalpel handle (note that
in this manoeuvre the blunt handle is moved but the sharp blade
remains still). Blades are placed in sharps
bins for disposal.
Instrument handling
Instrument handling
Scalpel should be held with the handle in
the anatomical snuffbox (like holding a
pen)
• Allows short, fine, precise incisions

• Skin is stabilized by exerting tension

with the opposite hand
• Thumb is placed on one side of the cut
with the other fingers placed on the
opposite side
Instrument handling
• Wrong way. The grip is unstable.
Instrument handling
• Handle with great care as blades are very sharp
• Practise attaching and detaching the blade using a haemostat - Never handle the blade
directly!
• Always pass the scalpel in a kidney dish
- Never pass the scalpel point first across the table
Suturing

• Sutures
An ideal suture should exhibit the following characteristics:
 easy to tie/secure;
 elicits very little tissue reaction;
 maintains its tensile strength for the period required for it to hold the tissue
together while it heals.
• Most suture material is now synthetic.
• Sutures can be absorbable or non-absorbable, and may be braided
or monofilament in construction.
• Each type has its own properties, which are largely concerned with memory and
with tensile strength.
Suture properties
Memory
• The extent to which the suture tries to
stay in its original shape.
• Memory can lead to difficulty tying a knot
as the suture may unravel as it tries to
return to its original shape (e.g. when it
was stored in the suture packet).
• This is more of a problem with larger
monofilament sutures.
Tensile Strength
• The amount of force required to snap a suture is
related to its tensile strength, which
diminishes with time.
• The length of time over which this occurs is dependent
upon the type of suture.
•
The measurement of tensile strength is expressed as
the time taken for the suture to lose half of its original
strength.
• For example, the 50% tensile strength of Polydiaxone
(e.g. PDS) is 28 days, whereas that of Polyglactin
(e.g.Vicryl) is 18 days.
Comparison of sutures
Advantages of Braided Sutures Advantages of Monofilament Sutures

• Tie more securely • Less tissue reaction

• Retain less memory than • Less incidence of micro-abscess
monofilament sutures formation in the tissue
• Less risk of the suture
“fracturing” when handled with
forceps
Comparison of sutures
Advantages of Absorbable Sutures Advantages of Non-Absorbable Sutures

• Not being required to be • Offer long-term support

removed
• Are not present after wound • Less tissue reaction
healing has been achieved
• Different suture types are suitable for different situations.
• Eg: most surgeons will close the skin layer by using either a subcuticular absorbable suture, or
an interrupted monofilament suture.

• For a continuous suture, most prefer a monofilament suture, which slides

through the tissues more easily, and reduces the chances of the tissue
“bunching”.
• For areas where wound healing takes longer, it is important to use a
suture that has a longer 50% tensile strength and absorption rate – e.g.
polydiaxone may be used to close the linea alba.
Size of Sutures
• Vary in size, depending on the job for which they are required.
• They are sized using the USP (United States Pharmacopoeia) system.
• Some examples of sizes and diameters are shown below:
6/0 = 0.07 mm
4/0 = 0.15 mm
3/0 = 0.2 mm
2/0 = 0.3 mm
0 = 0.35 mm
1 = 0.4 mm
2 = 0.5 mm
Tensile strengths and absorption times

• Giving an indication as to what situation you may wish to use

50% Tensile Strength Absorption Time
certain sutures
Polyglactin (vicryl) 18 days 28 days

Coated polyglactin (vicryl

rapide) 6 days 10 days

Polydiaxone (PDS) 28 days 180 days

Polyglycolic acid (Dexon 16 days 60-90 days
II)
Needles

• Needles may vary in size, and type.

• The shape of the needle is determined by the access to the tissue that requires to be sutured – normally
the tighter the operative space is, the greater the curvature of the needle is that is required. The basic
shapes used are: ¼, 3/8, ½, 5/8 Circle, J shape compound curved needle (used to close the sheath in
laparoscopic ports)

• Previously a straight needle was available for closing skin in a subcuticular fashion, but this is no longer
used as they are more prone to needle stick injuries
 Safe use of surgical
diathermy/electrosurgery
• “Electrosurgery” is generally used to describe operations that utilize
an alternating current to cut and coagulate tissue.
Introduction

• “Electrosurgery at least permits us today to remove certain brain tumors

from situations and under circumstances which a year ago – indeed six
months ago – I would not have thought possible.” Dr. Harvey Cushing, 1926.

• More recent quotes give a different impression:

• “Most hazardous device used on a daily basis” “Causes more patient injury
than any other electro-medical device used in the operating theatre”
History

• Development of the first commercial electrosurgical device is credited

to William T. Bovie, who developed the first electrosurgical device
while employed at Harvard University.
• The first use of an electrosurgical generator in an operating room
occurred on October 1, 1926 at Peter Bent Brigham Hospital in
Boston, Massachusetts.
• The operation—removal of a mass from a patient’s head—was
performed by Harvey Cushing.
What is an electrosurgical system?

• Electrosurgical system as the combination of components that enable

a physician to perform electrosurgery.
• Six components of an electrosurgical system: the generator, the
handpiece, the cables, the electrode, and the dispersive pad/return
electrode, the foot pedal/control.
• Electrosurgical devices are frequently used during surgical operations
helping to prevent blood loss in hospital operating rooms or in
outpatient procedures
• Principle: Convert normal frequency alternating current (50 Hz) to
high frequency alternating current (50 kHz)
• Ion Exchange is not possible at such a rapid rate of change of current
no stimulation
• Modern electrosurgical units can produce currents in the range of
200–300 kHz.
• High frequency AC to a small area raised temperature & coagulation.
Diathermy may be:

• Monopolar:
• Patient's body forms part of circuit
• Used for cutting and coagulating
• Bipolar:
• Current passes between tips of forceps, not through patient
• Used for fine coagulation

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 Monopolar Diathermy

• The plate contact is crucial

• Current ( heat) is focused at the point of the instrument and dissipated over the area of
the plate (10 000x larger)

46
 Monopolar diathermy (cont.)
• May earth if body comes into contact with metal or if
plate is not in full contact

47
 Bipolar diathermy

• 750 volts
• No return electrode

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Principle

• Whenever current is concentrated in a small

area heat is generated.

• This heat can be used for coagulating and cutting

tissue.
 Risks when using diathermy:

• Pacemaker malfunction
• Arcing to metal instruments and implants
• Burns if used with spirit-based skin
preparations
• Burns from shorting or improper application
of plate

50
• Electrocautery Smoke contains:
– Toluene, benzene, hydrogen cyanide, formaldhyde
– Potential carcinogens
– Avoid inhalation using Inline filters, effective evacuation systems,
improved masks
• Avoid using diathermy inside bowel as it contains flammable gases:
hydrogen, methane
 DIATHERMY
= DANGER!
It’s your responsibility!

53
•Thanks
References
• Bailey &Love 25th edition
•Foster, M.E. & Morris-Stiff, G. (2000) Basic Surgical Operations. Churchill Livingstone
•Kirk, R.M. (2002) Basic Surgical Techniques 5th Ed. Elsevier Churchill Livingstone
• Okoshi K, Kobayashi K, Kinoshita K, Tomizawa Y, Hasegawa S, Sakai Y. Health risks associated with
exposure to surgical smoke for surgeons and operation room personnel. Surg Today. 2015
Aug;45(8):957-65. doi: 10.1007/s00595-014-1085-z. Epub 2014 Nov 25. PMID: 25421864.
• National Association of Theatre Nurses (2004) Standards and Recommendations for Safe
Perioperative Practice. NATN