Introduction to Instrumentation Daniel Stokoe, CST, A.A.S.

Grades of Instruments 3 grades of instruments: Surgical – highest possible quality instrument. Stainless steel from Germany or U.S.A. only. Most made from either 300 or 400 series stainless steel or Electroplated steel (chrome plated) Few made from Vitallium (inert metal and very $$$$) Vitallium: Trademark for a cobalt–chromium alloy used for surgical appliances and implants Titanium Alloy (stronger than stainless, used for micro surgical instruments) Most important – these instruments go through a process called Passivation: a process in which a chemical dip removes all debris and creates a layer of chromium oxide. This makes the instruments more resistant to corrosion and stains. Floor Grade – medium/low level quality surgical instruments. Have shiny finish. Used to teach. Not to be used in surgical set. Disposable – low level quality surgical instruments. These items are single use only! Should NEVER be reprocessed. Stamped “single use” on instrument.

Anatomy and Classifying Instruments Jaws Box lock Shank Ratchets Finger ring

Anatomy

Five Basic Categories There are 5 basic categories of surgical instruments: Hand-held Largest category of instruements. Microsurgical Most are hand-held but require special handling. Ophthalmic, ENT (Ear, Nose and Throat) and Vascular instruments fall under this category. Will not have Tungsten Carbide tips (to small) Powered Drills, saws, etc. Endoscopic Includes Ridged and Flexible Endoscopes, fiber optic light cables, cameras and MIS ( Minimally Invasive Surgery) instrumentation. Laparoscopic This category includes Robotic instruments. Insulated and Non-insulated. Typically very long, thin and ringed instruments.

Classifications Cutting Grasping and holding Clamping Retracting Probing Dilating Suturing Suctioning Accessory

Cutting Instruments with sharp edges. Includes knives, scalpels, scissors, bone cutting instruments, saws, drills, punches, adenotomes, and Dermatomes. Sometime referred to as “sharps”

Cutting Instruments Scalpels Handles commonly come in #’s 3,4,7,and 9.

Cutting Instruments Scissors There are tissue, suture, wire, and dressing scissors. Can have Tungsten Carbide tips Very strong metal that helps tips stay sharper longer. Black handled scissors are referred to as “Super Sharps”. One tip can be serrated.

Basic Cutting/Dissecting Instruments (continued)

Grasping and Holding Designed to manipulate tissues. Use to dissect, suturing assistance, reduce, or stabilize.

Basic Grasping/Holding Instruments (continued)

Basic Grasping/Holding Instruments (continued)

Basic Grasping/Holding Instruments Forceps Do not have ratchets. May have teeth, serrations, or smooth. Vary in length and type. Common examples: Adson, DeBakey, Russian, Gerald, Cushing Bayonet forceps.

Basic Grasping/Holding Instruments

Ratcheted Grasping and Holding Instruments Allis Babcock Kocher Lahey thyroid tenaculum

Grasping and Holding Instruments Bone Holding Clamps Use to hold bone in place Ratcheted and vary in type and size Example are Lane, Kern, Lowman, and Lewin

Clamping/Occluding Designed to occlude or constrict tissue Vascular clamps are used in vascular and heart surgery Hemostats are use to occlude vessels until ligated

Basic Clamping/Occluding Instruments

Basic Clamping/Occluding Instruments (continued) Kelly

Basic Clamping/Occluding Instruments (continued)

Retracting Designed for exposure at the operative site May be hand held or self retaining Vary in size, length, and type May be sharp or dull May be malleable

Basic Retracting/Exposing Instruments Large Richardson or

Basic Retracting/Exposing Instruments (continued)

Basic Retracting/Exposing Instruments (continued)

Basic Retracting/Exposing Instruments (continued)

Probing Used for exploration of a fissure, fistula or duct Commonly found in gallbladder and rectal trays Wire like instruments with guides

Dilating/Probing Instruments

Dilating Used to gradually dilate an orifice to allow a larger instrument to be introduced or measurement of lumen diameter Used in Endoscopy, GYN, GU (cysto), Vascular surgery

Dilating Continued… Tapered at on end then increase in diameter Cervical dilators are double ended Urethral dilators are single ended Esophageal dilators are the longest and most flexible

Suturing Needle holders are used to hold needles for suturing Vary in shape and size Jaws have small serrations to hold needle in place Similar in part structure to the hemostat Can have Tungsten Carbide tips. These can be replaced!

Needle Holders

Suctioning Used in removing blood or body fluids from operative site to maintain surgeon visibility to perform surgical procedure Disposable or non disposable Type of suction based upon surgical site and procedure Common suction tips are Yankauer, Poole, and Frasier

Basic Visualization Instruments

Visualization Laparoscopic procedures require trocars, ports, cannulas for laparoscopic instrumentation access Is it a retractor or a speculum? Also for viewing called a speculum or specula (plural) Think ear speculum when you visit physician and he/she does an ear exam Ladies think GYN visit (it’s a Graves speculum they use)

Basic Visualization Instruments (continued)

Accessory Instruments Sponge sticks Towel clips Not really a clear use for it that is related to tissue handling Also multi-use instrument

Endoscopes Diagnostic Operative (channeled) Rigid Visualization: Direct (0°) Angled (30, 70, 120°) Semi-rigid Flexible Panoramic Two Types of Flexible: Fiberoptic Visualization through eyepiece Connect to light source Videoscope Visualization on monitor Connect to light source and camera

Diagnostic Endoscopes For observation No operating channels

Operative Endoscopes Channeled: irrigation, suction, insertion of biopsy forcep or needle, connection of accessory instruments such as cautery or laser

Tools Required to Perform Minimally-Invasive Surgery With an Endoscope

Robotics pages 103-105, 132 Robotic instruments Da Vinci Similar to laparoscopic instruments Jaw design and length similar Differences arise in handling and cleaning procedures Da Vinci Endo-Wrist instrumentation. Multi-use instruments

Endo-Wrist turn to page 104 Have 5 main components: Release levers (A) Instrument shaft (B) The wrist (C) The tip or end reflector (D) Instrument housing (E)

Summary 3 grades of instruments Anatomy and Classifying Instruments 5 basic categories of surgical instruments Classifications of surgical instruments Cutting, Grasping and holding, Clamping, Retracting, Probing, Dilating, Suturing, Suctioning, Accessory Scopes and Robotics

Instrument Care and Handling Minor and Major Trays

Micro Instrumentation Small and delicate instruments Used with a microscope Made of Titanium instead of stainless steel (Much lighter yet strong) Held with thumb and forefinger Beaver blades are used for knife blade Scissors and needle holders are spring loaded Usually hand washed after case Gas sterilized due to the delicate nature of instrumentation (may steam sterilize in separate load) Tips can be bent very easy Be very careful when handling and cleaning these instruments

Care and Handling Must be handled with care Very expensive Inspection for function before and after surgery in essential Do not place delicate instruments under heavier instruments Micro instruments should be hand washed

Types of Instrument Trays Varies from institution to institution Some procedures require smaller special trays These would have to be opened in addition to the primary instrument tray Types of sets include: Laparotomy,OB/GYN,Ophthalmic, ENT, Plastics, Genitourinary, Orthopedics, Cardiac, Thoracic, Peripheral Vascular, and Neuro.

Laparotomy Sets General abdominal procedures May use major or minor tray May also need: Long Instrument tray Balfour or Bookwalter retractor Gastrointestinal tray Gall Bladder tray

OB/GYN Instrumentation Include D&C, Abd. Hysterectomy, Vag. Hysterectomy, Laparoscopic procedures, LAVH, and C-Sections. Need: Abd. Hysterectomy tray Vag. Hysterectomy tray C-Section tray LAVH tray Misc. Lap instruments

Ophthalmic Instrumentation Eye procedures Need: Conjunctival tray Muscle tray Cataract tray Cornea tray Globe and Orbit tray Ophthalmoscope Retinal Instruments

ENT Instruments Use in Ears, Nose, and Throat surgery Trays for: Myringotomy Tympanoplasty Nasal procedures Tracheotomy All other head and neck type procedures

Plastic Instrumentation Covers cosmetic and reconstruction procedures Need delicate as well as larger instrumentation May include Reattachments Some small bone instruments may be needed Liposuction

Genitourinary Instrumentation Includes kidney and prostate procedures Need: Major tray. Kidney or flank tray. Vascular and a thorocotomy tray. Long Instrument tray. Prostatectomy: Prostatectomy tray. Long instrument tray Special trays for: Pyeloplasty, ureteroplasty, tuboplasty, and vasectomy.

Orthopedic Instrumentation Used for all bone and total joint procedures Universal bone Basic total joint tray Total tray Fracture systems Misc. bone holding instruments

Cardiac Instrumentation Cardiac procedures Need instruments for: Heart Great vessels Cardiopulmonary bypass Saphenous vein harvest or internal mammary artery dissection Coronary anastamosis Sternal saw and Sternal retractors Internal mammary artery retractor Valve sizers Valve instruments

Thoracic Instrumentation Chest/Thoracic procedures. Need: Major tray or cardiovascular tray Chest instrument tray Sternal saw available Self retaining chest retractors (Burford, Finochietto, or Tuffier) Thoracoscopy set if thoracoscopy Still need open instruments in case converts just like with laparoscopic cases

Peripheral Vascular Instrumentation Vascular repairs and shunts AAA trays Major tray or Cardiovascular tray Self Retaining Retractor (Bookwalter or Omni-tract) Carotid tray AV fistula tray Specialty surgeon trays

Neurosurgical Instrumentation Brain and Spine Need: Brain: Craniotomy tray Rhoton Instruments Micro scissors Farley or greenburg retractor Spine: Spine trays Self retaining retractors Spine fixation trays

Instrument Check List An inventory sheet with all instruments in that tray Used for counting Locate missing instruments or incomplete trays Tracking instruments out for repair