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

2. 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.

3. Anatomy and Classifying Instruments
Jaws
Box lock
Shank
Ratchets
Finger ring

4. Anatomy

5. 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.

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

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

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

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.

10. Basic Cutting/Dissecting Instruments (continued)

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

12. Basic Grasping/Holding Instruments (continued)

13. Basic Grasping/Holding Instruments (continued)

14. 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.

15. Basic Grasping/Holding Instruments

16. Ratcheted Grasping and Holding Instruments
Allis
Babcock
Kocher
Lahey thyroid tenaculum

17. 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

18. 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

19. Basic Clamping/Occluding Instruments

20. Basic Clamping/Occluding Instruments (continued)
Kelly

21. Basic Clamping/Occluding Instruments (continued)

22. 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

23. Basic Retracting/Exposing Instruments
Large Richardson or

24. Basic Retracting/Exposing Instruments (continued)

25. Basic Retracting/Exposing Instruments (continued)

26. Basic Retracting/Exposing Instruments (continued)

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

28. Dilating/Probing Instruments

29. 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

30. 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

31. 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!

32. Needle Holders

33. 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

34. Basic Visualization Instruments

35. 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)

36. Basic Visualization Instruments (continued)

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

38. 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

39. Diagnostic Endoscopes
For observation
No operating channels

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

41. Tools Required to Perform Minimally-Invasive Surgery With an Endoscope

42. 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

43. 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)

44. 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

45. Instrument Care and Handling Minor and Major Trays

46. 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

47. 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

48. 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.

49. 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

50. 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

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

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

53. 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

54. 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.

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

56. 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

57. 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

58. 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

59. 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

60. 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