Instrumentation for the operating room a photographic manual.

Contents

UNIT ONE: INSTRUMENT PREPARATION FOR SURGERY

1 Care and Handling of Surgical Instruments, 1 2 Sterilization Container Systems, 24

UNIT TWO: GENERAL SURGERY 3 Operating Room Suite/Basic Laparotomy, 31 4 Abdominal Self-Retaining Retractors, 39 5 Small Laparotomy Set, 45 6 Minor Laparoscopic Set, 47 7 Laparoscopy, 49 8 Laparoscopic Adult MIS Set, 54 9 Laser Laparoscope, 60 10 Laparoscopic Cholecystectomy, 61 11 Laparoscopic Bowel Resection, 63 12 Bowel Resection, 69 13 Sigmoidoscopy, 71 14 Laparoscopic Bariatric Surgery, 72 15 The da Vinci ® Surgical System and EndoWrist ® Instruments

(Robotic Instruments), 79 16 Breast Biopsy/Lumpectomy, 84 17 Mastectomy, 85

UNIT THREE: FEMALE REPRODUCTIVE SURGERY 18 Dilatation and Curettage of the Uterus, 88 19 Hysteroscopy, 91 20 Vaginal Laser, 94 21 Abdominal Hysterectomy, 96 22 Supracervical Laparoscopic Hysterectomy, 99 23 Vaginal Hysterectomy, 103 24 Laparoscopic Tubal Occlusion, 105

UNIT FOUR: GENITOURINARY SURGERY 25 Cystoscopy, 108 26 Urethroscopy, 112

27 Ureteroscopy, 113 28 Nephrectomy, 115 29 Laparoscopic Nephrectomy, 117 30 Pubovaginal Sling/Anterior Repair, 119 31 Prostatectomy, 122 32 Laparoscopic Prostatectomy, 127 33 Transurethral Resection of the Prostate, 128 34 Vasectomy, 130 35 Penile Prosthesis, 133

UNIT FIVE: ORTHOPEDIC SURGERY 36 Basic Orthopedic Surgery, 136 37 Power Saws and Drills, Battery Powered, 139 38 Small Joint Arthroscope Set, 144 39 Arthroscopic Carpal Tunnel Instruments, 145 40 Small/Minor Joint Replacement, 146 41 Total Ankle Prosthesis, 148 42 Arthroscopy of the Knee/Shoulder, 150 43 Arthroscopic Anterior Cruciate Ligament Reconstruction

with Patellar Tendon Bone Graft Instruments, 154 44 Total Knee Replacement, 157 45 Shoulder Surgery Instruments, 164 46 Hip Fracture, 166 47 Hip Retractors, 169 48 Total Hip Replacement, 170 49 Total Hip Instruments (Zimmer-VerSys), 174 50 Spinal Fusion with Rodding, 179 51 Long Bone Rodding for Fracture Fixation, 185 52 ASIF Universal Femoral Distractor Set, 187 53 Synthes Retrograde/Antegrade Femoral Nail, 188 54 Synthes Unreamed Tibial Nail Insertion and Locking

Instruments, 190 55 External Fixation of Fractures, 191 56 ASIF Pelvic Instrument Set, 194 57 Universal Screwdriver/Broken Screw Set, 196

https://kat.cr/user/Blink99/

Instrumentation for the

OPERATING ROOMA P H O T O G R A P H I C M A N U A L


Evolve Student Resources for Tighe: Instrumentation forthe Operating Room: A Photographic Manual, Ninth Edition,include the following:

• Additional Images

• Review Questions

Activate the complete learning experience that comes with each NEW textbook purchase by registering at

http://evolve.elsevier.com/Tighe/instrumentation

YOU’VE JUST PURCHASED

MORE THANA TEXTBOOK!

REGISTER TODAY!

You can now purchase Elsevier products on Evolve!Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products.


Instrumentation for the

9N I N T H ED I T I O N

OPERATING ROOM A P H O T O G R A P H I C M A N U A L

Shirley M. T ighe, BA, RN, RetiredAD in Applied Science in Photography

Consultant for the Operating RoomLake Havasu City, Arizona

with over 800 photographs


3251 Riverport LaneSt. Louis, Missouri 63043

INSTRUMENTATION FOR THE OPERATING ROOM: A PHOTOGRAPHIC MANUAL, NINTH EDITION ISBN: 978-0-323-24315-5

Copyright © 2016 by Mosby, an imprint of Elsevier Inc.Copyright © 2012, 2007, 2003, 1999, 1994, 1989, 1983, 1978 by Mosby, Inc., an affiliate of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechani-cal, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permis-sions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Brooks Tighe, Shirley M., author. Instrumentation for the operating room : a photographic manual / Shirley M. Tighe. -- Ninth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-24315-5 (alk. paper) I. Title. [DNLM: 1. Surgical Instruments--Atlases. WO 517] RD71 617.9’178--dc23 2014048834

Executive Content Strategist: Tamara MyersSenior Content Development Specialist: Laura SelkirkPublishing Services Manager: Pat JoinerProject Manager: Suzanne C. FanninDesigner: Margaret Reid

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1


http://www.elsevier.com/permissions

vDedication

Thank you to PeaceHealth Southwest Medical Center and their staff for allowing me to use their faculties for the photographing to update Instrumentation for the Operating Room: A Photographic Manual textbook, ninth edition.

It has been a real honor to work with the staff at PeaceHealth Southwest Medical Center in Vancouver, Washington. First, they were very knowledgeable about the work they were doing and were so willing to share it (so many new or improved instrumentation) with my staff who had worked in perioperative nursing. Second, they had their plan of what needed to be updated and were efficient in assisting us in photographing and labeling the instruments.

Wendy Weir-Raynor and Denise Reese were definite assets to the entire undertaking of updating the ninth edition of this textbook. They are clinical educators with over 2 decades working in the perioperative services. Wendy is located second from the right in the front row, and Denise is located first on the left in the last row. This photo includes some of the clinical consultants and many technicians who work in the central sterile processing depart-ment, where instrumentation processing takes place.

PeaceHealth Southwest Medical Center.


vi Dedication

Sincerely,Shirley M. Tighe, BA, RN, Retired, AD in Applied Science in Photography

Left to right: Jack Sanders, Glen Tighe, Shirley Tighe, Pauline Vorderstrasse, Gwen Graham, and Beverly Burns, all of whom came out of retirement and assisted Shirley in another edition of her textbook. It has been an honor to work with these friends and many other consultants for over 4 decades on the textbooks. Sharing their expertise of operating room nursing and the time to complete the textbooks, one should really call it “their textbook.” Many thanks to all.


viiContributors/Consultants

CONTRIBUTORS/CONSULTANTS

CLINICAL EDITOR

Denise A. Reese, RN, CNORClinical Educator─Perioperative ServicesPeaceHealth Southwest Medical CenterVancouver, Washington

Wendy M. Weir-Raynor, BSN, RNClinical Educator─Perioperative ServicesPeaceHealth Southwest Medical CenterVancouver, Washington

NURSE/CONSULTANTSMarcia Frieze, CEOCase Medical, Inc.South Hackensack, New Jersey

Cynthia C. Spry, MA, MSN, RN, CNOR(E), CBSPDTIndependent Consultant, Sterilization, Disinfection, and Related Infection PreventionNew York, New York

CLINICAL CONSULTANTSKathryn Diane Amer, BSN, RNAmbulatory SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

Joan Blackler, RN, CNORRN Surgical Specialist─Orthopedic SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

M. Tiffany Brenton, BSN, RNRN Surgical Specialist─EENT/Plastics/Robotics SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

Sheryl A. Bundy, RNPediatric Surgical CoordinatorLegacy Emanuel Hospital and Medical CenterPortland, Oregon

Robert L. Nyberg, RNRN Surgical Specialist─Cardiovascular SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington


viii Contributors/Consultants

Katherine Schneider, RN, CNORRN Surgical Specialist─NeurosurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

Jack Som, RNRN Surgical Specialist─General SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

Shannon Young, RNRN Surgical Specialist─GYN/GU SurgeryPeaceHealth Southwest Medical CenterVancouver, Washington

Sandy Zarosinski, RNOpen Heart/Vascular CoordinatorLegacy Good Samaritan Hospital and Medical CenterPortland, Oregon

CONTRIBUTORS/CONSULTANTSBeverly I. Burns, RN, CNOR(E)Clinical Education Specialist, RetiredSurgiCount MedicalPortland, Oregon

Gwendolyn Graham, MN, RNAssociate Professor in AD Nursing Program, RetiredUmpqua Community College, OregonSilverlake, Washington

Kia HolmesGraphic DesignerCase Medical, Inc.South Hackensack, New Jersey

Christianne C. Mariano, MAExecutive AssistantCase Medical, Inc.South Hackensack, New Jersey

Jack W. Sanders, BAMedical Photography/VideographerPortland, Oregon

Glen E. TighePhotography and Computer Consultant, RetiredLake Havasu City, Arizona

Pauline E. Vorderstrasse, BSN, RN, RetiredDirector/Instructor Surgical Technology, RetiredMt. Hood Community CollegeWest Linn, Oregon

PeaceHealth Southwest Medical CenterVancouver, Washington


ixPreface

Preface

The organization of this edition is the same as in the past editions, starting with the basic and continuing to the advanced, just as you would progress when working in the periopera-tive area.

Knowing the history of the instruments and understanding their care and handling, their classification, and the correct type of sterilization to be used for each instrument will assist you in any perioperative role, whether you work in central sterile processing, ambula-tory surgery, or the operating room. In addition, it is important to know the types of ster-ilization-container systems in which instruments can be sterilized and transported among departments while maintaining their sterility.

Instrumentation for 114 surgical procedures is shown in this textbook according to the body systems involved. Each unit begins with a basic set of instruments, or most of the instruments, required to perform that surgery. Most of the basic units begin with a descrip-tion of how the instruments are used in those procedures and then continue with photo-graphs of the sets of instruments. The sets are photographed in groups, showing instruments that are normally placed in a sterilizing container together. Some instruments are shown individually, with a close-up photograph of their tips if the tips are not visually clear in the group photograph. Once an instrument is shown individually, it will not be shown again as an individual instrument. If you are interested in a specific type of surgery and wish to learn about or review the instruments for that surgery, check the table of contents. If you are searching for an individual instrument, check the index, which provides you with the page on which the individual instrument and the close-up of its tip or tips are found.

Most of the clinical consultants are new reviewers to the textbook. They have years of experience in the perioperative area, which has added to the textbook. We deleted some basic sets from the textbook and have them available to you on the Evolve website. If a set-up or individual instrument is on Evolve, that information will be located on the front page of that chapter. The information you need to get to Evolve website is available to you on the Evolve page in the beginning of the book.

I wish to acknowledge all the valuable assistance I received from Cynthia Spry in her writing of Chapter 1: Care and Handling of Surgical Instruments, and Marcia Frieze, CEO of Case Medical, Inc., for her writing of Chapter 2: Sterilization Container Systems.

Three of the very important people who are in the background and who are rarely talked about how valuable they are to the publishing of my textbook are my Elsevier associates: Tamara Myers, Executive Content Strategist; Laura Selkirk, Senior Content Development Specialist; and Suzanne Fannin, Project Manager. You are very much appreciated by this author for all the dedicated work you do to make this textbook available. Thank you very much.

Sincerely,Shirley M. Tighe, BA, RN, Retired, AD in Applied Science in Photography


This page intentionally left blank


xiContents

Contents

UNIT ONE: INSTRUMENT PREPARATION FOR SURGERY

1 Care and Handling of Surgical Instruments, 1 2 Sterilization Container Systems, 24

UNIT TWO: GENERAL SURGERY 3 Operating Room Suite/Basic Laparotomy, 31 4 Abdominal Self-Retaining Retractors, 39 5 Small Laparotomy Set, 45 6 Minor Laparoscopic Set, 47 7 Laparoscopy, 49 8 Laparoscopic Adult MIS Set, 54 9 Laser Laparoscope, 60 10 Laparoscopic Cholecystectomy, 61 11 Laparoscopic Bowel Resection, 63 12 Bowel Resection, 69 13 Sigmoidoscopy, 71 14 Laparoscopic Bariatric Surgery, 72 15 The da Vinci® Surgical System and EndoWrist ® Instruments (Robotic Instruments), 79 16 Breast Biopsy/Lumpectomy, 84 17 Mastectomy, 85

UNIT THREE: FEMALE REPRODUCTIVE SURGERY 18 Dilatation and Curettage of the Uterus, 88 19 Hysteroscopy, 91 20 Vaginal Laser, 94 21 Abdominal Hysterectomy, 96 22 Supracervical Laparoscopic Hysterectomy, 99 23 Vaginal Hysterectomy, 103 24 Laparoscopic Tubal Occlusion, 105

UNIT FOUR: GENITOURINARY SURGERY 25 Cystoscopy, 108 26 Urethroscopy, 112 27 Ureteroscopy, 113


xii Contents

28 Nephrectomy, 115 29 Laparoscopic Nephrectomy, 117 30 Pubovaginal Sling/Anterior Repair, 119 31 Prostatectomy, 122 32 Laparoscopic Prostatectomy, 127 33 Transurethral Resection of the Prostate, 128 34 Vasectomy, 130 35 Penile Prosthesis, 133

UNIT FIVE: ORTHOPEDIC SURGERY 36 Basic Orthopedic Surgery, 136 37 Power Saws and Drills, Battery Powered, 139 38 Small Joint Arthroscope Set, 144 39 Arthroscopic Carpal Tunnel Instruments, 145 40 Small/Minor Joint Replacement, 146 41 Total Ankle Prosthesis, 148 42 Arthroscopy of the Knee/Shoulder, 150 43 Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon Bone Graft

Instruments, 154 44 Total Knee Replacement, 157 45 Shoulder Surgery Instruments, 164 46 Hip Fracture, 166 47 Hip Retractors, 169 48 Total Hip Replacement, 170 49 Total Hip Instruments (Zimmer-VerSys), 174 50 Spinal Fusion with Rodding, 179 51 Long Bone Rodding for Fracture Fixation, 185 52 ASIF Universal Femoral Distractor Set, 187 53 Synthes Retrograde/Antegrade Femoral Nail, 188 54 Synthes Unreamed Tibial Nail Insertion and Locking Instruments, 190 55 External Fixation of Fractures, 191 56 ASIF Pelvic Instrument Set, 194 57 Universal Screwdriver/Broken Screw Set, 196

UNIT SIX: EYE, EAR, NOSE, AND THROAT SURGERY 58 Basic Eye Set, 198 59 Clear Corneal Set, 201 60 Corneal Transplant, 205 61 Deep Lamellar Endothelial Keratoplasty, 210 62 Glaucoma, 212 63 Eye Muscle Surgery, 214 64 Retinal Detachment, 217 65 Vitrectomy, 219 66 Oculoplastic Instrument Set, 221


xiiiContents

67 Eye Enucleation, 223 68 Basic Ear Set, 224 69 Tympanoplasty, 225 70 Tonsillectomy and Adenoidectomy, 234 71 Transoral Surgery, 237 72 Tracheotomy, 238 73 Septoplasty and Rhinoplasty, 240 74 Nasal Polyp Instruments, 244 75 Nasal Fracture Reduction, 245 76 Sinus Surgery, 246

UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL SURGERY 77 Facial Fracture Set, 251 78 Orthognathic Surgery, 254 79 Titanium 2.0-mm Microfixation System, 257

UNIT EIGHT: PLASTIC SURGERY 80 Minor Plastic Set, 258 81 Micro Plastic Set, 260 82 Plastic Miscellaneous, 262 83 Skin Graft, 266

UNIT NINE: PERIPHERAL VASCULAR, CARDIOVASCULAR, AND THORACIC SURGERY

84 Endarterectomy, 268 85 Artery Bypass Graft, 269 86 Endovascular Abdominal Aortic Aneurysm Repair, 271 87 Abdominal Vascular Set (Open Procedure), 274 88 Thoracoscopy, 277 89 Thoracic Instruments, 280 90 Cardiac Surgery, 283 91 Open Heart Microinstruments, 287 92 Sternal Saws and Sternum Knife, 289 93 Open Heart Extras, 291 94 Cardiovascular Instruments, 296 95 Open Heart Valve Extras, 299 96 Return Open Heart Set, 301 97 Vein Retrieval Instruments, 304 98 Radial Artery Harvest Set, 306

UNIT TEN: NEUROSURGERY 99 Craniotomy, 307 100 Neurologic Bone Pan Instruments, 314


xiv Contents

101 Neurologic Retractors, 317 102 Medtronic Midas Rex Electric Drill, 320 103 Rhoton Neurologic Microinstrument Set, 322 104 Ultrasonic Handpieces, 325 105 Neurologic Shunt Instruments, 326 106 MINOP Neuroendoscopy Set, 328 107 Intracranial Pressure Monitoring Tray, 330 108 Yasargil Aneurysm Clips with Appliers, 331 109 Synthes Low-Profile Cranial Plating Set, 332 110 Laminectomy, 334 111 Williams Laminectomy Microretractors, 338 112 Minimally Invasive Spine Surgery, 339 113 Anterior Cervical Fusion, 341 114 ASIF Anterior Cervical Locking Plating Instruments, 344

UNIT ON PEDIATRIC SURGERY (ON EVOLVE WEBSITE)


1CHAPTER 1 Care and Handling of Surgical Instruments

Care and Handling of Surgical Instruments*

*This chapter was written by Cynthia C. Spry.

Although evidence exists that stone knives were used to perform surgery as early as 10,000 bc, modern surgical instrumentation began with the introduction of stainless steel in the early 1900s. Approximately 85% of all surgical instrumentation is now made of stain-less steel. Although stainless steel continues to compose the bulk of instrumentation used in surgery today, there have been dramatic changes over the past several decades. One has been the addition of new materials. In addition to stainless steel, titanium, Vitallium, and vari-ous polymers are also used. The introduction of minimally invasive surgery coupled with the availability of space-age materials have wrought instrumentation once only dreamed of. Cameras, flexible and rigid endoscopes, minimally invasive surgical techniques, and advanced imaging technology now make it possible to explore almost every crevice within the human body without having to perform open surgery and without requiring a hospital stay. Instrument design has focused on enhancing the surgeon’s ability to visualize, maneu-ver, diagnose, and manipulate tissue using minimally invasive surgical techniques. It is pos-sible to repair an aortic aneurysm, perform a coronary artery bypass, and operate on a fetus without making a major incision. Advances in instrumentation design have contributed significantly to improved patient outcomes, early discharge, reduced recuperation time, and less physical trauma and pain. In contrast to the general surgery instruments that have not changed markedly, minimally invasive and interventional procedure instrumentation has become more complex and delicate and requires special care and handling techniques. For example, the working channel of a flexible endoscope can be as small in diameter as 0.1 mm and as long as 2200 mm. The consequence of improved instrument design is higher cost, less inventory of like instrumentation, and greater cleaning, decontamination, and sterilization challenges. When surgical volume increases without a corresponding increase in inventory, instruments will experience increased utilization, handling, and processing. This in turn increases the risk of damage, which can lead to expensive repair costs and pos-sible cancellation of a surgical procedure. In today’s environment of cost consciousness, proper care and handling of surgical instrumentation is more critical than ever.

In addition to improvements in instrument design, advances have occurred with regard to cleaning, packaging, and sterilization technologies. Standards, guidelines, and recom-mended practices related to instrument processing are continually updated to reflect new evidence-based knowledge. As a result, the required knowledge base of the person respon-sible for the care and handling of instruments has expanded significantly. The person caring for instruments must know the intended uses, functions, and compatibility of instruments with various cleaning, disinfecting, packaging, and sterilizing methods. This person must also have an understanding of the equipment used to clean, decontaminate, package, and sterilize instruments. In recognition of the skill required to process surgical instruments properly, certification of processing personnel is required in many facilities and is a require-ment for employment in at least two states, with other states to soon follow. Although the care and handling of surgical instrumentation is not revenue producing, appropriate and meticulous care and handling can result in lower overall costs for a surgical department by preventing damage and consequently reducing expenditures for repair and replacement.

CHAPTER 1UNIT ONE: INSTRUMENT PREPARATION FOR SURGERY

Additional images are available at:

evolve.elsevier.com/Tighe/instrumentation



2 UNIT 1 Instrument Preparation for Surgery

However, the primary concern should be that the instrument be truly patient ready (i.e., safe for use on a patient in surgery). Instruments must be thoroughly cleaned and decon-taminated, and then properly packaged and sterilized in preparation for surgery. Instru-mentation that malfunctions or is not sterile can result in extended surgery time, poor technical results, patient infection, patient injury, and even death. Since the publication of the November 1999 report, “To Err is Human: Building a Safer Health System” issued by the Institute of Medicine in which it is stated that as many as 98,000 injuries to patients occur each year in hospitals, many other reports of patient injury have appeared in professional journals as well as the popular press.1 In a 2014 report from the staff of Senator Barbara Boxer of California it is estimated that between 210,000 and 400,000 patients die each year as a result of medical errors and other preventable harm at hospitals.2 In this same report that lists the most common events that result in patient injury, surgical site infection is number 7. A heightened awareness of the risk of harm to patients and the resulting eco-nomic impact has led to a focus on patient safety and financial initiatives to prevent harm. Several payors such as Medicare, Medicaid, and some private insurance companies will no longer pay a facility for the costs associated with care for a patient who sustains certain adverse events, such as some surgical site infections, that with proper care are preventable.3 There is an ongoing intense focus on patient safety throughout the health care industry. Proper care and handling of surgical instruments are critical components of patient safety (e.g., prevention of surgical site infection).

In summary, the proper care and handling of surgical instrumentation is not a simple rote task; it requires specialized knowledge, competence, critical thinking, judgment, and a commitment to excellent patient care.

EVOLUTION OF SURGERY AND SURGICAL INSTRUMENTATIONSurgery was practiced long before the development of sophisticated surgical instruments. Stone knives and sharpened flints and animal teeth were the instruments of choice for trephination, circumcision, and bloodletting in prehistoric times. In Corpus Hippocraticum, Hippocrates (460-377 bc) wrote of the use of iron and steel in instrument making; however, there are no existing examples of surgical instruments before the early Roman period. Exca-vations begun in 1771 in the city of Pompeii reveal surgical instruments that bear amaz-ing resemblances to contemporary instrumentation. Among the instruments found were a foreign-body remover, a speculum, retractors, probes, a periosteal elevator, forceps, and hooks. Metal analysis indicates three materials: copper, bronze, and iron.

Until the 1790s, surgery was not a strict discipline, and surgeons were not afforded equal status with physicians. Instruments were made by blacksmiths, cutlers, and armorers. How-ever, as surgery evolved into a scientific discipline and achieved a measure of status, the specialty of instrument making also emerged. Surgeons employed coppersmiths, steelwork-ers, silversmiths, wood turners, and other artisans who handcrafted instruments to indi-vidual specifications. Instruments often had ornate ivory or carved wooden handles and were cased in velvet.

The introduction of anesthesia in the 1840s and the adoption of Lister’s antiseptic tech-nique in the 1880s greatly influenced the making of surgical instruments. The use of anes-thesia enabled the surgeon to work more slowly and accurately and to perform longer, more complex procedures. The variety of surgeries performed increased, as did the demand for specialized instruments. The ability to sterilize instruments also had an impact on instru-ment design. When steam sterilization became a standard process, carved wood or ivory handles were replaced with all-metal instruments made of silver, brass, or steel. Velvet-lined boxes were replaced by trays that could be lowered into steam sterilizers.

MANUFACTURE OF STAINLESS STEEL INSTRUMENTATIONThe development of stainless steel in the 1900s provided a superior material for the man-ufacture of surgical instruments. Subsequently, instrument making evolved into a highly skilled occupation. Shortly thereafter, crafters from Germany, France, and England were



brought to the United States to instruct apprentices in their craft. Even today, many of the delicate, high-quality, stainless steel instruments are manufactured in Europe. Germany is often considered the home of high-quality surgical instruments. Other metals like Vital-lium and titanium are used today, but the bulk of surgical instrumentation is made of stain-less steel and is manufactured in the United States. Many surgical instruments are made from plastic polymers as well.

Stainless steel is a compound of varying amounts of carbon, chromium, and iron. Small amounts of nickel, magnesium, and silicone may also be incorporated. Varying the amount of these materials produces a variety of qualities, such as flexibility, temper, malleability, and corrosion resistance. There are more than 80 different types of stainless steel. The American Iron and Steel Institute uses three-digit numbers to grade steel based on its various qualities and composition. The most commonly used steel alloys for the manufacture of heat-stable, reusable surgical instruments are stainless steel series 300 and 400, with 400 being the most common. The 300 series is generally used for noncutting surgical instruments requiring high strength, such as speculums and large retractors. The 400 series is used for both cut-ting and noncutting instruments. Both series resist rust and corrosion, have good tensile strength, and will retain a sharp edge through repeated use. The chromium content in stain-less steel provides the stainless quality. Stainless steel is really a misnomer. The degree to which the steel is stainless is also determined by the chemical composition of the metal, the heat treatment, and the final rinsing process.

The first step in the manufacture of stainless steel instruments is the conversion of raw steel into sheets that are milled, ground, or lathed into instrument blanks. These blanks are then die-forged into specific pieces and, where appropriate, male and female halves. Excess metal is trimmed away and the pieces are milled and hand-assembled. Jaw serration and ratchet and shank alignment are achieved, after which the instrument is hand-assembled and then ground and buffed. It is then heat-treated to reach its proper size, weight, spring, temper, and balance. Following testing for desired hardness, jaw closure, and ratchet and locking action, a finish is applied.

The final two processes are passivation and polishing. Passivation is the immersion of the instrument in a dilute solution of nitric acid that removes carbon steel particles and promotes the formation of a coating of chromium oxide on the surface. Chromium oxide is important because it produces corrosion resistance. When carbon particles are removed, tiny pits are left behind. These are removed by polishing to create a smooth surface upon which a continuous layer of chromium oxide may form. Passivation and polishing effec-tively close the instrument’s pores and prevent corrosion.

There are three types of instrument finishes: highly polished, satin or dull, and ebony. The highly polished finish is the most common, but it does reflect light and can cause glare that may interfere with the surgeon’s vision. The satin finish does not reflect light and elimi-nates glare. The ebony finish is black and also eliminates glare. The ebony finish is suitable for laser surgery, in which it is critical that the laser not be accidentally reflected, creating the potential for burn or fire.

QUALITY OF STAINLESS STEEL INSTRUMENTSStainless steel instruments may appear to be of uniform quality when they are new. How-ever, there are various grades of quality, ranging from high quality and premium grade to operating room and floor grade. Some instruments appearing to be stainless steel are of such poor quality that they are sold as single-use instruments. In the United States, there is no agency that sets standards for instrument quality. Quality is determined by the manu-facturer. In addition, an instrument labeled Germany may have been forged in Germany but actually assembled in a country where quality standards are minimal or nonexistent. Because instruments represent a substantial portion of the budget of a surgical suite, it is important to be knowledgeable about buying and selecting products with the desired quality. Many factors affect quality. Two major factors are a balanced carbon-chrome ratio and the process of passivation. A balanced carbon-chrome ratio is important for instru-ment strength and long life. Instruments that are classified as premium have the correct



balance. The passivation process is important to create a protective coat on the outer layer of an instrument to prevent corrosion and extend its life. Electropolishing is sometimes substituted for passivation. The result is a less expensive instrument but one that will not last as long. When purchasing stainless steel instruments, it is best to deal with a reputable manufacturer who will explain the variation in quality of the products available.

It is important to verify that an instrument manufacturer has clearance from the U.S. Food and Drug Administration (FDA) to market its products. Instruments manufactured in some countries outside the United States have been known to enter the American market without this clearance and without providing adequate instructions for use and processing. Another reason to deal with a reputable instrument manufacturer is authenticity. When an instrument that usually sells for $150 is being offered for $50, the buyer should beware and should check for FDA clearance before considering purchase.

Instruments manufactured of materials other than stainless steel present an additional set of factors to consider before purchasing. These include their ability to be disassembled, cleaned, and reassembled; their life expectancy; and their compatibility with the existing resources within the sterile processing department (e.g., cleaning chemistries, disinfecting agents, and sterilization modalities) available within the institution.

CARE AND HANDLING OF BASIC SURGICAL INSTRUMENTS: OVERVIEWA well-made, properly cared for instrument can be expected to last 10 years. The most important considerations in extending the life of an instrument are appropriate use, careful handling, and proper cleaning, decontamination, and sterilization. Other considerations are disinfection, packaging, and storage. Every instrument is designed for a specific pur-pose. Using it for an unintended purpose is a sure method of damaging an instrument. Examples of misuse include securing surgical drapes or bending a wire with an instrument designed to grasp tissue.

RESOURCESThree must-have resources for personnel responsible for instrument processing are the Association for the Advancement of Medical Instrumentation’s (AAMI’s) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, the Asso-ciation of periOperative Registered Nurses (AORN) Recommended Practices for Steriliza-tion, for Care and Cleaning of Surgical Instruments and for Selection and Use of Packaging Systems for Sterilization, and the Centers for Disease Control (CDC) 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities.4,6 The other must-have resources are the instructions for use (IFUs) for all devices. The IFUs are those processes the manufac-turer has determined are necessary to obtain outcomes to render a device safe for use. The IFUs should contain explicit instructions for disassembly, cleaning and/or decontamina-tion, inspection, function testing, packaging, high-level disinfection, and sterilization as appropriate to the device. IFUs should be routinely reviewed. Instructions may change when manufacturers make modifications to their devices, when new regulatory require-ments become effective, or when new processing technologies come to market. In fact, in a statement relative to ambulatory surgery facilities, the Centers for Medicare and Medicaid Services (CMS) have issued the statement, “If manufacturers’ instructions are not followed, then the outcome of the sterilizer cycle is guesswork, and the Ambulatory Surgical Center’s practices should be cited as a violation of 42 CFR 416.44(b)(5)” (CMS, 2009).7

In addition to IFUs for devices, IFUs for cleaning chemistries, cleaning and steriliza-tion equipment, packaging materials and equipment, and quality monitors should also be reviewed before processing. In instances in which instructions are not compatible with each other, the vendor(s) should be contacted in an attempt to reconcile the incompatibilities. When it is not possible to reconcile instructions, product testing (see Sterilization section later in this chapter) should be performed.

Everyone responsible for instrument processing should have ready access to all neces-sary IFUs and should refer to them routinely. Surveyors, such as those from accrediting



agencies, have indicated that they will be asking to see IFUs and will be checking to see if personnel are adhering to them. Many facilities contract with a document management system to ensure ready availability and access to current IFUs. When a computerized docu-ment management system is in place, staff must be competent to operate the program.

PREPARING INSTRUMENTS FOR PROCESSING

Point of Use

The first steps in preparing an instrument to be processed in the sterile processing area should begin at the point of use. During surgery, instruments contaminated by blood or tis-sue should be wiped, rinsed, or irrigated in the sterile water at the sterile field. This should be accomplished in a manner that prevents splashing and aerosolization and can generally be done by wiping the device with a moistened lap pad and/or syringe. A syringe should be present on the sterile field for the purpose of flushing lumens throughout the procedure as appropriate. Flushing a lumen should be done below the surface of the water to prevent the aerosolization of debris. Saline should not be used for wiping or irrigating instruments. Prolonged exposure to saline can result in corrosion and can eventually lead to pitting of stainless steel. Pitting can cause entrapment of debris, interfere with sterilization, and result in destruction of the instrument. Blood and foreign matter that are not removed or are allowed to dry and harden may become trapped in jaw serrations, between scissor blades, or in box locks, making final cleaning more difficult and the sterilization or disinfection process ineffective. It can cause instruments to become stiff and eventually break.

Instruments should be handled carefully and gently, either individually or in small lots, to avoid possible damage caused by their becoming tangled, dented, and misaligned. They should be placed, not tossed, into the basin. In preparation for transport to the decon-tamination area, all disposable blades and sharps should be removed and placed in a des-ignated sharps container. Heavy instruments should be placed on the bottom of the pan, container, or basin, with the lighter, more delicate and fragile ones on top or protected in another manner. Care should be taken to ensure that instruments are not tangled or piled high. Rigid endoscopes and fiber optic cables should also be placed on top or separated. Fiber optic cables should be loosely coiled, never tightly wound. Instruments that can be disassembled should be disassembled. Ratchets should be opened. Instruments should be returned to their respective containers or baskets to prevent sets from becoming incomplete and should be contained or covered for transport to the decontamination area. The con-tainer for transport should be labeled with a biohazard symbol. A red bag or red container may be used instead.8 Delicate instruments, endoscopes, and other specialty instruments may need to be separated and transported to the decontamination area in containers spe-cifically designed to prevent damage. Instruments with cutting edges, pointed tips, or other sharp components should be placed in such a manner that sharp edges are protected and personnel responsible for cleaning and decontamination are not injured when reaching into the container.

CLEANING AND DECONTAMINATIONThe AAMI defines cleaning as “removal of contamination from an item to the extent nec-essary for further processing or for the intended use.” AAMI further notes that, “In health care facilities cleaning consists of the removal, usually with detergent and water, of adherent soil (e.g., blood, protein substances, and other debris) from the surfaces, crevices, serra-tions, joints, and lumens of instruments, devices, and equipment by a manual or mechani-cal process that prepares the items for safe handling and/or further decontamination.”4

Decontamination is defined by the Occupational Safety and Health Administration (OSHA) as “the use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.”8



Decontamination consists of cleaning and a disinfection process. Mechanical washing machines typically follow the washing phase of the cycle with a thermal or chemical disin-fection application that renders a device safe to handle.

AFTER SURGERY: CLEANINGWhenever possible, instruments should be taken apart at the point of use. Unless other-wise specified in the device manufacturer’s IFUs, anything that can be disassembled must be disassembled before cleaning. After surgery, instruments are transported in leak-proof containers or trays encased in plastic bags to a designated area for cleaning and decon-tamination. Instruments should not be transported in basins containing water because the water may spill. Instruments should be cleaned away from patient care areas or areas where clean activities are performed. The decontamination area may be within the operating suite or, more commonly, in the Central Processing Department, also referred to as the Sterile Processing Department. Instruments that can tolerate immersion and cannot be cleaned immediately should be treated with an enzymatic foam or gel to prevent debris from drying and adhering to the device and to prevent formation of biofilm. Another option is to sub-merge the instruments completely in a warm, noncorrosive enzymatic solution and allow to soak until cleaning can be performed. The foam or gel may be applied prior to transport to the dedicated decontamination area. Generally, instruments should be placed horizontally beneath the water; however, some types of lumened instruments may have to be soaked vertically, with the entire shaft submerged. Horizontal soaking of lumens can cause air bubbles to form that can prevent the solution from traveling the length of the inner lumen.

All instruments placed in the sterile field for use in a surgical procedure are considered contaminated and should be cleaned whether or not they were actually used. Blood, saline, or debris can be splashed or inadvertently deposited on any of the instruments; therefore, they all require decontamination and processing.

There are several methods of decontaminating instruments, but all begin with thorough cleaning. The usual steps in the decontamination process include sorting, soaking, rinsing, washing, rinsing, drying, and lubricating.

Cleaning is the removal of visible adherent soil from the surfaces, crevices, serrations, joints, and lumens of instruments. Cleaning may be manual or automated and is accom-plished with detergent, water, and friction. Proper use of the detergent is essential. Deter-gents should always be mixed according to the proportions indicated on the label or in the manufacturer’s IFUs. Enzymatic detergents that are over or under concentrated or have been improperly rinsed can interfere with subsequent disinfection and sterilization. Regardless of how heavily soiled instruments appear to be after use, adding more detergent to the water is inappropriate. To ensure proper detergent concentration, it is advisable to obtain an exact measuring device for the detergent and to mark the sink with a piece of tape or a nontoxic, permanent marker to indicate the correct water level. For example, if the instructions call for a mix of 1 oz of detergent to 1 gal of water, a 1-oz container should be obtained and kept next to the detergent bottle or sink. A 1-gal container should be filled with water and poured into the sink in which instruments are washed manually and where the water level is marked. Commercially prepared labels indicating desired water level that may be affixed to the sink are readily available. The presence of the 1-oz container and the mark in the sink should help to ensure the correct preparation of the detergent solution. In addition to concentration requirements, cleaning agents have temperature and contact time requirements. A thermometer and timer should be used to determine temperature and to set contact time. Instructions for rinsing are also important. Some products call for multiple rinses. When a choice is made to switch to an alternative detergent, it is important to ensure that all personnel responsible for instrument processing receive the appropriate notification and information as requirements for use may change.

When possible, mechanical cleaning is preferred. However, some instruments cannot tolerate immersion, high temperatures, or pressures of mechanical cleansing units and must be cleaned manually. Instruments that are washed manually should always be com-pletely immersed and allowed to soak in a cleaning agent intended for manual cleaning of



surgical instruments. Instruments should be disassembled and box locks, hinges, and joints should be opened. Serrations, box locks, crevices, and lumens must be brushed to remove imbedded particles. Scouring pads, stiff brushes, abrasive powders and soaps, and sharp implements should not be used to remove debris because they can destroy the protective coating on surgical instruments.

Instruments that are washed manually should always be washed one at a time beneath the surface of the water to prevent the aerosolization and splashing of debris.

The final rinse in the cleaning process, whether manual or mechanical, should be with treated water (e.g., distilled, deionized, reverse osmosis). Water quality varies by geographi-cal location and untreated water (tap water) may contain endotoxins. Endotoxins are essen-tially dead bacteria cells. When found on instruments used in surgery, endotoxins can cause a pyrogenic (fever) reaction in a patient.

Some instruments, because of their design, may require manual cleaning followed by mechanical cleaning. Debris and tissue can easily become trapped in complex devices, and mechanical cleaning alone may not be sufficient to remove the debris. Soaking in an enzymatic detergent can help to break down organic soil. Reamers with many crevices tend to trap debris and may have to be soaked and manually brushed before automatic cleaning. Much will depend upon the capability of the mechanical cleaners in the decon-tamination area. Lumened instruments should be flushed and brushed. Flushing can be achieved by attaching a Luer-Lok syringe filled with an enzymatic detergent solution to one of the ports on the instrument. Brushing must be carried out using a brush that is appropriate to the device (e.g., a brush made of the appropriate bristle material), intended for cleaning surgical instruments, and long enough to exit the distal end of the shaft and wide enough in diameter to cause friction on the walls of the lumen so soil is loosened. Brushes should be either single use disposable or, if reusable, should be cleaned and disin-fected at least daily. Mechanical washers and ultrasonic irrigators specifically designed for lumened devices do an excellent job of cleaning and are preferable for cleaning lumened devices.

Personnel responsible for cleaning must wear personal protective attire to prevent con-tact with blood or with fluid that might contain blood and/or other body fluids. Protective attire consists of a fluid resistant face mask and eye protection such as goggles or a full-length face shield, heavy-duty cuffed decontamination gloves, and a liquid-resistant gown with sleeves that cover the scrub suit underneath. Aprons are not acceptable. Masks are recommended when cleaning items that can create aerosols (e.g., lumened devices). Fluid-resistant shoe coverings or waterproof boots are appropriate when fluid may be expected to pool on the floor.4,5,8

Ultrasonic cleaning is another component of instrument cleaning. Ultrasonic cleaners should be used only on devices that can tolerate this process and only after gross debris has been removed. Ultrasonic washers use a process called cavitation to remove fine soil from difficult-to-reach areas of a device that manual cleaning may not remove. High-fre-quency sound waves are captured and converted into mechanical vibrations in the solution. The sound waves generate microscopic bubbles that form on the surfaces of the instru-ments. These bubbles expand until they become unstable and collapse or implode (col-lapse inwardly), creating minute vacuums that rapidly disrupt the bonds that hold debris to instrument surfaces. The tiniest particles are rapidly drawn from every crevice in the instrument. Ultrasonic cleaning is especially effective for box locks and instruments with serrations and interstices that are not easily accessible.

Ultrasonic cleaning does not kill pathogens; it only removes them and deposits them in the ultrasonic bath. The energy created in an ultrasonic cleaner is not biocidal, and unless the solution is changed frequently, the bioburden on instruments can actually increase. To prevent this, ultrasonic solutions should be changed between cycles and according to the ultrasonic IFUs. The cover of the ultrasonic cleaner should be closed during operation to prevent the spread of microorganism-containing aerosols that are created during the clean-ing process and that may be harmful to personnel.

Both the device manufacturer’s IFUs and the ultrasonic IFUs should be reviewed before using ultrasonic cleaning.



Instruments made of dissimilar metals can be damaged if sonicated together in the ultra-sonic cleaner. The electroplating of the more active metal onto the less active metal can result in permanent discoloration of the less active metal (e.g., brass plating on stainless steel turns the steel a golden color) and will eventually weaken the instrument from which the metal is being removed. In addition, some instruments cannot tolerate the energy waves of the ultrasonic cleaning process, and manufacturers of some instruments, such as lensed, in which the sonication process can loosen adhesives, may specifically state not to use ultra-sonic methods for cleaning.

There are a variety of ultrasonic cleaners on the market and some of them are designed and intended to be used for specific instruments such as robotic instruments. These may include attachments or ports that connect lumens to the cleaner and are especially efficient at removing debris from difficult to access locations on the device.

At the completion of the ultrasonic cycle, the instruments are placed in a mechanical washer or rinsed and dried.

The performance of ultrasonic cleaners should be tested periodically using monitors specifically designed and intended for this purpose. There is no nationally recognized stan-dard for frequency of testing, however some IFUs may recommend specific testing inter-vals. Weekly or daily testing is common.

The most common mechanical cleaning machine in use is the washer-decontaminator/disinfector. These machines offer a variety of cycles, including cool-water rinse, enzyme soak, wash, sonication (ultrasonic cleaning), hot-water rinse, germicide rinse, and dry.

For lumened devices, washers with connection ports that facilitate cleaning lumens should be utilized.

Instruments should be placed in a mesh bottom or perforated tray prior to placement within mechanical washing systems. Detergent should be selected according to the type of debris, the tolerance of the instrument, and recommendations from the device and washer manufacturers. The pH of a detergent can be alkaline, neutral, or acidic. A mildly alkaline or neutral detergent is generally preferred. Acidic or heavily alkaline detergents should not be used routinely because they can destroy the passivation layer and promote corrosion. When high-alkaline detergents are used, they must be completely and thoroughly neutral-ized. To accomplish this, some mechanical washers employ a high-alkaline detergent wash followed by an acid rinse.

Enzymatic detergents usually consist of a detergent base with a neutral pH in combi-nation with one or more enzymes and a surfactant. Surfactants lower the surface tension of water and allow the detergent to more easily penetrate into crevices and serrations. There are many enzymatic detergents on the market. Some formulations contain only one enzyme; others contain multiple enzymes. There are enzymatic detergent products suit-able for ultrasonic cleaners, mechanical washers, and manual cleaning. Some can be used for manual and mechanical cleaning. Some enzymatic cleaners are intended for specialties such as orthopedic or ophthalmic procedures. Some target blood, fat, or organic soil. As a general rule, a low-foaming detergent with a neutral pH is preferable. High-foaming deter-gents may not be completely rinsed off and can leave spots and stains on instruments. In areas where the water is hard, a water softener should be used to minimize scum and scale formation.

Placement of instruments within mechanical washers must be such that cleaning agents and water can make contact with all surfaces of the instrument.

Mechanical cleaning equipment should be tested at least weekly, and preferably daily. There are commercially available products that can be used to test the ability of the washer to clean effectively. These should be used according to the manufacturer’s written IFUs.

As a final step before inspection and packaging for sterilization, instruments should be lubricated with a nonsilicone, water-soluble lubricant. Mechanical washers often include a lubrication process as part of the cycle. In manual lubrication, instruments are dipped into a milky-white solution or bath. The manufacturer’s instructions for dilution of the lubricant should be followed, and the expiration date after mixing should be noted and indicated on the instrument milk bath.



SPECIALTY INSTRUMENTSSpecialty instruments require exceptional handling. Instruments used in microscopic sur-gery should be handled separately from those used for general surgery. They easily become tangled or misaligned when the heavier instruments used in general surgery are placed on top of them. Other specialty instruments, such as powered hand pieces and telescopes, will be destroyed if subjected to ultrasonic cleaning or to a washer-decontaminator and should be meticulously cleaned by hand. Other specialty instruments may have instructions that spec-ify steps not common to general surgery instruments (e.g., attachment of accessories, use of special cleaning tools, and use of pressurized water). The device manufacturers provide instructions for cleaning that are determined as necessary to obtain the desired outcome. The manufacturers’ instructions for care and handling of instruments should always be followed.

Eye Instruments

Toxic anterior segment syndrome (TASS) is an acute anterior segment inflammation that can lead to impaired vision. TASS has been associated with inadequate cleaning of ophthal-mic instruments following cataract and anterior segment surgery.9-14 Detergent residues, viscoelastic solution used in surgery that can quickly harden on instruments, preservatives, and foreign material can induce TASS. Irrigation ports of phacoemulsion hand pieces, tips, small-diameter tubings, and cannulated instruments coupled with viscous solutions used in eye surgery present unique challenges to cleaning eye instruments. Instruments used for cataract surgery are among those that are most commonly subjected to immediate use steam sterilization (IUSS). Although IUSS, if carried out properly, is safe and effective, the resources to process IUSS correctly may be less than ideal (see section on IUSS) and can lead to shortcuts that negatively impact the outcome of the processing.

Following surgery, eye instruments should be immediately immersed in sterile water, and lumens should be flushed with sterile water. The aspiration and irrigation ports and tubings on phacoemulsion hand pieces should be flushed prior to being disconnected. Instruments should then be cleaned with a detergent recommended by the instrument manufacturer.

Enzymatic detergents should not be used unless indicated in the device manufacturer’s IFUs. Detergent concentration and water quality should also comply with the device manu-facturer’s instructions. The final rinse should be done with sterile, distilled, or deionized water. Lumens should be dried with compressed air. Personnel responsible for processing ophthalmic instruments should refer to the AORN Recommended Practice for Cleaning and Care of Surgical Instruments and to the American Society of Cataract and Refractive Surgeons for recommendations specific to cleaning and processing of ophthalmic instru-ments.5,13

Flexible Endoscopes

Flexible endoscopes contain long, narrow lumens and are inherently difficult to clean. A failure to process properly has been reported in a number of studies. Thousands of patients who have undergone gastrointestinal (GI) endoscopy procedures have been sent letters advising them to return to the facility for testing to determine if they were infected from an improperly processed flexible endoscope.14-17 Instructions for cleaning flexible endo-scopes are quite detailed and specific and are beyond the scope of this review. In 2003, The Society of Gastroenterology Nurses and Associates released The Multisociety Guideline for Reprocessing Flexible Gastrointestinal Endoscopes,18 which provides detailed cleaning and disinfection protocols for flexible endoscopes and their accessories. The guideline, which was revised in 2011,19 has been endorsed by 11 agencies including the Joint Commission, professional nurse and physician endoscopic societies, and the Association for Practitioners in Infection Control and Epidemiology. In 2005, the American College of Chest Physicians and the American Association for Bronchology published an article entitled Prevention of Bronchoscopy-Associated Infection that provides recommendations for cleaning, disinfecting, and postprocedure processing of flexible bronchoscopes.20



Adherence to these guidelines is critical to proper processing. The endoscope manu-facturers’ guidelines should always be consulted for design features specific to the scope in question. Manufacturers usually provide in-service education in the cleaning and steriliza-tion of these devices. Personnel responsible for cleaning and processing these devices must have thorough knowledge of the process and must have demonstrated competence as well. Competence should be demonstrated for each model and type of scope.

Proper cleaning of flexible scopes should begin immediately after their use. The biopsy and suction channel should be flushed with an enzymatic detergent solution and the out-side wiped to remove gross soil. Debris must not be allowed to dry within the channel, and the scope should be delivered to the decontamination area as soon as possible after use. Meticulous cleaning must precede exposure to disinfecting or sterilizing agents. The lumens and internal channels should be cleaned using an appropriately sized brush and then rinsed. It is important that endoscope cleaning agents be mixed and used precisely according to the label. Following manual cleaning, the scope may then be processed in an automated endoscope reprocessor (AER) designed specifically for this purpose. The compatibility of the endoscope with the AER, the detergent, and the disinfectant must be determined. In the absence of an automated system, additional meticulous manual cleaning according to the manufacturer’s recommendations is required. Strict adherence to manu-facturers’ instructions concerning use of the disinfectant and the AERs is critical to achieve adequate cleaning and disinfection. As a final step, all channels should be flushed with 70% alcohol to facilitate drying. Some AERs include an alcohol flush. Storage in an appropriate drying cabinet that has humidity and temperature control is an additional method to facili-tate drying. Pathogenic microorganisms found in rinse water can colonize in a relatively short time (overnight) in an endoscope that has not been adequately dried. In addition, it is possible for a biofilm to form in a lumen that has not been sufficiently dried. A biofilm is an assemblage of microbial cells that forms when bacteria attach to a surface and then exude an extracellular polysaccharide that acts as a glue and a protective layer of slime in which the bacteria proliferate. The extracellular polysaccharide film prevents antibiotic penetration. Biofilms can be removed only by mechanical action. If a biofilm breaks from the surface and enters a patient, the consequences can be deadly because of the especially large number of bacteria in a biofilm. It can require more than 100 times the normal dose of an antibiotic to treat an infection caused by a biofilm. Biofilms have been found to form in moist endoscope lumens as a result of inadequate drying. An alcohol flush can prevent the growth of water-borne microorganisms and biofilms.

CONSIDERATIONS FOR INSTRUMENTS CONTAMINATED WITH PRIONSA prion is an infectious proteinaceous particle that is responsible for causing Creutzfeldt-Jakob disease and several other fatal degenerative neurological diseases. Because prions are resistant to routine disinfection and sterilization processes, instruments that have come into contact with prions require treatment according to special processing protocols. Infor-mation about appropriate processing protocols is not always consistent and continues to evolve. In February 2010, the Society for Health care Epidemiology of America (SHEA) published an article entitled Guideline for Disinfection and Sterilization of Prion-Contami-nated Medical Instruments.21 AORN and AAMI also provide recommendations and guide-lines related to processing prion-contaminated instruments. These guidelines as well as the most current literature should be consulted when developing a policy and procedure for processing prion-contaminated instruments.

Research on best practices related to processing instruments suspected or known to have been exposed to prions is ongoing. In addition, processing protocols are evolving and cleaning chemistries are increasingly being recognized as a critical factor in processing these instruments.22 Institutional policies and procedures for prion-contaminated instru-ments should be reviewed at least annually and revised accordingly. Processing protocols are based on the presence or suspected presence of a prion disease in a surgical patient, the type of tissue that comes into contact with the instruments used during the surgery, and whether the device is critical. Critical devices are those that enter sterile tissue or the



vascular system. High-risk patients are those with a known prion disease or those with rapidly progressive dementia consistent with prion disease. High-risk tissue includes brain, spinal cord, posterior eye, and pituitary. Critical instruments used on high-risk patients undergoing surgery on high-risk tissue require special processing protocols. Each health care facility should have policies and procedures for screening patients to determine the presence or possible presence of a prion disease, identifying and tracking the instruments used in these patients, and establishing protocols for processing these instruments.

SPOTTING, STAINING, AND CORROSIONAlthough stainless steel is highly resistant to spotting, staining, rusting, and pitting, these conditions can occur for many reasons. Understanding the cause of the specific problem usually provides an effective solution.

Minerals in the water may cause light and dark spots. Instruments processed in health care facilities in which the water supply has a high concentration of minerals may show spotting. When water droplets condense on the instruments and evaporate slowly, mineral deposits in the water can remain and leave spots. Sodium, calcium, and magnesium miner-als are particularly problematic. Using treated water (e.g., demineralized, reverse osmosis, and filtered) for rinsing and pure steam for sterilizing may solve the problem. After the sterilization cycle, the door to the autoclave should remain closed until all the steam in the chamber has been allowed to exhaust. This reduces the amount of condensate remaining on the instruments. Vigorous rubbing with a cloth or cleaning with a soft brush may be suffi-cient to remove mineral-deposit spotting. If spotting remains a problem, the autoclave may need servicing. Leaky or faulty gaskets may be the cause of the problem.

A rust-colored film on instruments may be the result of high iron content in the water or foreign material within steam pipes. Yellow-brown to dark-brown spots are sometimes mistaken for rust; the eraser test can be used to determine whether it is rust. If the stain disappears when it is rubbed with a pencil eraser, it is not rust. In some instances, the instal-lation of a steam filter may help prevent this type of stain.

Brownish staining can occur when the detergent used for cleaning contains polyphos-phates that dissolve copper elements in the sterilizer. The result is that a layer of copper is deposited on the instruments by electrolytic action. If this happens, a different detergent should be used and the manufacturer’s instructions followed.

Brownish-orange stains can be caused by a high pH level in the detergent used to clean the instruments.

Black spots are the result of exposure to ammonia, which is found in many cleaning agents. The problem can be resolved by using a different detergent and rinsing thoroughly. Black stains can also be caused by amine deposits that can be traced to the autoclave steam. Amines are used in the boiler to prevent mineral salt deposits on the walls of the boiler and steam pipes. Some of the amines are carried with the steam into the autoclave and by means of electroplating are deposited on the instruments, causing staining to occur. Adding amines to the boiler must be done in a controlled and gradual manner to minimize the risk of concentrations high enough to cause spotting on items to be sterilized.

A blue-gray stain can result when cold liquid sterilants are used beyond their recom-mended time limit.

Rusting of stainless steel is unlikely, and what often appears to be rust may actually be organic residue in box locks or mineral deposits baked onto the instrument surface. Unless the cause is remedied, corrosion may occur.

Actual corrosion is a physical deterioration of the stainless steel. Pitting is a severe form of corrosion in which small pits form on the surface of the instrument. Corrosion and pitting can occur when instruments are exposed to saline for extended periods of time and when organic debris such as blood and tissue is left in difficult-to-clean areas such as box locks, serrations, and ratchets. Detergents that are either too alkaline or too acidic can also cause corrosion and pitting. Detergents with a chlorine base or an acid pH should be avoided. Exposure to carbolic acid, calcium chloride, ferrous chloride, potassium perman-ganate, and sodium hypochlorite can cause severe pitting. To avoid electrolysis, stainless



steel instruments should not be mixed with instruments containing aluminum or copper. Improperly cleaned wraps can also create a corrosive environment. The detergent can leach from the wrap during exposure to heat and steam and remain on the instrument.

Measures that can be taken to avoid instrument corrosion and pitting include soaking or spraying instruments with an enzymatic foam or spray after use to prevent debris from dry-ing and hardening; scrubbing hard-to-clean areas; using a neutral pH detergent; thoroughly rinsing with treated water; and routinely cleaning the sterilizer according to the sterilizer manufacturer’s IFUs. Water and vinegar can also be used to remove impurities.

It is sometimes difficult to identify the cause of stains. Both the instrument manufacturer and the sterilizer manufacturer should be consulted when the cause is unclear.

In summary, the following steps should be taken to prevent spotting, staining, and corrosion: 1. Clean as soon as possible after use to prevent debris from drying on instruments.

(Cleaning begins at point of use.) 2. Apply enzyme spray or gel designed and intended to prevent debris from hardening

on instruments after use in surgery. 3. Clean well; remove all soil. 4. Rinse well. Use treated water for the final rinse. 5. Do not place instruments of dissimilar metal in the ultrasonic cleaner. Remove gross

debris prior to placement within the ultrasonic cleaner. 6. Select only detergents and disinfecting solutions that are recommended for

instruments. Check with the instrument and washer-decontaminator/disinfector manufacturers.

7. Mix and use detergent solutions exactly as indicated by the manufacturer’s IFUs. 8. Dry instruments before wrapping. Ensure adequate drying following exposure to

sterilization. Check autoclaves for proper functioning to ensure drying of packs. 9. Perform sterilizer maintenance according to the sterilizer manufacturer’s IFUs. 10. Periodically have the steam lines and boiler inspected and serviced to prevent boiler

additives from being discharged into the steam.

INSPECTION AND TESTINGPrior to packaging, instruments should be inspected for cleanliness, proper functioning, and absence of defects. An inadequately cleaned, improperly functioning, or damaged instrument is a source of frustration to the surgeon, can cause critical delays in surgery, and can contribute to patient infection or serious injury.

Instruments should be inspected for cleanliness and absence of defects under lighted magnification.

Box locks, serrations, crevices, and other hard-to-clean areas should be examined for cleanliness. Deposits left on instruments may prevent sterilization from being achieved and may dislodge in the patient.

Box locks should be inspected for minute cracks. Cracks are an indication that break-age is imminent. Other common areas where cracks may appear include hinges, lumens, and the base of needle jaws. Jaw movement, jaw alignment, and ratchet function should be checked on all hinged instruments. Joints should work smoothly, and jaws should be in perfect alignment and not overlap. Ratchets should close easily and hold securely. Joint movement can be tested by opening and closing the instrument several times. The instru-ment should close and release with ease. Stiff joints can be caused by inadequate cleaning, resulting in minute particles remaining in the joint. Stiffness can also result when water used to clean instruments contains impurities that collect in the joint. Joints that are stiff should be recleaned if necessary and lubricated with a water-soluble lubricant before they are packaged for sterilization.

Jaw alignment can be tested by lightly closing the instrument and inspecting the jaws. Any overlap indicates lack of alignment and need for repair. If there are serrations or teeth on the jaws, they should meet and mesh perfectly. This can be tested by closing the instru-ment and holding it up to the light. Light should not be visible through the jaws. Instruments



with misaligned jaws can damage tissue and will not effectively occlude bleeders. Misalign-ment of hemostatic clamps is a common problem most commonly caused by improper use of the instrument. Hemostatic clamps should not be used as towel clips, needle holders, or pliers or for purposes other than those for which they are designed and intended.

Ratchets may be tested by clamping the instrument on the first ratchet, holding it at the box lock, and lightly tapping the ratchet portion against a solid object. The instrument should remain closed. Instruments that spring open are faulty and require repair.

The edges of cutting instruments should be inspected for nicks, burrs, and broken tips. Dull, nicked, or dented cutting edges can cause trauma to tissue. Delicate knives, kera-tomes, needles, and rongeurs can be tested for burrs and rough edges by passing them through kidskin. The sensation of a slight drag is an indication of a burr or a rough edge. Scissors should be tested for cutting ability. Heavy scissors such as Mayo scissors should cut easily through four layers of gauze. The tips of Metzenbaum and other more delicate scissors should cut easily through two layers of gauze. One of the most frequent complaints regarding instruments is that scissors are not sharp. One solution is to create a preventive maintenance schedule for sharpening scissors before edges become dull and problematic. Scissors are most often damaged when used to cut material other than that for which they were designed. One example is the use of Metzenbaum scissors to cut suture material.

A needle holder must hold a needle securely without permitting it to slide or slip during suturing. Needle holders can be tested by grasping a needle in the jaws and locking on the second ratchet. If the needle can be turned easily by hand, the instrument should be tagged for repair or replacement. Inappropriate use is a common cause of damage. Needle holders should be selected to match needle size. Using a large needle with a delicate needle holder can spring the jaws of the holder and reduce its holding ability. If the needle holder has tungsten jaws, identified by gold handles, the jaws can be replaced when worn, thus extend-ing the overall life of the instrument.

Fiber optic light cords are checked by holding one end up to a light and looking through the other. Broken glass fibers will appear as black dots. The cord should be replaced if more than 20% of the area is affected.

Rigid endoscopes, once used only for diagnostic purposes in gynecology, are now used routinely in every surgical specialty. A rigid endoscope is one of the more expensive instru-ments used in the operating room. It is also easily damaged, and costly repair can be a frequent occurrence. Many operating rooms spend more annually for the repair of rigid endoscopes than for the purchase of new ones. Rigid endoscopes may be damaged in many ways: during surgery, such as during an arthroscopy procedure when the distal tip is nicked by an intraarticular shaver; by placement under heavy instruments that can cause a dent or bend in the shaft and subsequent damage to one or more of the glass rods inside the shaft; by sterilization using an incorrect cycle; and by careless handling of or dropping of the scope. Many companies offer scope repair services. It is important to ensure that only original parts are used during repair. Some third-party repair companies use replacement parts that can cause the endoscope to fail shortly after repair. The best assurance that the original parts will be used for repair is to use the original manufacturer’s repair services. Rigid endoscopes should be checked to ensure that the lens is not cloudy or otherwise occluded. Telescopes are checked by holding the scope up to the light and observing the lens image at the distal end. The image should be clear and easily visualized. The light source used in the operating room should not be used for this test because the high-powered light can cause eye damage.

A more precise test of optical resolution is to use a resolution chart. These can be obtained at low cost from an optical imaging company. A resolution chart consists of identical sets of increasingly small bars printed on a circular chart. A set is printed at five locations on the chart: in the center and at the circumference edges to the left, right, top, and bottom of the center. The bar sets are numbered. For example, a set of the largest bars is numbered 75 and a set of the smallest bars is labeled 450. The number represents the number of bars that can be seen if they were lined up across the image. The user should look through the scope and line up the chart so that it fills the field of view. The number in each of the five locations should be recorded. The lower the number is, the poorer the resolution. An optical resolu-tion chart is useful in determining the quality of repair. Measurements should be taken



when the scope is new (i.e., before the first use), between each use, and after each repair. If the resolution is lower after repair than before damage, the quality of the repair should be questioned. This is one way to hold repair companies accountable.

Each time they are processed, insulated instruments (i.e., laparoscopic and robotic) should be inspected for breaks in the insulation and for areas where the insulation has sepa-rated from the instrument shaft and appears loose. Both situations are indications that the insulation is not intact. Multiple studies have shown that insulation failures are not always detected with visual inspection.23 In addition to visual inspection, an insulation test device should be used to test insulation integrity. Reusable and single-use insulation testers are available. Testers are also available that may be used from the sterile field in the operating room allowing testing just prior to use rather than only prior to packaging. If either defect is observed, the instrument should be removed from service. Loose or nonintact insulation is a serious defect and can result in an unintended burn inside the patient at the point where the insulation is not intact. Insulated instruments are used in endoscopic surgery where the field of vision is limited by the scope’s distance from the operative site. The site of the burn may not be within the surgeon’s field of vision and can go unnoticed. The patient may even be discharged before a complication is noted. In the case of a burn that causes bowel per-foration, the patient can develop peritonitis, which in turn can lead to additional surgery, extended recovery, and even death caused by infection.

Microscopic instrumentation should be examined under a microscope to check for burrs or nicks on tips and to check alignment. Some of the teeth on microscopic forceps are very difficult to see with the naked eye, and forceps alignment should be inspected under a microscope.

PREPARATION FOR STERILIZATION OR DISINFECTION

Classification of Surgical Instruments

In 1972, Dr. E. Spaulding classified medical devices and instruments into three categories based on the risk of infection involved in their use. The categories are critical, semicritical, and noncritical. This classification was accepted by the Centers for Disease Control and Prevention and is used today to determine the processing strategy for surgical instruments. Critical devices are the devices that penetrate mucous membranes and enter normally sterile areas of the body. Examples of critical devices are instruments used in surgery, needles, and scalpels. Critical devices must be sterile. Semicritical devices contact, but do not penetrate, intact mucous membranes and must be high-level disinfected, at a minimum. Examples of semicritical devices are bronchoscopes, thermometers, and endotracheal tubes. Noncritical items contact intact skin and require low-level disinfection or cleaning with soap and water. Examples of noncritical devices are crutches and blood pressure cuffs.

Instruments classified as critical are packaged prior to sterilization. Packaging used for sterilizing instruments includes paper-plastic pouches, Tyvek/mylar, rigid sterilization con-tainers, polypropylene wrap, and nonwoven fabric. All packaging should be used in accor-dance with the manufacturer’s written IFUs.

Packaging

In preparation for sterilization, instruments should be carefully arranged in containers or baskets with wire mesh or perforated bottoms or in other trays that are compatible with the intended sterilization method and that may be wrapped in reusable or single-use wrap-ping material. Alternatively, instruments can be arranged within rigid instrument contain-ers made of plastic or metal that are compatible with the intended sterilization method. Rigid containers do not require outer wraps. They offer the advantage of greater protection to the instruments during handling and transport and can be stacked for efficient storage after sterilization. Containers should not be stacked within the sterilizer unless indicated in writing by the manufacturer of the container. Stacking can interfere with sterilization and drying. Personnel responsible for packaging should refer to the container manufacturer’s



written IFUs for instructions for cleaning, inspection, replacement of filters and valves, ster-ilization methodologies, and sterilization exposure times.

The combined weight of an instrument set and its containment device should be no more than 25 lb.4,24,25 Sets weighing more than 25 lb increase the risk of injury to workers who must lift them during processing and increase the risk that a set will retain moisture after sterilization. Whenever practical, contents of instrument sets should be standardized. Standardization reduces the need for inventory, facilitates instrument replacement, and makes it easier to identify and locate sets needed for a surgical procedure.

Placement

Instruments should be placed so that joints and hinges are in the open position. Instru-ments with multiple parts should be disassembled. Retractors and other heavy instruments should be placed on the bottom or at one end of the basket, with lighter instruments strung open and placed alongside or on top. Sharp edges should be protected. Delicate, fragile, and lensed instruments should be protected from collision with other instruments in the set. Fingered mats, foam pockets, scope holders, and tip protectors are examples of items that protect instruments. Some instrument sets are supplied in specialized containers, either to secure and protect the instruments, as in the case of fine microsurgical instruments, or to facilitate their location within the set, as with some orthopedic joint replacement sets.

Plastic/paper pouches should not be placed within sets. Instruments should not be dou-ble pouched unless the pouch manufacturer has validated the plastic pouch for this use. Loading and operating any sterilizer should be carried out in accordance with the sterilizer manufacturer’s written instructions.

Sterilization

Steam sterilization is the most commonly used method for sterilizing instruments. Instru-ments that can tolerate repeated exposure to the moisture and high temperature of steam should be steam sterilized. Steam sterilization is an economical and reliable method avail-able in almost every health care facility. Items sensitive to heat and moisture are sterilized using alternative methods, such as ethylene oxide and hydrogen peroxide gas plasma. Cut-ting instruments and other instruments with sharp edges, although they can be processed in steam, will hold their edges longer if sterilized in low-temperature sterilization systems.

Instruments, pans, containers, and any packaging material, as well as any padding or protective material used in the pan, must be compatible with the sterilization method. For example, placing a cotton surgical towel in the bottom of a pan or container is use-ful in steam sterilization to absorb condensate and facilitate drying. However, cotton or other cellulose-containing materials cannot be used in some low-temperature sterilization technologies.

Although one sterilization cycle may be appropriate for the majority of instruments, there are instrument sets that require extended exposure time. Sterilization cycles should be selected according to the device, the packaging, and the sterilizer manufacturer’s IFUs. Any discrepancy between the IFUs should be resolved prior to sterilization. In the absence of resolution, product testing may be appropriate. Essentially, product testing consists of plac-ing multiple biological and chemical indicators in the areas within the instrument set that are considered to be the least accessible to the sterilant, exposing the set to the sterilization process, and evaluating the results of the chemical and biological monitors. If monitoring results are negative, the instruments may be washed, packaged in the same manner as they were packaged for product testing, sterilized, and entered into service. Personnel attempt-ing to perform product testing should refer to the AAMI publication ST79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities,4 for a much greater detailed explanation of this process.

Because prions, the causative agent of Creutzfeldt-Jakob disease, are resistant to routine sterilization cycles, instruments known or suspected to have contacted prion- contaminated tissue require special procedures and extended sterilization cycles. Extended cycles



recommended by the Society for Health care Epidemiology of America for prion-contam-inated instruments include: • Autoclave (sterilize) at 134°C for 18 minutes in a prevacuum sterilizer. • Autoclave at 132°C for 1 hour in a gravity displacement sterilizer. • Immerse in 1 N NaOH (1 N NaOH is a solution of 40 g NaOH in 1 L water) for

1 hour; remove and rinse in water, then transfer to an open pan and autoclave at 121°C in a gravity displacement sterilizer or 134°C in a prevacuum sterilizer for 1 hour.21

Instruments should be dry prior to sterilization. Processing wet instruments by steam sterilization may cause difficulties in obtaining a dry set. Sterile items that are not com-pletely dry at the end of the cycle are considered contaminated because the moisture inside the package can breach the sterile barrier and create a pathway for microorganisms to enter the package.

Lumens should not be moistened prior to sterilization unless the device manufacturer specifies this in the IFUs.

Sterilizing wet instruments in ethylene oxide can lead to the formation of ethylene gly-col (antifreeze), a by-product of water and ethylene oxide. This chemical by-product is not removed during the aeration process and can harm patients. Wet instruments processed in hydrogen peroxide gas plasma or vapor will cause the sterilization cycle to cancel.

Immediate Use Steam Sterilization

IUSS, formerly known as flash sterilization, is sterilization that does not include a dry time or may include a very minimal dry time. Immediate use is defined as the shortest possible time between the removal of a sterilized item from the sterilizer and its aseptic transfer to the sterile field. Items subject to IUSS may not be stored for future use nor held from one case to another.26 IUSS cycles do not include a dry time or may include a very short dry period. Immediate use is not to be used for purposes of convenience or as a substitute for sufficient inventory.6 Previously, IUSS was carried out in an open pan and cleaning was often done in an area not specifically dedicated for decontamination under less than ideal conditions. Current guidelines call for cleaning to be carried out in a dedicated decontamination area, that the same critical reprocessing steps (such as cleaning, decontaminating, and transport-ing sterilized items) must be followed, and that items are sterilized in a container.26

Disinfection

Common liquid chemicals used to disinfect surgical instruments include glutaraldehyde, hydrogen peroxide, peracetic acid, and orthophthalaldehyde. Each has unique characteristics and should be chosen in accordance with department needs and instrument compatibility.

Instruments to be disinfected should be cleaned and dried before placement into the disinfectant. Moisture from instruments that are not dry can dilute the disinfectant, causing it to lose its effectiveness. The disinfectant solution should be tested for minimum effec-tive concentration (MEC) according to the manufacturer’s instructions. Testing should be performed before each use. If the MEC falls below the accepted level as indicated by the test strip, the solution should be discarded. The immersion time required for high-level disinfection is indicated on the product’s label and should be strictly adhered to. Follow-ing disinfection, items should be rinsed with copious amounts of water according to the manufacturer’s instructions. Disinfected instruments should be allowed to dry and should be stored in a clean, dry area in a manner that protects the device from contamination. Personnel responsible for carrying out high-level disinfection should refer to the AORN Recommended Practices for High-Level Disinfection.27

IDENTIFICATION SYSTEMSInstrument identification and related instrument-tracking systems are becoming com-monplace in health care facilities. Instrument identification is used for inventory control,



reordering, and as a deterrent to theft. Color coding and etching are two methods of coding. Color coding may be adapted for a specific instrument set, specialty, department, or sur-geon. Most systems use a hard color coating that is permanently fused to the instrument’s ring handle. For example, a set with green ring handles may indicate that the set belongs within a specific specialty. If colored tape is used to mark instruments, it is important to follow the manufacturer’s instructions for proper tape application and to obtain written verification of tape compatibility with the intended sterilization method. It is important to inspect the condition of the tape before packaging the instrument. Tapes may peel or flake over time and harbor microorganisms. Loose, cracked, or flaking tape must be removed, all adhesive removed, and new tape applied. For these reasons, taping is not a preferred method of marking instruments.

Another method of instrument identification is etching or engraving the shaft with the desired information. Vibrating mechanical engravers that scratch the surface should not be used because they break down the rust-resistant protective coating of the instrument, potentially allowing corrosion to begin. When a mechanical engraver is used in the area of the box lock, minute fault lines can be created and can result in premature breakage of the lock. Newer acid or laser etching processes are preferred because they do not harm the instruments.

It is important to check with the manufacturer of the instrument to ensure that the instrument can withstand the desired coding system. Many instrument companies offer engraving at the time of purchase.

CLASSIFICATION OF INSTRUMENTSThe three broad categories of instruments are handheld, nonpowered surgical instru-ments; powered tools or devices; and endoscopic equipment and instrumentation. Handheld, nonpowered instruments are used for cutting, clamping, grasping, retracting, chiseling, and manipulating tissue and bone. Powered instruments are used for drill-ing, sawing, or cutting bone and cauterizing tissue. Drills, oscillating and sagittal saws, and wire drivers are examples of powered devices. They may be powered by electricity, compressed gas, or battery. Endoscopic equipment and instruments are used to perform minimally invasive surgery and to examine internal organs through very small incisions. Examples of endoscopic instruments are rigid and flexible endoscopes along with cam-eras and light cords.

Interventional procedures under advanced imaging systems are increasingly being per-formed in the operating room. Many of the devices that are used in these procedures are single-use disposable and outside the scope of this chapter. These devices should not be reprocessed within health care facilities.

The following information describes the general classifications of handheld, nonpow-ered instruments. Descriptions and examples are included. The names of the instruments may vary with the manufacturer, the geographic location within the country, the surgeon’s preference, and the health care facility in which they are used. The different instrument names are used interchangeably by surgeons and staff. In this textbook, the names given for instruments that appear in the photographs are the manufacturer’s names.

Handheld, Nonpowered General Surgery Instruments

ClampsHemostats are used to control the flow of blood. The jaws of a hemostat contain horizontal serrations designed to close the severed edge of a blood vessel, allowing for minimal tissue damage. There are several sizes of hemostats: for example, mosquito, Crile, Halsted, and Mayo-Péan. The larger hemostats are also used to clamp tissue.

Occluding clamps are used to clamp bowel or vessels that will be reanastomosed. The jaws of occluding clamps used on bowel contain vertical serrations. Occluding clamps used on blood vessels contain multiple longitudinal rows of finely meshed teeth. Both are designed to prevent leakage while minimizing trauma to the tissue.



1-1 Components of a typical clamping instrument.

Ratchet

Box Lock

Jaws

Tip

Shank

RingHandles

1-2 Scissors. Left to right: Mayo dis-secting scissors, straight; Metzen-baum dissecting scissors; iris scissors, straight; and Westcott tenotomy scissors, straight.

Cutting InstrumentsKnife handles are usually straight handles that hold knife blades of various shapes that are used for incision and dissection. Examples of knife handles are Bard-Parker and Beaver. Other knives, such as Fisher tonsil, Smillie cartilage, and myringotomy knives, incorporate the blade into the structure of the handle.

Scissors exist in many different forms; the two basic types are dissection and suture scissors. Dissection scissors are manufactured according to their intended purpose. Small,



delicate scissors, such as iris or Westcott scissors, are used in ophthalmic, plastic, and microscopic surgery. Metzenbaum scissors are used in intraabdominal and other general surgeries. More sturdy scissors such as Mayo scissors are appropriate for cutting fascia or sutures. Metzenbaum and Mayo scissors are found in most general surgery instrument sets. Curvature, weight, size, and flexibility vary according to intended use.

RetractorsRetractors are used to hold back the edges of a wound to permit visualization of the opera-tive site. A handheld retractor consists of a shaft to hold and an end piece for retracting. The end piece may be a hook, a blade, or a rake. Examples of handheld retractors are skin hook, Senn, Army Navy, Parker, and rake. Self-retaining retractors do not require that someone hold them in place. Some self-retaining retractors consist of two blades that are held apart by a ratchet, such as the weitlaner, Jansen, and Gelpi. Larger self-retaining retractors consist of a series of blades that attach to bars that are held in place by a screw or similar device. The bars that hold the blades may be attached to the operating table itself. Examples of larger self-retaining retractors are the O’Sullivan-O’Connor, Thompson, and Balfour.

1-3 Handheld retractors. Top to bottom: Skin hook and double-ended Richardson retractor.

1-4 Self-retaining retractors. Top to bottom: Weitlaner retractor and unassembled O’Sullivan-O’Connor retractor.



Grasping and Holding InstrumentsForceps, also referred to as pickups, are shaped like tweezers and are used to grasp and hold tissue. The tips of forceps vary according to their intended uses. The tips may be smooth or serrated or have single or multiple teeth that interlock.

1-5 Grasping and holding instruments. Top to bottom, left to right: Adson tissue forceps without teeth; Ferris Smith tissue forceps (1 × 2); tissue forceps with teeth (1 × 2). Tips on the right, top to bottom: Fer-ris Smith tissue forceps (1 × 2); tissue forceps with teeth (1 × 2); and Adson tissue forceps without teeth.

Examples of common clamp-shaped grasping instruments include the Ochsner, Kocher, Allis, and Babcock. The Ochsner and Kocher forceps have a heavy tooth at the jaw tip and are used to grasp and hold tissue without concern for trauma. The Allis clamp has multiple noncrushing teeth and is used to grasp tissue without crushing. The Babcock clamp tissue forceps has a curved, fenestrated tip without teeth. It is useful for grasping structures such as the fallopian tube or ureter.

A

B

A

B

1-6 Grasping instruments. Top to bottom: A, Ochsner forceps and tip; B, Allis tissue forceps and tip.



A needle holder is a grasping instrument designed to secure a suture needle in its jaws. A needle holder may be a clamp type with a ratchet handle or may be a spring-action type. Size and jaw surface vary and are selected with regard to the procedure and the size of the needle being used.

A towel clamp is a holding instrument that is used to secure towels and drapes in place. The tip may be blunt or pointed and designed to penetrate.

A sponge holder is a clamplike instrument with rounded jaws that is used to hold a folded 4 × 4 sponge.

1-7 Grasping instruments. Top to bottom: Foerster sponge forceps with sponge in the jaws, and Backhaus towel forceps.

1-8 Accessory instruments. Top to bottom: Frazier suction tube with stylet below; Poole abdominal suction tube with shield below; and Yankauer suc-tion tube with tip off.

Accessory InstrumentsSuction instruments/tubes vary in length, curvature, and lumen diameter and are selected according to the type of surgery and the amount and depth of fluid to be suctioned. Minor, delicate surgery and surgery on small vessels require small-diameter suction. Two examples of small-diameter suction tubes are Frazier and antrum. Abdominal, deep-joint, and other general surgeries usually require a Yankauer or Poole suction tube. Poole suction tubes are used in areas where the fluid is deep. Yankauer suction tubes are curved, and the suction opening is on the tip. Poole suction tubes are straight and have multiple holes along the length of the shaft.



REPAIR CONSIDERATIONSPreventive maintenance coupled with careful handling and proper use are the best ways to prevent deterioration and equipment failure and to extend the lives of instruments. Regard-less of the care in handling and use, some instruments will need replacement or repair. The facility may choose to send the item to the original manufacturer or an outside contractor or may utilize the services of an independent service manufacturer that repairs instruments and performs preventive maintenance on site. When selecting a repair facility or service, the following should be considered: • Company reputation • References from other users • Liability and shipping insurance • Cost • Response time • Turnaround time • Loaner program • Repair exchanges: Will your original equipment be returned? • Quality measures: Is quality measured according to ISO 9000? • Replacement parts: Are original manufacturer parts provided? • On-site inspection visits: Are they unrestricted?

INSTRUMENT TRACKINGSeveral companies offer instrument-tracking software that allows the facility to monitor the productivity of processing personnel and track the use, inventory, and location of surgical instrument sets. These programs make it possible to know where any set is within the sys-tem at any time. Instruments can be tracked by serial number, where appropriate, according to the patient, surgeon, and procedure. This information would be particularly helpful, for example, in tracking sets used in neurosurgery when the patient is known, or suspected, to have Creutzfeldt-Jakob disease and the set must be quarantined until a definitive diagnosis is made. Bar coding can be used to identify whether a set is complete and what needs to be ordered when a replacement is necessary. Replacement orders can be made via an auto-mated procurement system that interfaces with the tracking program. Data from a track-ing system can be used to identify the costs of acquisition and repair. Information about repair rates, reasons for repair, and costs is useful when determining where to focus quality-improvement efforts. Tracking systems also facilitate the optimization of instrument-set inventory based on actual use.

SUMMARYSurgical instruments are a major financial investment in every surgical facility, and pro-cesses should be in place to protect this investment. The life of a surgical instrument is dependent upon the way it is used and the care it receives. It is the responsibility of the surgical team and the personnel who process the instruments to handle them carefully, use them for the purpose for which they were designed, and process and maintain them appro-priately. The extra time it takes to properly care for instruments is well worth the investment and is always in the patients’ best interests.

REFERENCES 1. Brennan T, et al.: Incidence of adverse events and negligence in hospitalized patients — results of

the Harvard Medical Practice Study 1, N Engl J Med I, Feb 9, 1991. 2. Medical Errors: A report by the staff of US Senator Barbara Boxer. 2014, http://www.boxer.senate

.gov/en/press/releases/042514.cfm. Accessed May 8, 2014. 3. Agency for Healthcare Research and Quality (AHRQ): Never events, http://psnet.ahrq.gov/prim

er.aspx?primerID=3. Accessed May 8, 2014.


http://www.boxer.senate.gov/en/press/releases/042514.cfm

http://www.boxer.senate.gov/en/press/releases/042514.cfm

http://psnet.ahrq.gov/primer.aspx?primerID=3

http://psnet.ahrq.gov/primer.aspx?primerID=3


4. AAMI/ANSI ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013: Comprehensive guide to steam sterilization and sterility assurance in health care facilities, Arlington, Va, 2013, Associa-tion for the Advancement of Medical Instrumentation.

5. AORN: Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN.

6. Rutala WA, Weber DJ, and the Healthcare Infection Control Committee Practices Advisory Com-mittee (HICPAC): Guideline for disinfection and sterilization in healthcare facilities, http://www. cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf, 2008. Accessed May 7, 2014.

7. Centers for Medicare and Medicaid Services (CMS): Flash sterilization clarification-FY 2010 Am-bulatory Surgical Center (ASC) surveys. https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf US. Accessed May 19, 2014.

8. Department of Labor: Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens, CFR 29:1030, 1910, https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed May 10, 2014.

9. Holland SP et al: Update on toxic anterior segment syndrome, http://unboundmedicine.com/ medline/. Accessed May 8, 2014.

10. Mathys KC, et al.: Identification of unknown intraocular material, J Cataract Refract Surg 34: 465–469, 2008.

11. Maier P, et al.: Toxic anterior segment syndrome following penetrating keratoplasty, Arch Oph-thalmol 126(12):1677–1681, 2008.

12. Hellinger WC, et al.: Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave moisture, Infect Control Hosp Epidemiol 27(3):294–298, 2006.

13. American Society of Cataract and Refractive Surgery and American Society of Ophthalmic Reg-istered Nurses Recommended Practices for Cleaning and Sterilizing Intraocular Surgical Instru-ments: Special report, J Cataract Refract Surg 32(2):22–28, 2007.

14. Ofstead CL, et al.: Re-evaluating endoscopy-associated infection risk estimates and their implica-tions, AJIC: Am J Infect Control 41(8):734–736, 2013.

15. Ofstead CL, et al.: Endoscope reprocessing methods: a prospective study on the impact of human factors and automation, Gastroenterol Nurs 33:304–311, 2010.

16. Schaefer MK, et al.: Infection control assessment of ambulatory surgical centers, JAMA 303: 2273–2279, 2010.

17. Langlay AM, et al.: Reported gastrointestinal endoscope reprocessing lapses: the tip of the ice-berg, AJIC: Am J Infect Control 41(8):1188–1194, 2013.

18. Multisociety Guideline on Reprocessing Flexible Gastrointestinal Endoscopes 2011. Ameri-can Society for Gastrointestinal Surgery, https://www.google.com/search?newwindow=1&site=&source=hp&q=multi+society+guideline+for+reprocessing+flexible&oq=Multisociety&gs_l=hp.1.0.0i10i30l2.1644.4278.0.5939.13.12.0.1.1.0.259.1845.1j10j1.12.0....0...1c.1.43.hp..2.11.1456.0.cj_1kvZMURc. Accessed May 9, 2014.

19. ASGE and SHEA: Updated Announcement, http://www.shea-online.org/View/ArticleId/82/ASGE- and-SHEA-Issue-Updated-Multisociety-Guideline-on-Reprocessing-Flexible-Gastrointestinal-Endosco.aspx. Accessed May 9, 2014.

20. Moses L, et al.: Prevention of flexible bronchoscopy-associated infection: consensus statement, Chest 128(3):1742–1755, 2005, http://dx.doi.org/10.1378/chest.128.3.1742.

21. Rutala W, Weber D: SHEA guideline: guideline for disinfection and sterilization of prion- contaminated medical instruments, Infect Control Hosp Epidemiol 31(2):107–117, Feb 2010.

22. McDonnell G, et al.: Cleaning, disinfection and sterilization of surface prion contamination, J Hosp Infect 85(4):268–273, 2013.

23. Montero PN, et al.: Insulation failure in laparoscopic instruments, Surg Endosc 24(2):462–465, 2010.

24. AORN: Recommended Practices for Selection and Use of Packaging Systems. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN.

25. AAMI/ANSI ST77: Containment Devices for Reusable Medical Device Sterilization, Arlington, Va, 2013, Association for the Advancement of Medical Instrumentation.

26. AAMI: Immediate-Use Steam Sterilization, https://www.aami.org/publications/standards/ST79_Immediate_Use_Statement.pdf. Accessed May 10, 2014.

27. AORN: Recommended Practices for High-Level Disinfection. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN.


http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf

http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and

https://www.cms.gov/Medicare/Provider-Enrollment-and

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051%26p_table=STANDARDS

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051%26p_table=STANDARDS

http://unboundmedicine.com/medline/

http://unboundmedicine.com/medline/

https://www.google.com/search?newwindow=1%26site=%26source=hp%26q=multi+society+guideline+for+reprocessing+flexible%26oq=Multisociety%26gs_l=hp.1.0.0i10i30l2



http://www.shea-online.org/View/ArticleId/82/ASGE-and-SHEA-Issue-Updated-Multisociety-Guideline-on-Reprocessing-Flexible-Gastrointestinal-Endosco.aspx



http://dx.doi.org/10.1378/chest.128.3.1742


Sterilization Container Systems*

*This chapter was written by Marcia Frieze, CEO of Case Medical Inc., South Hackensack, New Jersey.

INTRODUCTIONSterilization packaging systems are required to secure instrument sets, provide for sterilant penetration of contents, and withstand multiple handling events during a prolonged period of storage and handling. There are two types of containment devices: rigid reusable sealed containers with filters and valve systems and perforated case trays, which are designed to be wrapped. Rigid reusable container systems provide an efficient, cost-effective way to package and protect surgical devices in order to sterilize the contents, maintain the sterility of the contents until the package is opened at point of use, and to allow for the removal of contents without contamination; some containment devices can be designed to aid in the efficiency of the surgical procedure. They are sealed systems and serve as an alternative to disposable and reusable sterilization wrap. The rigid sides of a sterilization container pro-tect fragile devices within and eliminate the tears associated with sterilization wrap. Some containers are cleared for steam sterilization only, others for low-temperature sterilization. Only one is universal and corrosion resistant, cleared by the FDA for all current sterilization methods from steam to various low-temperature methods.

Rigid container systems have been used in the United States for over three decades with the preference for sealed containers instead of wrapped sets increasing in recent years. The rigid sterilization container systems are intended to be used as packaging for medical devices before, during, and after sterilization. Sterilization is required to secure instrument sets, provide for sterilant penetration of contents, and withstand multiple handling events during a prolonged period of storage and handling.

GENERAL DESCRIPTIONContainment devices for reusable medical device sterilization include perforated trays, case trays with a lid and base, and sealed container systems. Containers are most typi-cally constructed from anodized aluminum and have a boxlike structure with removable lids, base, filter mechanism, and gasket to secure a tight seal. Sealed containers include tamper-proof locking mechanisms, a location for labeling set name and external indica-tor/load card, and handles for ease of transport. All sterilization containers have a filter mechanism designed to permit the sterilant to enter and exit as well as to act as a microbial barrier. Filters may be disposable and manufactured from cellulosic, polypropylene, or synthetic materials. Most sealed container systems are designed for terminal sterilization and extended storage, utilizing a disposable filter secured by a filter retention plate with a gasket. Some containers have a filter-less system equipped with a pressure-sensitive or thermostatic valve that opens and closes within the sterilizer. Such devices are cleared for prevacuum steam sterilization only, and a few may be used for sealed flash sterilization, including gravity displacement steam.

All sealed container systems require an inner basket or tray to secure the contents of the load. The basket may contain accessories including instrument brackets, partitions, and posts to secure, organize, and protect contents. Some may include stackable trays to

CHAPTER 2





25CHAPTER 2 Sterilization Container Systems

separate contents into levels and protect contents from damage during transport. Peel pouches may not be used within sealed or wrapped container systems as they are not able to stand on their sides for sterilization. Small highly perforated trays or insert boxes to ensure adequate air removal are recommended in lieu of pouches. All perforated trays and case trays may either be wrapped with medical grade wrappers or placed within a sealed container cleared for the intended purpose. Although the wrapper must be both porous for sterilant penetration and intact, it must also be free of rips and tears. The perforated basket should be designed for decontamination, cleaning, and rinsing of contents by means of manual or automated methods.

2-1 SteriTite Container group with MediTray basket inserts. (Courtesy Case Medical Inc., South Hackensack, N.J.)

2-2 SteriTite Container. (Courtesy Case Medical Inc., South Hackensack, N.J.)



CARE AND HANDLINGRigid sterilization systems should be cleaned and inspected after each use. The disposable filter should be discarded and the components disassembled for cleaning, including remov-ing the lid from the base and removing the filter retention plate and placing it in a perforated basket. According to AAMI ST79 guidelines, “For all reusable devices, the first and most important step in the decontamination of medical devices is thorough rinsing and cleaning. Cleaning primarily removes rather than kills microorganisms.”1 Valve-type closures must be decontaminated following the manufacturer’s written instructions. Particular attention should be given to the type of detergent used because alkaline cleaners and those followed by acid neutralizers can damage the passive layer of sealed systems, creating the oppor-tunity for corrosion to develop. Validated, pH-neutral cleaners including multienzymatic detergents can be used for both manual and automated cleaning of containment devices. If cleaned manually, a dry, lint-free cloth should be used to wipe off additional moisture. If placed in a cart washer for automated cleaning, ensure that all components are disas-sembled and placed at an angle to prevent water collection. A chemical disinfectant wipe

2-3 Small, perforated metal case basket inserts.

2-4 SteriTite container with basket designed for Solera instrumentation. (Courtesy Case Medical Inc., South Hackensack, N.J., and Medtronic, Louisville, Colo.)



should never be used in lieu of a thorough cleaning and rinsing of the container after each use. Inspection procedures should include verification that gaskets are intact and latches are properly functioning. If the hardware is riveted to the container, such devices may become compromised over time as rivets loosen and create pathways for entry of microorganisms.

Aseptic presentation is important with all sterilization packaging systems. To properly remove the inner basket or tray from the container, the sides of the basket must not touch the edge of the container or else the contents will be considered contaminated. Neither the exterior of the container nor the outer wrapping of wrapped trays is sterile. Proper removal and handling at point of use is required. All containers sterilized in an outside contract facility should be double wrapped in plastic bags during transport.

Furthermore, the contents of the container system must be dry. Wet packs are consid-ered nonsterile. The contents of the containment device, if wet, must be reprocessed. The only exception to this is for flashed items that are properly cleaned, decontaminated, and sterilized for immediate use only. To manage wet packs, be sure that the contents are dry prior to sterilization. Preheat the load to reduce the formation of condensation during the cycle, evaluate the weight and density of the set, and review the manufacturer’s recom-mendations for processing, including proper cool-down prior to transport to sterile stor-age. Plastic containers may require additional drying time as they do not have the thermal conductivity properties of aluminum and other metals. Metal materials used to construct containment devices must be corrosion resistant or treated to improve their corrosion resis-tance. These materials must not affect the biocompatibility of the device.

STORAGE AND STERILITY MAINTENANCESterilized items should be stored in well-ventilated, limited-access areas with controlled temperature and humidity, separated from cleaned items. Sterilized items should not be stored near sinks or any water source from which they can become wet. Although sealed containers may be stacked on top of one another for storage and transport, wrapped pack-ages should not be stacked to avoid tears, crushing, bending, or cramming by other pack-ages. Perforated or wire shelving is commonly used for storage of containment systems to avoid dust accumulation. Wire shelving can contribute to torn wrappers when sterile pack-ages are removed from the shelf. The addition of pull out, perforated shelves can address the environmental as well as ergonomic concerns when removing heavy items from carts and shelving.

The shelf life of containment devices may be determined by time or conditions during storage and handling. Event-related sterility maintenance means that if a package is not contaminated during storage and handling, it will remain sterile indefinitely. Shelf life is related to an event that can occur when sterilized items can be compromised or contami-nated. Proper packaging, storage, handling, and environmental conditions can affect how

2-5 Case Solutions pH neutral cleaning products. (Courtesy Case Medical, Inc., South Hackensack, N.J.)



long a product will remain sterile. Most facilities have eliminated time dating with expira-tion dates and have gone to an event-related sterility maintenance program. Items pack-aged in a sealed container have a longer shelf life than wrapped items. Sealed containers are not as easily compromised by environmental or handling issues, nor is there an opportu-nity for tears in the wrapper.

INSTRUMENT PLACEMENTThere are specific guidelines for the placement and organization of surgical instrumen-tation within sealed containers. Sealed containers must utilize inserts, such as perfo-rated or mesh instrument baskets or trays to secure the contents. Some sealed container systems have been cleared for stacking of multiple levels of inserts to distribute the load. Selecting the correct size container is dependent on the length, height, and volume of the instrumentation within the set to be containerized. AAMI ST79 states, “If a rigid ster-ilization container is used, the basket(s) placed in the container system should be large enough to allow the metal mass of instruments and devices to be distributed equally in the basket(s). . . Instruments should be positioned to allow the sterilant to come into contact with all surfaces. All jointed instruments should be in the open or unlocked position.” Brackets, posts, partitions, and stringers may be used to secure instruments in place or in an open position. Another important guideline is placing heavy instru-ments below lighter, delicate instrumentation to avoid damage. The user must refer to the medical device manufacturer’s written instructions regarding set preparation and assembly.

Weight and density of the set are integral components to consider during the configu-ration of the instrument set. If a set is too densely packed or heavy, sterilization efficacy, degree of dryness, and proper body mechanics may be adversely affected. ST79 recom-mends that, “The weight of the instrument set should be based on whether personnel can use proper body mechanics in carrying the set, on the design and density of indi-vidual instruments comprising the set, on the recommendations of the medical device manufacturer and on the distribution of mass in the set and sterilizer load.” In some cases where the set is too heavy and exceeds the AAMI and AORN recommended total weight of 25 lb, the set should be distributed in more than one sealed container. In other cases, a dense set can be stacked in multiple baskets within the sealed container for better orga-nization and efficiency. The heavier sets should be placed below the delicate instrumenta-tion. Sets should be organized to correlate with the procedure. Items used first should be placed on top or easily accessible.

2-6 Cranial tray with instrumentation. (Courtesy Case Medical Inc., South Hackensack,N.J.)



Graphics trays or loaners are offered for specialty sets, primarily for orthopedic pro-cedures. Some containment devices that are designed for specific instrument sets may include graphics to locate and identify placement of devices within the tray system. The specific information may be silk screened, laser etched, or stamped into the tray base. Custom brackets or inserts included in the tray provide instrument protection and a spe-cific location for a device to be placed. In the past, such graphic trays were designed to be wrapped, but recently a number of sets have been placed alternatively in rigid reus-able, sealed containers. Some sealed containers meet the size requirements of the German Institute for Standardization (DIN) and have proven to provide seamless integration from wrap to containerization.

SELECTION AND SPECIAL CONSIDERATIONSWhen selecting a container system, it is important to identify the needs of the facility and to assess what the container system is capable of and for which sterilizers it is compatible. Not all container systems are compatible with low-temperature sterilization or with lumened devices. For example, a container cleared for steam sterilization may not be suitable for use in a different modality. If not provided in the labeling or instructions for use (IFUs), the user should consult the container system manufacturer for testing and validation confirma-tion of the container system for a specific sterilization method.

There are numerous factors to consider when selecting a container system. Among these are options such as container size, estimated life of the container system, asep-tic presentation of contents, protective accessories for tray customization, ease of use, maximum load, and cost effectiveness. It is important to review any special instructions for decontamination and handling. Although manufacturers are required to validate for efficacy and safety, verification of the packaging within the hospital system is recom-mended in the guidelines. When verifying containers at health care facilities, biological indicators and integrators (process indicators) must be placed within the containers in areas that will provide the greatest challenge. This may include areas such as the opposing corners of the instrument basket and the underside of the lid away from the perforated area (vent).

MANUFACTURERS’ INSTRUCTIONS FOR USEThe written recommendations of the device manufacturer should always be followed. The device manufacturer is responsible for ensuring that the device can be effectively cleaned and sterilized. It is important that all rigid containers be completely disassembled, washed,

2-7 Spinal tray with instrumentation. (Courtesy Case Medical Inc., South Hackensack, N.J.)



and dried after each use. Most sterilization container systems are manufactured from anod-ized aluminum alloy, which requires cleaning with a pH neutral detergent to maintain integrity. Thorough rinsing is essential for the removal of all soil and for removal of cleaning agents. A truly dry container and contents are critical for sterilization. Some low-tempera-ture steri lization systems will abort if the container and its contents are not properly dried. Moisture within containers can create wet packs.

An extended reprocessing time may be required when container systems are processed in gravity displacement steam. In addition, the materials of construction and the design of the containment device itself may increase either processing time or drying time. Internal chemical indicators or integrators should be placed in the corner of each inner basket for routine monitoring. Biological indicators should be utilized for verification of an instru-ment set and for weekly or daily monitoring of the load. In addition, an external indicator and tamper-evident seal, which serves as a security lock, should be assembled to the con-tainer prior to sterilization. Such indicators demonstrate that the set has been processed when a color change is confirmed.

Containment devices must be placed flat on the sterilizer cart. If wrapped items are included in the sterilizer load, they must be placed on the shelf above the containment device to avoid moisture in the load. To minimize the potential for condensate forma-tion within the sealed container system, a gradual cool down is required. The door of the steri lizer may be cracked after processing for a minimum of 10 to 15 minutes to facilitate a gradual cool down and reduce condensate formation. Wet packs are unac-ceptable for terminal sterilization and storage. Once removed from the sterilizer, the containers should be placed on a rack in a draft-free area until cool enough for han-dling and then placed in storage or transported to point of use. The only exception is when flash sterilization or immediate use sterilization is required in an emergency. Moisture will most likely occur when items are processed for immediate use without proper drying.

REGULATORY REQUIREMENTSAll containment devices, whether sealed containers or wrapped trays, are considered Class II medical devices and must be cleared by the FDA for their intended use. According to the Association of periOperative Registered Nurses (AORN) recommended practices,2 “Pack-aging systems should be evaluated before purchase and use to ensure that items to be pack-aged can be sterilized by the specific sterilizers and/or sterilization methods to be used and should be compatible with the specific sterilization process for which it is designed.” AAMI ST773 provides guidelines for manufacturers of containment devices for reusable medical devices. Many international standards have been adopted into U.S. documents with the goal of providing minimal labeling, safety, performance, and validation requirements. Manufac-turers are required to validate their containment devices and provide the data to the FDA for clearance. Efficacy testing, material compatibility, sterility maintenance, reuse testing, and whole package microbial testing are examples of the various studies to be presented to the FDA and required before containment devices may be sold to health care facilities. However, health care personnel bear the ultimate responsibility for ensuring that the con-tainment device or sterilization packaging is compatible with, or can be effectively sterilized within, the health care facility.

REFERENCES 1. ANSI/AAMI ST79: 2008/2010 & A12010: Comprehensive Guide to Steam Sterilization and Steril-

ity Assurance in Health Care Facilities, Arlington, Va, 2010, Association for the Advancement of Medical Instrumentation.

2. AORN Recommended Practice for Selection and Use of Packaging Systems for Sterilization, Denver, Colo, 2010, AORN.

3. ANSI/AAMI ST77: 2006/2013: Containment Devices for Reusable Medical Device Serilization, Arlington, Va, 2013, Association for the Advancement of Medical Instrumentation.


31CHAPTER 3 Operating Room Suite/Basic Laparotomy

Operating Room Suite/Basic Laparotomy

CHAPTER 3



UNIT TWO: GENERAL SURGERY

3-1 Operating room equipment: 1, ring stand; 2, back table; 3, Mayo stand; 4, surgical step lifts; 5, sponge bucket; 6, sponge count bags; 7, garbage; 8, timeout briefing/ debriefing poster; 9, nurses’ station/desk; 10, integration/video equipment (i.e., printer); 11, stop/start clock; 12, nitrogen regulator.

4 5

6 3

12

11

1

7

2

89

10

3-2 Basic back table setup.



32 UNIT 2 General Surgery

A laparotomy is an incision into the abdominal cavity for the purpose of exploration or the performance of an operative procedure on organs or structures within.

To start the procedure, a dissection set is placed on the Mayo stand. Possible instruments needed include: 1. A Bard-Parker scalpel handle #4 with a #20 blade, used for the skin incision. 2. A Bard-Parker scalpel handle #3 with a #10 blade, used for the abdominal layers. 3. 2 Ferris Smith tissue forceps, used for grasping the abdominal layers. 4. A curved Mayo dissecting scissors, used for the dissection. 5. A straight Mayo dissecting scissors, used for cutting the suture. 6. 6 straight Crile hemostatic forceps, used for clamping the bleeders. 7. 6 curved Crile hemostatic forceps, used for clamping bleeders in the deeper abdomen. 8. 2 Army Navy retractors, used for retracting the abdominal layers. 9. 2 small Richardson retractors, used for retracting the abdominal layers.

During the exploration, longer and heavier instruments may be needed. Add the follow-ing instruments to the Mayo stand: 1. A Bard-Parker scalpel handle #7 with a #10 blade, used for the deeper dissection. 2. A Bard-Parker scalpel handle long #3 with a #10 blade, used for the deeper dissection. 3. A Mayo-Péan hemostatic forceps, used for clamping the deeper bleeders. 4. A Babcock clamp tissue forceps, used for “running the bowel” and retracting structures

without injury to tissue. 5. A tonsil hemostatic forceps, used for clamping the deeper bleeders.

If heavy graspers are needed, add the following instruments: Kocher clamps, regular and long, used for grasping structures that may be removed; Ochsner hemostatic forceps; and Allis tissue forceps, regular and long.

For deeper retraction, add the following instruments: a large Richardson retractor; medium and wide Deaver retractors; Ochsner malleable retractors (ribbons); and a self-retaining retractor such as a Balfour, O’Sullivan-O’Connor, Harrington, or Thompson.

After the exploration has been completed, remove the instruments from the sterile field, and bring up the following incision-closing instruments: 1. 4 curved Crile hemostatic forceps, used to grasp the peritoneum. 2. An Army Navy retractor, used to retract the abdominal layers. 3. A Ferris Smith tissue forceps, used to hold the layer being closed. 4. A 7-inch Mayo needle holder with suture and needle, used for suturing the tissue. 5. Straight Mayo dissecting scissors, used for cutting suture.

To close the skin, possible instruments include Adson tissue forceps with teeth used to grasp the tissue and a skin stapler.

3-3 Two basic Mayo stand setups for starting a procedure. The same instruments and equipment are on the stands, just arranged differently. The arrangement is determined by the individual scrub personnel.



3-4 Left to right: 2 Mayo-Hegar needle holders, 7 inch; 2 Ayers needle holders, 8 inch; 3 Foerster sponge forceps; 2 Mixter hemostatic forceps, long, fine-point; 2 Babcock clamp tissue forceps, long; 2 Allis tissue forceps, long; 6 Ochsner hemostatic forceps, long, straight; 4 Mayo-Péan hemostatic forceps, long, curved; 6 tonsil hemostatic forceps; 2 Westphal hemostatic forceps; 4 Babcock clamp tissue forceps, short; 4 Allis tissue forceps, short; 8 Crile hemostatic forceps, curved, 6½ inch; 1 Halsted mosquito hemostatic forceps, straight; 6 paper drape clips.

3-5 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #7; 1 Bard-Parker knife handle #3, long; 1 Mayo dissecting scissors, curved; 2 Mayo dissecting scissors, straight; 1 Metzenbaum dissecting scissors, 7 inch; 1 Snowden-Pencer dissecting scissors, curved; 1 Snowden-Pencer dissecting scissors, straight.



3-6 Left to right: 2 Adson tissue for-ceps with teeth (1 × 2 teeth); 2 Ferris Smith tissue forceps; 2 Russian tissue forceps, medium; 2 DeBakey vascular atraugrip tissue forceps, medium; 2 DeBakey vascular atraugrip tissue forceps, long; 2 Russian tissue forceps, long.

3-7 Left to right: 2 Goelet retractors; 2 Army Navy retractors; 1 Richard-son retractor, medium; 1 Richardson retractor, large; 1 Yankauer suction tube and tip; 1 Poole abdominal shield and suction tube.



3-8 Left to right: Deaver retractors, small, medium, and large; Ochsner malleable retractors, narrow, medium, and wide.

A B C D

A B C D

3-9 Left to right: A, Adson tissue forceps and tip; B, Ferris Smith tissue forceps and tip; C, Russian tissue forceps and tip; D, DeBakey vascular atraugrip tissue forceps and tip.



A B C

A B C3-10 Left to right: A, Paper drape clip and tip; B, Halsted mosquito hemostat-ic forceps, straight, and tip; C, Halsted hemostatic forceps and tip.

A B C

A B C

3-11 Left to right: A, Crile hemostatic forceps and tip; B, Allis tissue forceps and tip; C, Babcock clamp tissue forceps and tip.



A B C

A B C

D

3-12 Left to right: A, Tonsil hemostatic forceps and tip; B, Westphal hemostatic forceps and tip; C, Mayo-Péan hemostatic forceps, curved, and tip; D, Mixter hemostatic forceps, fine-point tip.



3-13 Left to right: A, Ochsner hemostatic forceps and tip; B, Foerster sponge forceps and tip; C, Mayo-Hegar needle holder and tip.

A B C

A B C

3-14 Basic Mayo stand setup for closing the skin. After the sponge count is completed and correct, have a few instruments, sponges, suture and needles, or skin stapler available to complete the skin closure.


39CHAPTER 4 Abdominal Self-Retaining Retractors

Abdominal Self-Retaining Retractors

Abdominal self-retaining retractors are retractors that do not require a person to hold them in the proper position. Once the surgeon places the retractor and sets the racket, nut, or universal joint, the retractor stays open until released.

CHAPTER 4



4-1 Top to bottom: Bookwalter retrac-tor table post; Bookwalter retractor horizontal bar; Bookwalter retractor horizontal flex bar.

4-2 Top to bottom: Bookwalter retrac-tor oval ring, medium; Bookwalter retractor: Balfour blades, second blade, side view.




4-3 Top to bottom: Book walter retrac-tor: segmented parts (2 segmented half-circles, medium; 2 segmented straight extensions) placed together with 4 locking screws; 1 vertical exten-sion bar; 1 Kelly retractor blade with ratchet mechanism attached; 2 post couplings.

4-4 Left to right: 1 Harrington retrac-tor blade; 1 Kelly retractor blade (2 × 6 inch); 1 Kelly retractor blade (2 × 4 inch); 1 Kelly retractor blade (2 × 3 inch); 2 Kelly retractor blades (2 × 2½ inch); 6 ratchet mechanisms; 2 malleable retractor blades (2 × 6 inch); 2 malleable retractor blades (3 × 6 inch).



4-5 O’Sullivan-O’Connor retractor with 3 blades.

4-6 Top to bottom, left to right: Balfour abdominal retractor: retractor frame with 2 detachable shallow fenestrated blades; 1 shallow center blade; 2 deep fenestrated blades; 1 deep center blade.



4-7 Top to bottom, left to right: Upper hand retractor: 2 Balfour abdominal blades, deep and shallow; 1 Deaver blade, side view; 1 Weinberg blade (modified Joe’s Hoe); 1 malleable blade.

4-8 Thompson bariatric posts and bars.



4-9 Thompson bariatric retractor blades and clamps.

4-10 Left to right: Thompson retractor rotatable blades: 1 Deaver, medium, side view; 1 Harrington, side view; 1 Deaver, medium (2½ × 5 inch), side view; 1 Deaver, large, front view.

4-11 Left to right: Thompson retrac-tor rotatable blades: 1 finger mal-leable; 2 Balfour, side view and back view; 1 rake Murphy, sharp, 3 prong; 1 Balfour-Mayo center (2¾ × 5 inch), side view.



4-12 Left to right: Thompson retrac-tor rotatable blades: 1 Weinberg (3¼ × 5¼ inch), side view; 1 Richardson (2 × 5 inch), side view; 1 Kelly (2½ × 3 inch), side view; 1 Kelly (2 × 2½ inch), front view; 2 Richardson carotid (1 × ¼ inch and ¾ × 1 inch), side view.

4-13 Top to bottom, left to right: Thompson retractor joints: 1 exten-sion arm, angular, 12 inch; 1 wrench, universal; 1 adapter blade, universal; 2 universal (½ × ¼ inch); 2 universal split (½ × ¼ inch); 2 universal (½ × ½ inch); 2 universal (½ × ½ inch), large.


45CHAPTER 5 Small Laparotomy Set

Small Laparotomy Set

A smaller number of instruments may be used for less involved procedures, such as an appendectomy or an inguinal herniorrhaphy. An appendectomy is the removal of the ver-miform appendix of the bowel. An inguinal herniorrhaphy is the repair of an outpouching through an abnormal opening in the abdominal muscle wall in the lower right or left quad-rant of the abdomen. These procedures may also be done through a laparoscope.

A brief description of the instruments follows: 1. Adson tissue forceps without teeth, used for the handling of delicate tissue. 2. Adson tissue forceps with teeth, used for grasping the skin edges. 3. Halsted mosquito hemostatic forceps, used for clamping the bleeders. 4. Babcock clamp tissue forceps, used for handling the appendix or hernia sac. 5. Short Allis forceps, used for grasping the tissue when closing the incision. 6. Weitlaner self-retaining retractor, used for the retraction of the abdominal layers. 7. Farr spring retractors, used for retracting the skin edges.

CHAPTER 5



5-1 Top, left to right: 1 Brown-Adson tissue forceps (9 × 9 teeth); 2 Adson tissue forceps with teeth (1 × 2). Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Cushing forceps with teeth (1 × 2); 1 Ferris Smith tissue forceps (1 × 2); 2 DeBakey vascular atraugrip tissue forceps, medium; 4 paper drape clips; 6 Halsted mosquito hemostatic forceps, curved; 1 Halsted mosquito hemostatic forceps, straight; 8 Crile hemostatic forceps, curved, 5½ inch; 1 Halsted hemostatic forceps, straight; 6 Crile hemostatic forceps, curved,6½ inch; 4 Allis tissue forceps, short; 4 Babcock clamp tissue forceps, short; 4 Ochsner hemostatic forceps, short; 1 Westphal hemostatic forceps; 2 tonsil hemostatic forceps; 1 Foerster sponge forceps; 2 Mayo-Hegar needle holders, 6 inch; 1 Crile-Wood needle holder, 6 inch.




5-2 Top pairs, left to right: 2 Army Navy retractors, front view and side view; 2 Miller-Senn retractors, side view and front view. Bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum dissecting scissors, 7 inch; 1 Metzenbaum dissecting scissors, 5 inch; 2 Goelet retractors, front view and side view; 2 Richardson retractors, small, side view and front view.

5-3 Left, top to bottom: 1 Metal medicine cup; 1 weitlaner retractor, medium. Right, top to bottom: 1 Yankauer suction tube with tip; 1 Poole abdominal suction tube with shield; 1 Ochsner malleable retrac-tor, medium; 1 Ochsner malleable retractor, narrow; 1 Deaver retractor, medium.


47CHAPTER 6 Minor Laparoscopic Set

Minor Laparoscopic Set

A minor laparoscopic set is used for the placement of the trocars and a laparoscope in preparation for the examination of the abdominal cavity.

CHAPTER 6



6-1 Left to right: 4 Crile hemo-static forceps, 6½ inch; 2 Péan artery clamps, 7¼ inch; 1 Péan artery clamp, 8 inch; 2 Allis clamps, 5 × 6 teeth, 6 inch; 2 Kocher clamps, 1 × 2 teeth, 6½ inch; 1 right angle Gemini, fine curved, 8 inch; 1 Randall kidney stone forceps, quarter curved; 1 Schroeder Braun uterine tenaculum, 91⁄2 inch; 1 Foerster sponge stick, straight; 1 Mayo-Hegar needle holder, 8 inch; 1 Crile-Wood needle holder, 6¼ inch; 2 needle holders, 51⁄2 inch; 1 Baumgartner serrated tungsten carbide needle holder, 5 inch; 2 Backhaus towel forceps.




6-2 Top to bottom, left to right: 1 Knife handle, #3; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum scissors, curved, 7 inch; 2 Adson tissue forceps, 1 × 2 teeth, 4¾ inch; 1 tissue forceps, 1 × 2 teeth, 6¾ inch; 1 Bonney tissue forceps, 1 × 2 teeth, 6¾ inch; 1 DeBakey-Diethrich coronary artery tissue forceps, 6 inch; 1 Russian tissue forceps, 6 inch; 2 Senn retractors, sharp, 6¾ inch; 2 Army Navy retrac-tors, double-ended; 2 Richardson retractors, 9½ inch. Bottom, left to right: 1 Suture passer pistol grip; 1 blue clip; 1 fascia closure inlet trumpet.


49CHAPTER 7 Laparoscopy

Laparoscopy

Laparoscopy is visualization within the abdominal cavity. The structures have to be moved away from the abdominal wall so the scope can be inserted safely. Pneumoperitoneum is accomplished by insufflation of carbon dioxide.

Laparoscopes, like arthroscopes, cystoscopes, hysteroscopes, nephroscopes, sigmoido-scopes, sinuscopes, thoracoscopes, and urethroscopes, are types of endoscopes. Endoscopy is the introduction of a small tube to visualize inside a body cavity or structure. The tube (endoscope) has a lens and a light source for vision. The lens angle determines the area that will be seen inside the patient. The most common lens angles are 0 degrees, 30 degrees, and 70 degrees.

Many of the endoscopic instruments can be used interchangeably within the various endoscopic specialties. Interchangeable terms include obturator/trocar and cannula/port or sleeve. The addition of instruments, either through attachments to the scope or through another port into the cavity or structure, allows the surgeon to perform operative proce-dures. The light source is usually a fiber optic cable, or cold light, that prevents injury to internal structures.

Minimally invasive surgery (MIS) incorporates all the fields of endoscopic surgery (orthopedic; genitourinary; gynecological; and ear, nose, and throat) using small incisions or no incisions, such as when using an endoscope rather than using traditional open meth-ods. The advantages of MIS include: (1) decreased size of the incision sites, (2) decreased postoperative pain, (3) decreased recovery period, and (4) quicker return to work and fam-ily. Almost all surgical specialties now perform MIS procedures on most anatomical areas.

In laparoscopy, the Mayo stand is set up to include a Bard-Parker scalpel handle #3 with a #11 blade; 2 Backhaus towel forceps; a Verres needle for insufflation; insufflation tubing; trocars with sleeves; a laparoscope; and a fiber optic light cable.

A brief description of the laparoscopic procedure follows: 1. The abdominal wall is elevated with 2 Backhaus towel clips. 2. A stab wound is made near the umbilicus with a Bard-Parker scalpel. 3. The Verres needle is inserted at a 45-degree angle. 4. The insufflation tubing is attached to the needle and the CO2 is insufflated to create the

pneumoperitoneum. At 12 to 15 mm Hg pressure, the needle is removed. 5. A trocar with sleeve is introduced. 6. The trocar is removed and the laparoscope is inserted. 7. The fiber optic cable is attached.

CHAPTER 7






7-1 Top to bottom: Nondisposable laparoscopic lens: 0-degree, 5 mm; 25-degree, 5 mm; 50-degree, 5 mm; 25-degree, 10 mm; 50-degree, 10 mm.

7-2 Left to right: Camera and light cord.



7-3 Olympus EndoEye rigid 5-mm 0-degree laparoscope.

7-4 Olympus EndoEye flexible 3D HD 10-mm laparoscope.



7-5 Kronner laparoscopic scope holder.

7-6 Left to right: 1 Port and 1 trocar, 5 mm × 100 mm, separated, then together; port and trocar together and then separated, 11 mm × 100 mm; 1 Hasson trocar, 12 mm. 5 mm × 100 mm 11 mm × 100 mm

11 mm × 100 mm

12 mmHasson trocar



7-7 Left to right: 1 Verres needle, disposable; 3 dilating-tipped trocars, disposable, 5 mm, 10/11 mm, and 12 mm; 1 optical trocar, disposable, 10 mm; 1 blunt-tipped trocar (Hasson type), disposable, 10 mm.

7-8 Left to right: Insufflation tubing and insufflation tubing with battery-operated suction/irrigator system.



Laparoscopic Adult MIS Set

A minimally invasive laparoscopic instrument set is used for the placement of trocars, laparo scope, and camera. Laparoscopic instruments are used to examine the abdominal cavity to diagnose, remove, or repair structures with small multiple incisions. Examples of laparoscopic procedures include bowel resections, cholecystectomies, and hernia repairs.

CHAPTER 8



8-1 Left to right: Nondisposable cautery cord; instrument pan with 1 applied obturator 5 mm ×100 mm; 3 applied cannulas, 5 mm; 1 Verres needle stylet; 1 Verres needle, me-dium; 1 Nezhat dorsal plug; 1 applied obturator 10 mm × 100 mm; 3 applied cannulas, 10 mm. Bottom, in pan: 2 Red port caps; 5 gray port caps; 1 red cap with pinhole; 1 gray cap with 3-mm hole; 1 male Luer-Lok adapter.



55CHAPTER 8 Laparoscopic Adult MIS Set

8-2 Top, left to right: 5 Gray port caps; 1 male Luer-Lok adapter. Bottom, left to right: 1 Gray rubber cap with 3-mm hole; 2 red port caps; 1 red rubber cap with pinhole.

8-3 Top to bottom, left to right: 1 Double-action fenestrated grasper with handle, closed; 1 double-action aggressive grasper with handle, open; 1 single-site surgery triport sleeve; 1 guide to introduce triport into abdomen; 1 active cord.



8-4 First rack with laparoscopic instruments that fit inside a steriliza-tion container.

B DA H

B

C

D

E

F

A

G

H

C E F G

8-5 Top to bottom: A, Nezhat-Dorsey L-shaped cautery with sheath below, tip (note A below has protec-tive cover); B, needle-tip suction, tip; C, spatula cautery, tip; D, spatula suction, tip; E, L-hook cautery, tip; F, Marlow knot pusher, tip; G, Ranfac knot pusher, tip; H, 10-mm and 5-mm Nezhat-Dorsey suction, tips. (Tips shown below are enlarged.)



8-6 1 Disposable ligating and dividing clip applier.

8-7 Top to bottom: 1 Maryland bipolar dissector with handle; 1 Mini-Metzen-baum scissors with handle; 1 active cord; 1 J-hook cautery electrode; 1 Endoweave grasper with handle; 1 fenestrated single action grasper with handle; 1 Wave grasper with handle.



8-8 Second rack with laparoscopic instruments that fit inside a steriliza-tion container.

B C D E

F

A

G H I J

8-9 Tips of most of the instruments in the above rack: A, 10-mm Cup forceps; B, 5-mm grasper with teeth; C, 10-mm grasper with teeth; D, Olsen clamp; E, double-action grasper; F, Hook scissors; G, 5-mm Apple needle holder with left curve; H, 5-mm Babcock clamp grasping forceps; I, monopolar scissors, 5 mm × 32 mm; J, Maryland bipolar dissector.



AS

SIS

TA

NT

ANESTHESIA

OPTIONALASSISTANT

CA

ME

RA

HO

LDE

R

SC

RU

B

VIDEO2 VIDEO

1

__5

__10

Can be variableif staples = 12 mm.

VIDEO2(alternate

position)*

* Change per physician preference

__5 SU

RG

EO

N

BA

CK

TA

BLE

8-10 Position for laparoscopic appendectomy and herniorrhaphy.



Laser Laparoscope

CHAPTER 9

Laser laparoscope is using a laser beam as a precision tool for cutting, coagulating, vapor-izing, and welding tissue during the surgical intervention. It is very important that basic education on the written laser policies and procedures for all personnel in the surgical envi-ronment are mandatory within the health care facility. Policy and procedure topics should include the following: eye protection, controlled access, fire safety, smoke (plume) evacu-ation, documentation, laser team responsibilities, skin tissue protection, electrical safety, education/training, and credentialing.

9-1 Top to bottom: 1 Suction tip; 1 medicine cup, metal. Bottom: 1 Bard-Parker knife handle #3; 1 Adson tissue forceps with teeth (1 × 2); 2 Allis tissue forceps; 1 Crile-Wood needle holder, 7 inch; 1 Mayo dissecting scissors, straight; 2 Crile hemostatic forceps, curved; 2 Kocher clamps; 1 Backhaus towel clip; 2 paper drape clips; 2 Senn retractors; 1 News tracheal hook.

9-2 Top to bottom: Laser laparoscope; 3 disposable ports, 2 with adapter on side. Bottom: 1 Applied cannula, 10 mm; disposable trocar; 1 applied cannula, 5 mm; 1 obturator, 5 mm; 1 applied cannula, 5 mm; 1 Verres needle stylet.





61CHAPTER 10 Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder by means of a laparoscope or an abdominal incision.

Possible equipment needed for the procedure includes a minor laparoscopic set, a laparoscope set, and an adult minimally invasive surgery set.

A brief description of the procedure through a laparoscope, after the abdomen has been insufflated, follows: 1. 3 or 4 trocars with sheaths are needed. There is one port for the laparoscope with camera

attached; one port for the retraction instruments; one port for dissection; and one port for ligation.

2. Claw forceps are used to stabilize the gallbladder. 3. An Olsen clamp is used to stabilize the cystic duct during cholangiograms. 4. Metzenbaum scissors are used for dissection. 5. Ligaclip appliers are used for hemostasis. 6. An Apple needle holder is used for suture ligation. 7. A Marlow knot pusher is used for suture tightening. 8. Ligature scissors are used for cutting suture. 9. An Endo catch retriever is used for removing the specimen.

If electrosurgery is to be used, the equipment needed for the procedure includes: 1. A spatula electrode, used for hemostasis. 2. A monopolar Metzenbaum scissors, used for dissection. 3. A Maryland bipolar dissector, used for soft tissue dissection and to remove the specimen.

CHAPTER 10

10-1 A, Endo catch retriever with the tip closed; B, Endo catch retriever with the tip expanded.

A

B






*Video position change per physician preference

__

__10

5

55

AS

SIS

TA

NT

ANESTHESIA

CA

ME

RA

HO

LDE

RS

UR

GE

ON

VIDEO2ELECTRO-

CAUTERY

VIDEO

2*

LASER ORELECTROCAUTERY

USED

BACKTABLE

SC

RU

B

10-2 Position for laparoscopic cholecystectomy.


63CHAPTER 11 Laparoscopic Bowel Resection

Laparoscopic Bowel Resection

CHAPTER 11

11-2 Top to bottom: 1 Endoflex protective cover; 1 Endoflex retractor, triangle, 5 mm, 80-mm length; 1 biopsy forceps, 5 mm, and tip.

A bowel resection is the excision of a portion of the small or large intestine and the reanas-tomosis of it through a laparoscope or through an abdominal incision.

Possible equipment needed for the procedure includes a minor laparoscopic set, laparo-scope, laparoscopic camera, fiber optic light cord, and trocars.

A brief description of the procedure through a laparoscope, after the abdomen is insufflated, follows: 1. An Endoflex retractor is used for visualization. 2. A Hunter (Glassman) bowel grasper is used for handling the bowel. 3. A Maryland bipolar dissector is used for freeing up the bowel. 4. A Nezhat suction/irrigator is used for lubrication and removal of fluid. 5. A linear stapling device is used for transecting the bowel. 6. A Ligaclip applier is used for hemostasis. 7. A needlepoint suture passer is used in suturing. 8. A Marlow knot pusher is used for suture tightening. 9. A linear stapling device is used for reanastomosis of the bowel.

11-1 Applied Medical Alexis protractor 5 to 9 cm.






11-3 FastClamp with Endoflex snake retractor. Top to bottom: 1 Table bar; 1 table attachment; 1 Endoflex snake retractor (in coiled position); 1 supporting arm (attached to snake retractor).

11-4 Top to bottom: 1 EEA anvil grasper and 1 esophageal retractor.

11-5 Top to bottom: These are extra long instruments; 1 Hunter (Glassman) bowel grasper, 5 mm, 45-cm length; 1 Nezhat suction/irrigator, 5 mm, 45-cm length; 1 Maryland bipolar dissector, monopolar, 5 mm, 45-cm length.



11-7 1 Laparoscopic ligating and dividing disposable clip applier.

A

B

11-9 A, 1 Ethicon SecureStrap laparoscopic tacker. B, SecureStrap tack.

11-8 1 Linear cutter with reloadable head.

A B C11-6 Left to right: Tips: A, Hunter (Glassman) bowel grasper, 5 mm, 45-cm length; B, Nezhat suction/irrigator, 5 mm, 45-cm length; C, Maryland bipo-lar dissector, 5 mm, 45-cm length.



A

B

11-11 Top to bottom: 1 Contour curved cutter; 1 proximate linear stapler, 60 mm; 1 proximate linear stapler, 90 mm.

11-10 A, Ethicon Echelon Flex 60 Endo GIA power stapler. B, Endo GIA power stapler tip.



11-12 1 Ethicon endoscopic curved intraluminal stapler ECS33.

11-13 Top to bottom: 1 Covidien Endoscopic 60 Endo GIA tri-stapler, power and 1 radial attachment.

11-14 Endo GIA stapler with universal handle and tip with staples.



A B11-16 A, Top to bottom: 1 Covidien Sonicision cordless ultrasonic dissec-tion, 5 mm, 39 cm with tightening key. B, Enlarged tip: Covidien Sonicision cordless ultrasonic dissection.

A B11-15 A, Top to bottom: 1 Ethicon Laparoscopic Enseal, 5 mm 35 cm; 1 Ethicon Laparoscopic Harmonic scalpel, 5 mm 23 cm. B, Enlarged tip: Ethicon Laparoscopic Enseal, 5 mm.

AS

SIS

TA

NT

ANESTHESIA

CA

ME

RA

HO

LDE

R

SCRUB

SU

RG

EO

N

VIDEO

2*

VIDEO1

BACKTABLE

REVERSE FOR RIGHT SIDEPATIENT IN LOW ALLEN STIRRUPS

5, 10, or 12 mmVARIABLE; DEPENDS

ON SURGERY

* Video position change per physician preference

__5

__10

__5__5

11-17 Position for laparoscopic bowel resection.


69CHAPTER 12 Bowel Resection

Bowel Resection

Possible equipment needed for a bowel resection includes a basic laparotomy set and a self-retaining retractor.

A brief description of the procedure, doing the surgery through an abdominal incision, includes: 1. A self-retaining retractor is used for visualization after the abdomen is opened. 2. A Doyen intestinal forceps is used for atraumatic bowel clamping. 3. A Carmalt hemostatic forceps is used for hemostasis and blunt dissection. 4. A long Babcock clamp tissue forceps is used for handling the bowel. 5. An Ethicon linear cutter is used for dissection of the bowel. 6. An Ethicon linear stapler is used for reanastomosis of the bowel.

Resection of the sigmoid colon may need a special stapling device (EEA) that also cuts the tissue.

CHAPTER 12

12-1 Left to right: 2 DeBakey vascular atraugrip tissue forceps, short; 2 Doyen intestinal forceps, straight; 2 Doyen intestinal forceps, curved; 12 Halsted mosquito hemostatic forceps, curved; 4 Carmalt hemostatic forceps, long, curved; 6 Carmalt hemo-static forceps, long, straight.






12-3 Top to bottom: 1 Ethicon stapler PPH (utilized for prolapse rectal hemorrhoid tissue) and attachment; 1 Covidien purse string, disposable.

12-2 Left to right: Tips: A, Doyen intestinal forceps, straight and curved; B, Carmalt hemostatic forceps, long, curved, and straight.

A B


71CHAPTER 13 Sigmoidoscopy

Sigmoidoscopy

A sigmoidoscopy is the visualization within the sigmoid and descending colon with the aid of a scope and a light source. Also used is a laparoscopic sigmoid colectomy to check the anastomosis after stapling.

A brief description of the procedure follows: 1. The scope is inserted with the obturator in place. 2. The obturator is removed. 3. The air hose and bulb are attached to the scope. 4. The colon is inflated. 5. The light source is attached to the scope.

CHAPTER 13



13-1 Welch Allyn operative sigmoido-scope. Left to right: 1 Fiber optic cord; 1 light handle; 1 obturator; 1 disposable sigmoidoscope; 1 colonic insufflator.




Laparoscopic Bariatric Surgery

Bariatrics is the field of medicine that deals with obesity and weight-related conditions. Laparoscopic surgery decreases the surgical incision on individuals that may be obese and have impaired healing. Bariatric instruments are the same as basic laparoscopic instruments except they are longer and may be wider to accommodate a patient’s larger size. Possible equipment needed for laparoscopic bariatric surgery includes laparoscopic instrumenta-tion, trocars, and obturators that are longer in length.

A brief description of the procedure follows: 1. The laparoscope is inserted in the usual manner. 2. The Nathanson retractor is positioned to retract the liver. 3. Depending on the scheduled surgery, various types of instrumentation may be used. 4. To assist closure, a fascia closure device may be used.

CHAPTER 14



14-1 Left to right: 1 Bard-Parker knife handle #3; 2 Adson tissue forceps with teeth (1 × 2); 2 thumb tissue forceps without teeth, short; 1 Mayo dissect-ing scissors, curved; 1 Metzenbaum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, straight; 2 Mayo-Péan hemostatic forceps, curved; 2 Kocher clamps; 1 Crile-Wood needle holder, 7 inch; 1 Crile-Wood needle holder, 5 inch; 6 Crile hemostatic forceps, curved, 6½ inch; 4 Backhaus towel clips; 8 paper drape clips; 3 noninsulated rotating handles.



73CHAPTER 14 Laparoscopic Bariatric Surgery

14-2 Two baby Deaver retractors.

14-3 Left to right: 2 Sets of trocars and obturators, 1 set 5 mm × 100 mm (standard), 1 set 5 mm × 150 mm (bariatric); 2 sets of trocars and obturators, 1 set 11 mm × 150 mm (bariatric), 1 set 12 mm × 150 mm (bariatric); 1 set Hasson trocar and obturator, 12 mm.



14-4 Left to right: Disposable high-flow insufflation tube and InsuFlow heater hydrator insufflation tubing.

14-5 Top to bottom: 1 Bariatric telescope, 10 mm, 30 degrees; 3 tele-scopes, 45, 30, and 0 degrees; 1 telescope, 5 mm, 30 degrees.



14-6 Nathanson retractor with lapa-roscopic Thompson retractor holder.

14-7 Top: 2 Apple needle holders with locks, 5 mm, right and left curves. Bottom, left to right: 1 Inlet fascia closure device; 1 cone, long; 2 medicine cups, metal, side view and top view; 1 Nathanson liver retractor.



14-8 A, Top to bottom: 1 Harmonic scalpel 5 mm, 23 cm; 1 Harmonic cord and 1 tightening key. B, Enlarged tip: Harmonic scalpel 5 mm with curved shears.

A

B

14-9 Rack with laparoscopic instru-ments that fits inside a sterilization container.



14-10 Top to bottom: 1 Switchblade scissors, bariatric; 1 switchblade scissors, regular; 1 bariatric spatula; 1 Nezhat-Dorsey irrigator.

14-11 Top and bottom instruments work together: bottom: fenestrated bowel grasper that slides inside the noninsulated sheath at the top; both connect to the noninsulated metal handle; middle: DeBakey tissue for-ceps, 10 mm, curved.

14-12 Three Hunter (Glassman) bowel graspers.



A B14-13 Tips of Hunter (Glassman) bowel grasper, 5 mm: A, Closed; B, open.

14-14 A, 3 Apple needle holders, 2 left curved, 1 right curved. B, 5-mm Apple needle holder with left curve.

A

B


79CHAPTER 15 The da Vinci ® Surgical System and EndoWrist ® Instruments (Robotic Instruments)

The da Vinci ® Surgical System and EndoWrist ®

Instruments (Robotic Instruments)

EndoWrist instruments are manufactured by Intuitive Surgical, Inc. specifically for use with the da Vinci Surgical System. The EndoWrist instruments provide surgeons with natural dexterity and a full range of motion for more precise operation through tiny incisions. Simi-lar to the human wrist, an EndoWrist instrument allows for rapid and precise suturing, dis-section, and tissue manipulation.

The EndoWrist instrument line features a variety of specialized tip designs, including forceps, needle drivers, and scissors; monopolar and bipolar electrocautery instruments; scalpels, and more. The EndoWrist instruments are available in 5-mm and 8-mm diameters to meet surgeons’ requirements.

After an EndoWrist instrument is installed on the da Vinci System, the interface is designed to recognize the type and function of the instrument and to display the number of uses available. This interface allows the da Vinci System to detect when an instrument needs replacement.

Because of the delicate nature of these instruments, all handling, cleaning, and steriliza-tion must be performed in strict accordance with the manufacturer’s guidelines. Intuitive Surgical, Inc. has training courses available to assist with education.

CHAPTER 15



A B15-1 Snap-fit scalpel instruments, shown with Snap-fit: A, 15-Degree blue blade; B, paddle blade. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B C15-2 Scissors: A, Potts scissors; B, round tip scissors; C, curved scissors. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)




L

E F G H

I J K

A B C D

15-3 Forceps/graspers: A, DeBakey forceps; B, Cadiere forceps; C, Resano forceps; D, double-fenestrated grasper; E, Cobra grasper; F, long tip forceps; G, ProGrasp forceps; H, tenaculum forceps; I, thoracic grasper; J, fine tissue forceps; K, Graptor (grasping retractor); L, black diamond microforceps. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B C15-4 EndoWrist monopolar cautery instruments: A, Hot Shears, also called monopolar curved scissors; B, per-manent cautery hook; C, permanent cautery spatula. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)



15-5 EndoWrist bipolar instruments: A, PreCise bipolar forceps; B, Mary-land bipolar forceps; C, fenestrated bipolar forceps; D, PK® dissecting forceps; E, microbipolar forceps. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B

D E

C

15-6 Harmonic® curved shears. (Courtesy of Intuitive Surgical, Inc., Sunnyvale, Calif.)

A

C D

B 15-7 EndoWrist needle drivers: A, Large needle driver; B, large SutureCut needle driver; C, Mega needle driver; D, Mega SutureCut needle driver. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)



15-8 Specialty instruments: A, Atrial retractor; B, atrial retractor short right; C, dual blade retractor; D, EndoPass delivery instrument; E, cardiac probe grasper; F, valve hook; G, pericardial dissector. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B C

D E

G

F

A B15-9 EndoWrist clip appliers: A, Small clip applier; B, large Hem- o-lok® clip applier. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B15-10 EndoWrist 5-mm instruments (graspers): A, Schertel grasper, 5 mm; B, bowel grasper, 5 mm. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-11 EndoWrist stabilizer shown with tubing. (Courtesy Intuitive Surgi-cal, Inc., Sunnyvale, Calif.)



15-12 da Vinci Si HD Surgical Systems. Left to right: Two surgeons’ consoles (power cables do not show on this photo); nurse at the operating table by Mayo stand in surgical attire and in front of patient cart, with a vision cart to her right. During an operation, you would see an assistant to the surgeon at the patient’s cart with the scrub nurse (photographed on the right), an anesthesiologist at his or her machine, a circulating nurse, and the surgeon or surgeons in an anteroom next to the operating room where the patient is being operated upon. In most situations the da Vinci Si HD Surgical Systems are located within the operating room, and the surgeons are wearing proper operating room attire, including head covers and masks. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)



Breast Biopsy/Lumpectomy

A breast biopsy is the removal of suspicious breast tissue for the purpose of microscopic examination.

A brief description of the procedure follows: 1. A Halsted mosquito forceps is used for hemostasis. 2. A DeBakey tissue forceps is used for atraumatic handling of breast tissue. 3. A Lahey thyroid tenaculum is used for grasping the pathology. 4. A Senn retractor is used for deeper retraction. 5. Joseph hooks are used for skin retraction.

CHAPTER 16



16-1 Top, left to right: 1 Medicine cup, metal; 2 Army Navy retractors, front view and side view. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Adson tissue forceps (1 × 2); 1 Brown-Adson tissue forceps (9 × 9); 2 DeBakey vascular atraugrip tissue forceps, short (front view and side view); 2 paper drape clips; 4 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps, 5½ inch; 2 Allis tissue forceps; 2 Lahey goiter vulsellum forceps; 1 Crile-Wood needle holder, 6 inch; 2 Mayo dissect-ing scissors, straight and curved; 1 Metzenbaum dissecting scissors, 5 inch; 2 Joseph skin hooks, double; 2 Miller-Senn retractors, side view and front view.



85CHAPTER 17 Mastectomy

Mastectomy



CHAPTER 17

A mastectomy is the removal of a breast (mammary gland).A brief description of the procedure follows:

1. Lahey traction forceps are used for grasping skin edges. 2. Prince-Metzenbaum scissors are used for dissecting. 3. Hayes Martin tissue forceps are used to help with dissection. 4. Volkmann (rake) retractors (sharp and dull) are used for visualization. 5. A Poole suction tip with tubing is used to improve visualization. 6. Adair breast clamps are used for grasping breast tissue. 7. Curved Crile hemostatic forceps are used for hemostasis and blunt dissection. 8. A skin stapler is used for skin closure.

For the axillary node dissection, a brief description of the procedure follows: 1. A Green retractor is used for visualization. 2. A Cushing vein retractor is used for retracting small structures. 3. A Yankauer suction tube and tip are used for visualization.

17-1 Top to bottom: Yankauer suction tube and tip; Poole abdominal suction tube and shield. Bottom, left to right: First instrument stringer: 6 paper drape clips; 2 Backhaus towel forceps; 8 Halsted mosquito hemostatic forceps, curved; 12 Crile hemostatic forceps, 5½ inch; 8 Crile hemostatic forceps, 6½ inch; 2 Mayo-Péan hemo-static forceps, long; 2 Halsey needle holders, serrated, 5 inch; 2 Crile-Wood needle holders, 7 inch. Second instru-ment stringer: 12 Allis tissue forceps; 4 Babcock tissue forceps; 4 Ochsner hemostatic forceps, straight, short; 8 Adair breast clamps, short; 4 tonsil hemostatic forceps; 4 Westphal hemostatic forceps; 4 Lahey traction forceps.




17-2 Top, left to right: 2 Bard-Parker knife handles #3; 1 Hoen nerve hook; 1 Bard-Parker knife handle #4. Bottom, left to right: 2 Metzenbaum dissecting scissors, 5 inch and 6 inch; 1 Prince-Metzenbaum dissecting scissors; Mayo dissecting scissors: 2 straight and 1 curved.

17-3 Left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Brown-Adson tissue forceps (9 × 9), front view and side view; 1 Adson tissue forceps without teeth, front view; 2 DeBakey vascular atraugrip tissue forceps, short, front view and side view; 2 Hayes Martin tissue forceps, short, front view and side view; 2 DeBakey vascular atrau-grip tissue forceps, medium, front view and side view.

17-4 Left to right: 2 Richardson retractors, small and medium; 2 Volkmann retractors, 6 prong, sharp, front view and side view; 2 Volkmann retractors, 6 prong, dull, front view and side view; 2 Volkmann retractors, 4 prong, dull, front view and side view; 2 Volkmann retractors, 4 prong, sharp, front view and side view.


87CHAPTER 17 Mastectomy

17-5 Left to right: 2 Army Navy retractors, side view and front view; 2 Langenbeck retractors, side view and front view; 2 Green goiter retractors, side view and front view; 2 Cushing vein retractors, side view and front view; 2 Miller-Senn retractors, side view and front view.

B C DA

B C DA

17-6 Left to right: A, Halsey needle holder, serrated, 5 inch, and tip; B, Crile-Wood needle holder, 7 inch, and tip; C, Adair breast clamp and tip; D, Lahey traction forceps and tip.


88 UNIT 3 Female Reproductive Surgery

Dilatation and Curettage of the Uterus

A dilation and curettage of the uterus (D and C) is performed to treat illness or to obtain a specimen for microscopic evaluation.

A description of the procedure follows: 1. An Auvard speculum is placed to open the posterior wall of the vagina. 2. A Heaney right-angle retractor is placed to elevate the anterior wall of the vagina. 3. A Schroeder tenaculum is placed on the cervix to stabilize the uterus. 4. A Sims uterine sound is inserted to determine the depth of the uterus. 5. Hegar dilators are inserted to dilate the cervix (from the smallest to the largest). 6. A Sims uterine curette is inserted to scrape tissue from the uterus. 7. A Thomas dull curette is used to remove any remaining tissue.

CHAPTER 18



18-1 Left to right: 1 Bard-Parker knife handle #7; 1 Ferris Smith tissue forceps; 1 dressing forceps, long; 1 Mayo dis-secting scissors, curved; 4 paper drape clips; 2 Backhaus towel forceps; 4 Crile hemostatic forceps, 5½ inch; 2 Allis tissue forceps; 1 Randall stone forceps, ¼ curved; 1 Bozeman uterine forceps, S-shaped; 2 Schroeder uterine tenacu-lum forceps, single tooth; 1 Foerster sponge forceps; 1 Crile-Wood needle holder, 7 inch.

UNIT THREE: FEMALE REPRODUCTIVE SURGERY



89CHAPTER 18 Dilatation and Curettage of the Uterus

18-2 Top, left to right: 1 Graves vaginal speculum; 1 Auvard weighted vaginal speculum, medium lip. Bottom, left to right: 1 Heaney retractor; 1 set of Hegar dilators, sizes 3 to 13½ (including half sizes).

18-3 Left to right: 1 Sims uterine sound; 1 Heaney uterine biopsy curette, sharp, serrated, 5-mm wide; 1 Thomas uterine curette, semirigid, dull, small, 0.6-mm wide loop; 1 Sims uterine curette, semirigid, sharp, medium, 2.8-mm loop; 1 Kevorkian-Younge endocervical biopsy curette, 2-mm loop.



B C

D E F

A18-4 Left to right: Tips: A, Sims uter-ine sound; B, Heaney uterine biopsy curette, sharp, serrated, 5-mm wide; C, Thomas uterine curette, semirigid, dull, small, 0.6-mm wide loop; D, Sims uterine curette, semirigid, sharp, medium, 2.8-mm loop; E, Kevorkian-Younge endocervical biopsy curette, 2-mm loop; F, Bozeman uterine forceps, S-shaped.


91CHAPTER 19 Hysteroscopy

Hysteroscopy

Hysteroscopy is an endoscopic visualization of the uterine cavity and is usually performed to aid in the diagnosis and treatment of intrauterine diseases.

Possible equipment needed for the procedure includes a hysteroscope, dilatation and curet-tage instruments, and possibly if the surgeon wishes to examine inside the abdomen, a lapa-roscope, insufflation tubing, fiber optic light cord, and camera (see Chapter 7: Laparoscopy).

CHAPTER 19



19-1 VersaPoint hysteroscopic resectoscope unassembled.

19-2 VersaPoint resectoscope assembled. Top to bottom: 1 Resecto-scope assembled with cautery cord; 1 sheath with obturator; 1 multitooth, semirigid grasping forceps, 5 Fr.




19-3 Top to bottom: Enlarged tips of multitoothed semirigid grasping forceps, 5 Fr; semirigid Metzenbaum scissors; semirigid cup biopsy forceps.

19-4 Top to bottom: 1 Versascope; 1 Versascope sheath.


93CHAPTER 19 Hysteroscopy

19-5 Top to bottom: 2 TruClear hysteroscopy systems, top is 9.0 system and bottom is 5.0 system with each system containing 1 obturator, 1 telescope with working channel, and 1 sheath.

19-6 TruClear hand piece.



Vaginal Laser

The term laser stands for Light Amplification by Stimulated Emission of Radiation. Ordi-nary light, such as that from a light bulb, has many wavelengths and spreads in all direc-tions. Laser light, on the other hand, has a specific wavelength. It is focused in a narrow beam and creates a very high intensity light. This light can burn the patient or cause blind-ness to health care workers if special glasses or other precautions are not taken. Because lasers can focus very accurately on tiny areas, they can also be used for very precise surgical work or for cutting through tissue. Vaginal instruments have a special coating called ebon-ization, so they do not reflect the laser beam onto unintended tissues. The coating is one example of a precaution taken by trained laser staff to protect patients and staff. Examples of surgical procedures that lasers may be used on are vaginal warts, tumors, or small lesions.

CHAPTER 20



20-1 Left to right: 1 Hook, 10 inch; 1 Schroeder uterine tenaculum forceps, 9½ inch; 1 tonsil forceps; 2 Heaney retractors (lateral vaginal retractors); 1 Auvard weighted vaginal speculum; 1 Graves vaginal speculum with smoke evacuation attachment.



95CHAPTER 20 Vaginal Laser

20-2 Left to right: 1 Graves bivalve speculum, full view, purple; 1 Graves bivalve speculum, wide view, purple; 1 lateral vaginal retractor, purple.



Abdominal Hysterectomy

Abdominal hysterectomy is the removal of the uterus through an abdominal incision. Additional structures that may be removed through the same incision and at the same time are the ovaries (oophorectomy) and fallopian tubes (salpingectomy).

Instruments needed for the procedure include a basic laparotomy set, an O’Sullivan-O’Connor retractor, and Z clamps.

A brief description of the procedure follows: 1. An abdominal incision is made and dissection occurs. 2. A Schroeder uterine tenaculum forceps is used for grasping and manipulating the

uterus. 3. Heaney forceps, Heaney-Ballantine forceps, or Z clamps are used for clamping uterine

ligaments and vessels. 4. A Jorgenson dissecting scissors is used for dissection. 5. A Heaney needle holder is used for suture ligation.

CHAPTER 21

21-1 Top, right: 1 O’Sullivan-O’Connor retractor body. Bottom, left to right: 1 Mayo dissecting scissors, curved, 9 inch; 1 Jorgenson dissecting scissors, curved, 9 inch; 4 Ochsner hemostatic forceps, 8 inch; 2 Heaney hysterectomy forceps, single tooth; 2 Heaney-Ballantine hysterectomy forceps, single tooth; 4 Ochsner he-mostatic forceps, 8 inch; 1 Schroeder uterine tenaculum forceps, single tooth; 1 Schroeder uterine vulsellum forceps, double tooth; 2 Jarit hysterec-tomy forceps, straight, 8½ inch; 2 Jarit hysterectomy forceps, curved, 8½ inch; 2 Heaney needle holders; 2 medium blades for O’Sullivan-O’Connor retractor, side view; 1 large blade, front view.





97CHAPTER 21 Abdominal Hysterectomy

A B C D

A B C D

21-2 Left to right: A, Heaney hysterectomy forceps, single tooth, and tip; B, Heaney-Ballantine hysterec-tomy forceps, single tooth, and tip; C, Schroeder uterine tenaculum forceps, straight, with single-tooth tip, and Schroeder uterine vulsellum forceps, with double-tooth tip; D, Z clamp, in tips, straight and curved.



B C D EA

B CA

21-3 Left to right: A and B, Jarit hysterectomy forceps: A, Straight, 81⁄2 inch, and tip; B, curved, 81⁄2 inch, and tip. C, Heaney needle holder, curved, 81⁄2 inch, and tip. D and E, Jorgenson dissecting scissors: D, Front view; E, side view.


99CHAPTER 22 Supracervical Laparoscopic Hysterectomy

Supracervical Laparoscopic Hysterectomy

Supracervical laparoscopic hysterectomy is the removal of the uterus without the cervix through a laparoscope.

Possible equipment needed for the procedure includes a laparoscope, laparoscopic instrumentation, a Harmonic scalpel, an electrosurgical unit, and a morcellator or minor laparotomy instrumentation.

A brief description of the procedure follows: 1. A Graves bivalve speculum is inserted into the vagina. A Schroeder uterine tenaculum

forceps grasps the cervix and a Cohen cannula is inserted into the cervix to establish uterine manipulation, or disposable uterine manipulators may be used.

2. The laparoscope is inserted in the usual manner. 3. A laparoscopic tenaculum is used to grasp the uterus. 4. A Harmonic scalpel and a LigaSure sealer/divider is used to dissect and cauterize the

uterine ligaments and vessels and to transect and cauterize the uterus above the cervix. 5. If used, a morcellator is inserted through another port. The morcellator is used to shave

the uterus into pieces so it may be removed. A heavy grasper is inserted through the morcellator to remove the uterine tissue fragments.

6. If a morcellator is not used, a mini laparotomy is performed to remove the uterus.

CHAPTER 22

22-1 Left to right: 1 Uterine manipulation probe; 1 Cohen cannula; 2 black Cohen cones; 1 uterine sound; 1 Schroeder uterine tenaculum forceps, single tooth; 1 Graves bivalve speculum.






22-3 Top to bottom: 1 Harmonic scalpel, 5 mm, 23 cm; 1 Harmonic cord; 1 tightening key.

22-2 Disposable uterine manipulators.


101CHAPTER 22 Supracervical Laparoscopic Hysterectomy

22-4 Top to bottom: 1 LigaSure impact sealer/divider, curved, 18 cm; 1 LigaSure sealer/divider, 19 cm; 1 LigaSure laparoscopic sealer/divider, 5 mm, 37 cm.

A B22-5 Tips: A, LigaSure impact sealer/divider; B, LigaSure laparoscopic sealer/divider.



22-6 Suction/irrigator with pump.

AS

SIS

TA

NT

ANESTHESIA

CA

ME

RA

HO

LDE

R

SCRUB

SU

RG

EO

N

VIDEO

2*

VIDEO1

BACKTABLE


Patient in stirrups

__5__10

__5


22-7 Position for hysteroscopic procedures.


103CHAPTER 23 Vaginal Hysterectomy

Vaginal Hysterectomy

A vaginal hysterectomy is the removal of the uterus through a vaginal incision. Possible equipment needed for this procedure are Z clamps.

A brief description of the procedure follows: 1. An Auvard speculum and Heaney retractor are placed to visualize the cervix. 2. A Schroeder vulsellum forceps is used to grasp the cervix. 3. A Bard-Parker long scalpel handle #3 with a #10 blade is used to incise into the perito-

neum. 4. Heaney forceps and Z clamps are used for clamping uterine ligaments and vessels. 5. A long curved Mayo scissors is used to bisect the ligaments and vessels. 6. A curved Heaney needle holder is used to ligate the ligaments and vessels with the use of

Russian tissue forceps. 7. Foerster forceps with 4 × 4 sponges are used for hemostasis and visualization. 8. Allis-Adair forceps are used to approximate the peritoneum edges. 9. A long Crile-Wood needle holder is used to suture the peritoneum edges.

CHAPTER 23



23-1 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #4, long; 1 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, 7 inch; 1 Mayo dissecting scissors, curved; 1 Mayo dissecting scissors, long, curved; 2 Ferris Smith tissue forceps; 2 Russian tissue forceps; 1 tissue forceps without teeth, long.




23-2 Top to bottom: 1 Uterine sound; 1 Yankauer suction tube with tip. Bottom, left to right: 4 Paper drape clips; 2 Backhaus towel clips; 8 Crile hemostatic forceps, 6½ inch; 4 Halsted hemostatic forceps; 12 Allis tissue forceps; 6 Allis-Adair tissue forceps; 4 tonsil hemostatic forceps; 2 Heaney needle holders; 2 Crile-Wood needle holders, 8 inch; 2 Heaney hysterec-tomy forceps, single tooth, curved; 2 Heaney-Ballantine hysterectomy forceps, single tooth, curved; 2 Och-sner hemostatic forceps, 8 inch; 2 Allis tissue forceps, long; 2 Babcock clamp tissue forceps, medium; 2 Schroeder uterine tenaculum forceps, single tooth; 1 Schroeder uterine vulsel-lum forceps, double tooth, straight; 2 Foerster sponge forceps.

23-3 Top, left to right: 1 Graves vaginal speculum; 1 Auvard weighted vaginal speculum, medium lip. Bottom, left to right: 2 Heaney retractors; 1 Auvard weighted vaginal speculum, long lip; 2 Deaver retractors, narrow.

B C D E FA

23-4 Left to right: Tips: A, Allis tissue forceps; B, Allis-Adair tissue forceps; C, Heaney hysterectomy forceps, single tooth, curved; D, Heaney-Ballantine hys-terectomy forceps, single tooth, curved; E, Schroeder uterine tenaculum forceps, single tooth; F, Schroeder uterine vulsellum forceps, double tooth, straight.


105CHAPTER 24 Laparoscopic Tubal Occlusion

Laparoscopic Tubal Occlusion

Tubal occlusion is the interruption of the fallopian tubes for the purpose of permanent sterilization.

Possible equipment needed for the procedure includes laparoscopic instrumentation and the method of tubal occlusion. There are various options: Falope rings and applier, Filshie clips and applier, or bipolar and electrosurgical generator.

A brief description of the procedure follows: 1. A Cohen cannula is inserted into the cervix vaginally to elevate the uterus (see Figure 21-2). 2. The laparoscope is inserted in the usual manner. 3. A manipulation probe is used to expose the fallopian tube. 4. The Endoflex retractor is used to retract the structures away from the tube. 5. Babcock tissue forceps are used to stabilize the tube. 6. A Falope ring applier with silastic band, a Filshie clip applier with clip, or a bipolar for-

ceps is introduced. 7. The ring is placed over a loop of the fallopian tube or a clip is placed over a segment of the

fallopian tube. If the bipolar forceps are used, a segment of the fallopian tube is cauterized.

CHAPTER 24

24-1 Top to bottom, left to right: 1 Wolf bipolar outer sheath; 2 bipolar internal graspers; 1 handle; 1 cord.






24-2 Top to bottom: 1 Fallopian ring applicator, extended; 1 fallopian ring separate and 1 in package; 1 fallopian applicator tip; 1 fallopian ring pusher; 1 Filshie clip applicator with clip; 1 Filshie clip separate with blue dispos-able handle.

24-3 Left to right, top to bottom: 1 Fallopian applicator tip; 1 fallopian ring; 1 Filshie clip with blue handle; 1 Filshie clip.


107CHAPTER 24 Laparoscopic Tubal Occlusion

24-4 Position for tubal occlusion.

AS

SIS

TAN

T

ANESTHESIA

CA

ME

RA

HO

LDE

R

SCRUB

SU

RG

EO

N

VIDEO

2*

VIDEO1

BACKTABLE


Patient in stirrups

__5__5



108 UNIT 4 Genitourinary Surgery

Cystoscopy

Cystoscopy is the visualization of the urinary bladder, urethra, bladder neck, and ureteral orifices via a cystoscope. Males will also have their ejaculatory duct and the lobes of the prostate examined. Possible procedures include cystograms, retrograde pyelograms, ful-guration of the bladder, bladder biopsies, stone removal, transurethral resections of the prostate (TURPs), transurethral resections of bladder tumors (TURBTs), and urethrotomy.

If the urethra is constricted for any reason, possible equipment needed for the proce-dure includes passing graduated sized Van Buren dilators for men and Walther dilators for women and a urethrotome with blades.

A brief description of the procedure follows: 1. A sheath and obturator are lubricated and inserted into the urethra. 2. An obturator is removed, the bladder is drained, and the cystoscope 30-degree telescope

is inserted into the sheath. 3. Irrigation tubing and the fiber optic light cord are attached and the bladder is filled with

solution for visualization. 4. A visual obturator may be used if there is difficulty placing the sheath and obturator. 5. If ureteral catheterization is necessary, an Albarran deflector is used to help guide the

catheter into the ureter. If a stone presents within the bladder, a stone breaker may be utilized. This is a handheld intracorporeal contact lithotripter. It is nonelectric, powered by high-pressure carbon dioxide gas. This device is used most commonly via a passage through a cystoscope to destroy a bladder stone, sometimes a distal ureteral stone, and percutaneously via a nephroscope to break up a large kidney stone.

CHAPTER 25



UNIT FOUR: GENITOURINARY SURGERY



109CHAPTER 25 Cystoscopy

25-1 Top to bottom: 1 Olympus cysto-scope high-definition urology camera; 1 light cord.

25-2 Basic cystoscope. Top to bot-tom, left to right: 1 Grasping forceps, 7 Fr, flexible; 1 stopcock, 3 mm; 2 silicon seal caps (1 on side); 1 cystoscope obturator; 1 cystocope sheath, 21 Fr; 1 cystoscope lens, 70-degree; 1 cystoscope lens, 30-degree; 1 catheter deflector; 1 single bridge channel adapter; 1 double bridge channel adapter.



25-3 Left to right: Double-action stent grasper; biopsy forceps, straight; biopsy forceps, angled.

25-5 Top to bottom: 1 Bugbee elec-trode; 1 Bugbee cord.

A B25-4 Left to right: Tip: A, Double- action stent grasper; B, biopsy forceps, straight and angled.


111CHAPTER 25 Cystoscopy

25-7 Top to bottom, left to right: 1 single-use probe; 1 CO2 cartridge; 1 sterilization cap; 1 exhaust cap; 1 stone breaker pneumatic lithotripter with attached CO2 exhaust line.

25-6 Left to right, top to bottom: 1 Olympus flexible cystoscope; 1 irrigation plug adapter; 1 light cord; 1 flexible tooth grasping forceps, alliga-tor open.



Urethroscopy

Urethroscopies are usually done in addition to a cystoscopy and, as such, have very little additional instrumentation besides the cystoscope set. A common reason for doing a ure-throscopy is to treat a urethral stricture in which an internal urethrotomy is done with a urethrotome.

A brief description of the procedure follows: 1. A sheath and obturator are lubricated and inserted into the urethra. 2. The obturator is removed, and a telescope adapting bridge and telescope are inserted.

CHAPTER 26

26-1 Left to right: 1 Wolf optical urethrotome obturator, hollow 20.5 Fr; 1 Wolf optical urethrotome sheath; 1 cystoscope lens, 0 degree; 1 scalpel rigid stricture; 1 scalpel rigid stricture, ½ moon. Top to bottom: 1 Working element (handle) urethrotome; 1 single bridge channel adapter.





113CHAPTER 27 Ureteroscopy

Ureteroscopy

Ureteroscopies are procedures in which small scopes are inserted into the bladder and the ureters to diagnose and treat a variety of problems. Usually this procedure is performed so that the urologist can locate ureteral stones and then pass a tiny wire basket up into the ureter to grab the stones and remove them. Sometimes it is difficult to basket a stone due to the location or the size of the stone, and other equipment is necessary to treat the stone and decrease its size. This is usually done internally with either a holmium laser or externally with extracorporeal shock wave lithotripsy. Many times after these additional treatments no basketing is necessary and the stones will pass out of the urinary tract on their own. Sometimes a ureteral stent may be placed to help facilitate the passage of stones out of the urinary tract.

CHAPTER 27

27-1 Olympus flexible ureteroscope.






27-2 Top to bottom: 2 Sealing caps (1 on side), 3 mm; 1 rigid ureteroscope, dual lumen; 1 rigid ureteroscope, single lumen.

27-3 Left to right: 1 Disposable stone extractor, partially open; 2 channel adapters.

27-4 1 Holmium laser fiber.


115CHAPTER 28 Nephrectomy

Nephrectomy

A nephrectomy is the removal of a kidney. This can be done with a subcostal, transthoracic, transabdominal, or a laparoscopic approach. Instrumentation needed for an open proce-dure includes a basic laparotomy set and a self-retaining retractor.

A brief description of the nephrectomy procedure follows: 1. A Thompson retractor is used to expose the kidney area. 2. Metzenbaum dissecting scissors are used to incise Gerota’s capsule. 3. Adson tissue forceps are used for blunt dissection and hemostasis. 4. Curved Mayo dissecting scissors are used for sharp dissection. 5. Mixter hemostatic forceps are used to double-clamp the ureter. 6. Long Metzenbaum dissecting scissors are used to cut the ureter. 7. A Guyon-Péan vessel clamp or Herrick kidney clamps are used to double-clamp the

kidney pedicle.

CHAPTER 28

28-1 Left to right: 1 Lincoln- Metzenbaum scissors, narrow dissect-ing tip; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 1 probe dilator; 1 grooved director; 2 Hoen nerve hooks; 2 Love nerve retractors, straight, front view, 90-degree angle, side view; 2 Little retractors, medium; 4 Gil-Vernet retractors, assorted sizes.






28-2 Left to right: 4 Westphal he-mostatic forceps; 6 tonsil hemostatic forceps; 2 Adson hemostatic forceps, fine, curved; 1 Guyon-Péan vessel kidney clamp; 2 Herrick kidney clamps; 2 Satinsky (vena cava) clamps; 6 tonsil hemostatic forceps, 9½ inch; 2 tonsil hemostatic forceps, 10½ inch; 2 Babcock tissue forceps, extra long; 4 Mixter hemostatic forceps, 10½ inch, fine tip; 2 Ayers needle holders, extra long; 2 Heaney needle holders, long; 4 Randall stone forceps: full curve, ¾ curve, ½ curve, and ¼ curve.

B C D EA

B C DA

28-3 Left to right: A, Adson hemostatic forceps, fine curve, and tip; B, Herrick kidney clamp and tip; C, Satinsky (vena cava) clamp, medium, 4 cm, 9½ inch, and tip; D, Mixter hemostatic forceps, fine tip, 10½ inch, and tip; E, tip of Guyon-Péan vessel clamp, 9½ inch.


117CHAPTER 29 Laparoscopic Nephrectomy

Laparoscopic Nephrectomy

CHAPTER 29

29-1 Top to bottom: 3 Endoscopic Hem-O-Lok appliers with clips, 1 large, 1 small, and 1 medium; 1 Endoscopic Hem-O-Lok remover.

29-2 Hem-O-Lok, tip.






29-3 Top to bottom: 1 Laparoscopic Satinsky atraumatic clamp, short, 5 mm; 1 monopolar handle with ratchet; 1 laparoscopic Satinsky atraumatic clamp, long, 5 mm.

29-4 Percutaneous nephroscope with graspers. Top to bottom, left to right: 1 Stone grasping forceps; 1 tooth forceps, 3 prong, 42 cm; 1 red operat-ing channel seal; 1 green scope cap on operating telescope, 30 degree, 4-mm channel; 1 outer sheath, 25 Fr (on telescope), continuous flow; 1 at-tachment with stopcock.


119CHAPTER 30 Pubovaginal Sling/Anterior Repair

Pubovaginal Sling/Anterior Repair

Anterior and/or posterior repair procedures are used to repair prolapses of the vaginal wall or bulging that occurs when the bladder or urethra sink into the vagina. Pubovaginal slings are done to help control urinary stress incontinence by closing the urethra and bladder neck. Pubovaginal slings are done surgically with various materials and methods. Tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures are just a few of the methods that are used. The surgeon places a band of synthetic material around the urethra to lift the bladder and urethra with the right amount of support (like a hammock) via inci-sions in the groin, lower abdomen, and vagina. The tape is held in place by friction between the tape and the surrounding tissue.

CHAPTER 30

30-1 Left to right: 4 Halsted mosquito clamps, curved, 5 inch; 2 Crile forceps, straight, 6¼ inch; 2 Crile forceps, curved, 6¼ inch; 1 Péan artery forceps, 6½ inch; 2 Ochsner-Kocher artery for-ceps, 1 × 2 teeth, 6½ inch; 4 Allis tissue forceps, 5 × 6 teeth, 6 inch; 2 Adair tis-sue forceps, 6¼ inch; 1 right-angle for-ceps, 7 inch; 4 Boettcher tonsil artery forceps, curved, 7½ inch; 2 Wikstroem dissecting forceps, right angle, 8 inch; 1 Foerster sponge stick; 1 Crile-Wood needle holder, 6¼ inch; 1 Mayo-Hegar needle holder, 8 inch; 1 Heaney needle holder, curved, serrated, 8 inch; 1 Hegar uterine dilator, 7-8 mm.






30-2 Left to right: 1 Knife handle, #3; 1 Mayo dissecting scissor, curved, 6¾ inch; 1 Metzenbaum dissecting scissor, curved, blunt, 7 inch; 1 Mayo scissor, straight, 6¾ inch; 1 Forester scissor, curved, fine, blunt, 9 inch; 1 tissue forceps, 1 × 2 teeth, 61⁄4 inch; 1 tissue forceps, 1 × 2 teeth, 7½ inch; 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 1 DeBakey vascular tissue forceps, 7¾ inch; 1 Russian tissue forceps, 10 inch.

30-3 Left to right: 2 Volkmann rake retractors, sharp, 4 prong, 8¾ inch; 2 Army Navy retractors; 1 Richardson-Eastman retractor, double-ended; 1 Deaver retractor blade 1 × 123⁄8 inch; 1 Heaney-Simon vaginal retractor, 1 × 4½ inch; 1 Garrigue weighted vaginal speculum, short blade; 1 Garrigue weighted vaginal speculum, long blade.


121CHAPTER 30 Pubovaginal Sling/Anterior Repair

30-4 Left to right: 1 Cystoscope, 4 mm, 12-degree lens; 1 cystoscope, 4 mm, 70-degree lens. Top to bottom: 2 Red nipples 1-2 mm (1 on side); 1 single port bridge; 1 light cord; 1 stopcock; 1 Albarrán bridge; 1 cystoscope obtura-tor, 21 Fr.



Prostatectomy

A prostatectomy is a surgical procedure that removes either all or a portion of the prostate for treatment of prostate cancer or benign prostatic hyperplasia. There are many ways to remove the complete prostate including incisions via a retropubic, suprapubic, or perineum incision, and/or a laparoscopic or robotic approach. A partial prostatectomy is most com-monly done for benign prostatic hypertrophy via a transurethral approach.

Instruments needed for a suprapubic approach include an electrosurgical unit, addi-tional retractors, and a disposable skin stapler.

A brief description of the procedure follows: 1. After the abdomen is opened, a Balfour retractor with blades may be placed for visu-

alization. 2. A Harrington retractor may be needed to retract the abdominal structures superiorly. 3. Long Allis forceps may be used to stabilize the bladder. 4. A Bard-Parker long scalpel handle #3 with a #10 blade may be used to incise into the

bladder. 5. Long, curved Metzenbaum dissecting scissors may be used to extend the incision. 6. A small Richardson retractor may be used to hold the bladder walls open. 7. The prostate gland is enucleated manually. 8. Horizon clip appliers and clips may be used for hemostasis. 9. A long, fine-needle holder and a long DeBakey vascular atraugrip tissue forceps may

be used to close the bladder. 10. After closing the abdominal layers, the skin may be closed with staples with the aid of

Adson tissue forceps.

CHAPTER 31



31-1 Top: 1 Poole abdominal suction tube and shield. Left to right: 2 Yankauer suction tubes and tips; 6 paper drape clips; 4 Halsted mosquito hemostatic forceps, curved; 4 Halsted mosquito hemostatic forceps, straight; 1 Halsted hemostatic forceps; 6 Crile hemostatic forceps, 6½ inch; 4 tonsil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, curved; 2 Allis tissue forceps, medium; 1 Babcock tissue forceps, medium; 4 Ochsner hemostatic forceps, straight, long jaw; 6 Mixter hemostatic forceps, 9 inch; 6 tonsil hemostatic forceps, long; 4 Allis tissue forceps, extra long, curved; 4 Mixter hemostatic forceps, extra long; 3 Foerster sponge forceps; 2 Crile-Wood needle holders, 7 inch; 2 Crile-Wood needle holders, 8 inch; 2 Mayo-Hegar needle holders, 12 inch.



123CHAPTER 31 Prostatectomy

31-2 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #3, long; 2 Mayo dissecting scissors, curved and straight; 2 Metzenbaum dissecting scissors, 7 inch and extra long; 2 Snowden-Pencer scissors, straight and curved; 1 Jorgenson dissecting scissors; 1 Mayo dissecting scissors, long, curved.

31-3 Left to right: 2 Adson tissue for-ceps (1 × 2), front view and side view; 2 Ferris Smith tissue forceps (1 × 2), front view and side view; 2 Russian tissue forceps, front view and side view; 2 thumb tissue forceps with teeth (1 × 2), long, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, extra long, front view and side view.



31-4 Left to right: Hemoclip-applying forceps, 2 medium, 2 large.

31-5 Left to right: 1 Gil-Vernet retrac-tor; 2 Goelet retractors, front view and side view; 2 Gelpi retractors.


125CHAPTER 31 Prostatectomy

31-6 Left to right: 2 Greenwald suture guides, 24 Fr and 28 Fr; 3 Deaver retractors: narrow, side view; medium, front view; wide, side view; 2 Har-rington splanchnic retractors, small and large, side view.

31-7 Top: 2 Balfour abdominal retrac-tor fenestrated blades, large. Left to right: 1 Balfour abdominal retractor frame; 2 Balfour abdominal retractor fenestrated blades, small; 2 Balfour abdominal retractor center blades, large and small; 2 Richardson retrac-tors, medium and large; 3 Ochsner malleable retractors, narrow (side view), medium, and large.



31-8 Left to right: 1 Lone Star steel retractor, hinged; 1 Lone Star retractor hook, disposable; 1 Lone Star wrench, hex round, knurled handle.


127CHAPTER 32 Laparoscopic Prostatectomy

Laparoscopic Prostatectomy

CHAPTER 32



32-1 Laparoscopic Bull Dog Set. Right top, top to bottom: 1 Vascular bulldog, 45 mm, straight; 1 vascular bulldog, 45 mm, curved; 1 vascular bulldog, 25 mm, curved; 1 vascular bulldog, 25 mm, straight, (loaded into clip applier); 1 laparoscopic clip applier/remover, angled, 12.5-340 mm; 1 laparoscopic clip applier/remover, straight, 12.5-340 mm.




Transurethral Resection of the Prostate

Transurethral resection of the prostate (TURP) is the removal of the enlarged portion of the prostate gland with a resectoscope. Possible equipment needed for the procedure includes an electrosurgical unit, volumes of irrigating solution, a light source, and an Ellik evacuator. Today most TURPs are performed with bipolar energy.

A brief description of the procedure follows: 1. A Van Buren dilator is inserted to enlarge the urethra. 2. The resectoscope sheath with obturator is passed into the bladder. 3. Irrigating tubing is attached and the bladder is filled with solution. 4. A fiber optic cord and electrosurgery cord are connected. 5. The obturator is removed and the working element is inserted. 6. A cutting electrode is inserted to remove prostate tissue. 7. A ball electrode is used to cauterize bleeders. 8. An Ellik evacuator is used to retrieve the specimen that has floated into the bladder. 9. A spoon is used for prostate tissue that is drained from the bladder and collects on the

screen of the drape.

CHAPTER 33



33-1 Left to right: 1 Telescope 30-degree, 4 mm; 1 dual valve sheath, 22.5 Fr; 1 standard obturator; 1 visual obturator; 1 continuous flow resecto-scope inner sheath, 24 Fr; 1 deflecting obturator; 1 continuous flow resec-toscope outer sheath, 27 Fr with 2 vertical stopcocks; 1 high-frequency bipolar cable 4 mm; 1 working element, passive.



129CHAPTER 33 Transurethral Resection of the Prostate

33-2 Left to right, top to bottom: 8 Van Buren sounds; 1 spoon; 1 Ellik evacuator; 1 light cord.

A B C A B C

33-3 Left to right: A, Cutting electrode with pointed end and tip; B, coagulating electrode with ball end and tip; C, cutting electrode with round wire and tip.



Vasectomy

A vasectomy is the transection of both vas deferens in the scrotum for the purpose of per-manent sterilization.

A brief description of an open procedure follows: 1. A Beaver knife is used to make an incision over the vas. 2. Providence Hospital hemostatic forceps are used for clamping bleeders. 3. Westcott tenotomy scissors are used for blunt dissection of the vas. 4. Jeweler’s forceps are used to grasp the vas. 5. Providence Hospital hemostatic forceps are used for clamping the vas. 6. A Beaver knife is used to bisect the vas. 7. DeBakey tissue forceps are used to assist in closing the incision. 8. A Barraquer needle holder is used to suture the incision.

CHAPTER 34

34-1 Top to bottom, left to right: 1 Beaver knife handle, knurled, with tip; 1 Jeweler’s forceps; 2 DeBakey vas-cular atraugrip tissue forceps, short. Bottom, left to right: 1 Iris scissors, straight, sharp; 1 Stevens tenotomy scissors; 4 Providence Hospital hemostatic forceps; 2 Backhaus towel forceps.





131CHAPTER 34 Vasectomy

34-2 Left to right: 1 Vannas capsu-lotomy scissors; 1 Westcott tenotomy scissors; 3 Henle probes, assorted sizes; 1 lacrimal probe, 0-00; 1 titanium microneedle holder, nonlocking; 1 Bar-raquer needle holder, extra delicate, tapered, curved, with lock; 1 Troutman tier needle holder with lock.

34-3 Top, left to right: 2 Chamber maintainers; 1 Silber vasovasostomy clamp; 1 Strauch vasovasostomy approximator, hinged, small; 1 vasova-sostomy approximator, hinged, large. Bottom, left to right: 2 McPherson tying forceps, angled, front view and side view; 1 Castroviejo suturing forceps, 0.12 mm, front view; 3 Jeweler’s forceps #3, side view, front view, and side view; 2 Jeweler’s forceps #4, front view and side view; 1 Jeweler’s forceps #5, front view; 1 Snowden-Pencer dissecting forceps; 1 Snowden-Pencer fixation forceps.



34-4 Left to right: 1 Snowden-Pencer dissecting forceps; 1 Snowden-Pencer fixation forceps.


133CHAPTER 35 Penile Prosthesis

Penile Prosthesis

A penile prosthesis is a surgical treatment for erectile dysfunction. Erectile dysfunction can either be of an organic nature or a common cause from nerve damage due to a radical pros-tatectomy. Penile prostheses can be either bendable or inflatable. The bendable prosthesis is comprised of rods implanted into the erection chambers of the penis. These rods can be bent and positioned to the individual’s preference depending on their activity. An inflatable prosthesis enables the man to have an erection whenever he chooses and can be disguised more easily.

CHAPTER 35

35-1 Left to right: 1 Joseph scissors, curved, 5 inch; 1 Mayo TC scissors, curved, 6½ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Vital Mayo dissecting scissors, beveled blades, straight, 6¾ inch; 2 Vital Mayo-Hegar TC needle holders, 6¼ inch; 1 Crile-Wood TC needle holder, 6 inch; 2 Babcock tissue forceps; 4 Allis forceps, 5 × 6 teeth, 6 inch; 1 Kantrowitz right angle forceps, ser-rated, 8 inch; 2 Schnidt forceps, 7½ inch; 6 Crile forceps, curved, 6¼ inch; 6 Halsted mosquito forceps, straight, 5 inch; 22 Halsted mosquito forceps, curved, 5 inch.






35-2 Left to right: 2 Knife handles, #3; 1 tissue forceps, 1 × 2 teeth, 6 inch; 1 Adson forceps, delicate, 1 × 2 teeth with serrations, 4¾ inch; 2 Adson forceps, 1 × 2 teeth, 6 inch; 2 DeBakey vascular atraugrip tissue forceps, 7¾ inch; 1 Hegar uterine dilator, 7-8 mm, 8 inch; 1 Hegar uterine dilator, 9-10 mm, 8 inch; 1 Hegar uterine dilator, 11-12 mm, 8 inch; 1 Hegar uterine dilator, 13-14 mm, 8 inch; 1 Hegar uterine dilator, 15-16 mm, 8 inch; 1 steel ruler, gradu-ated in millimeters and inches, 6 inch.

35-3 Left to right: 1 Richardson retractor, double-ended, large; 1 Deaver retractor, 3⁄8 inch blade width, 8 inch; 2 Army Navy retractors, 8 inch; 2 S-retractors; 1 Davis brain spatula, 3⁄8 inch; 1 Davis brain spatula, ¼ inch; 2 Senn retractors, sharp, 6¾ inch; 2 Ragnell-Davis retractors; 2 Volkmann rake retractors, medium.


135CHAPTER 35 Penile Prosthesis

35-4 Left to right: 1 Killian nasal speculum, 5-inch blade, 85 × 8.5 mm wide; 1 Furlow insertion tool; 1 Furlow insertion tool obturator; 1 cavernotome, 6 mm; 1 cavernotome, 7 mm; 1 cavernotome, 9 mm; 1 cavernotome, 11 mm; 1 cavernotome, 13 mm; 1 AMS closing tool; 1 AMS Quick Connect assembly tool; 1 tubing passer, curved.


136 UNIT 5 Orthopedic Surgery

Basic Orthopedic Surgery

Orthopedics is surgery on the skeletal system. The variety of procedures that may be per-formed are too numerous to be included in this book.

In most surgeries, a small soft-tissue dissection set is needed to expose the bony struc-tures. The general instrumentation and a description of possible equipment needed for orthopedic procedures include the following: 1. Chisels are used to shape bone. They come in several widths and require the use of a

mallet. Hoke and Hibbs chisels are two that are commonly used. 2. Periosteal elevators are used for removing periosteum. They, too, require the use of a

mallet. Key and Langenbeck elevators are commonly used. 3. Bone curettes are used to scrape and shape bone. They are available in several cup

sizes. Spratt and Cobb curettes are commonly used. 4. Rongeurs, used to shape bone, include Luer, Kerrison, Adson, and Smith-Petersen

rongeurs. 5. Bone cutters are used to cut bone for removal. They include Ruskin-Liston

bone cutters. 6. Bone clamps are used to stabilize the long bones during fixation. They include Low-

man and Kern clamps. 7. Retractors are used for visualization and sometimes for supporting structures during

surgery. There are, among others, Hibbs, Taylor, Doane, and Bennett retractors. 8. Rasps are used to smooth the bone or to ream the shaft of a long bone for implanta-

tion. They include Putti, Aufricht, Wiener, and Lewis rasps. 9. Gouges are used for removing large pieces of bone. They are used with a mallet and

include such names as Smith-Petersen, Hibbs, and Cobb. 10. Bone hooks are used to stabilize bone. 11. Bone forceps such as the Joplin forceps are used to hold bone. 12. Mallets are used with chisels, periosteal elevators, gouges, impactors, and osteotomes.

Some mallets are the Lucae, Mead, Heath, and Kirk mallets. 13. Osteotomes are used to shape bone and are used with a mallet. Cottle and Converse

are the names of two osteotomes.

CHAPTER 36



UNIT FIVE: ORTHOPEDIC SURGERY



137CHAPTER 36 Basic Orthopedic Surgery

36-1 Top, left to right: 1 Metal medicine cup, 2 oz; 1 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, 5 inch. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 plastic scissors, straight, sharp; 1 plastic scissors, curved, sharp; 2 thumb tissue forceps with teeth (1 × 2), front view and side view; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Brown-Adson tissue forceps with teeth (9 × 9), front view and side view; 2 paper drape clips; 2 Backhaus towel forceps; 6 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps, curved, 5½ inch; 2 Allis tissue forceps; 2 Ochsner hemostatic forceps; 2 Crile-Wood needle holders, 6 inch; 1 Crile-Wood needle holder, 7 inch.

36-2 Top: 2 Adson suction tubes with finger valve controls and stylets, 9 Fr and 11 Fr. Bottom, left to right: 2 Joseph skin hooks, double prong, front view and side view; 2 Miller-Senn retractors, side view and front view; 2 Hohmann retractors, mini, front view and side view; 1 Freer elevator; 5 Hoke chisels, assorted sizes; 3 front view, 4th side view, and 5th front view; 1 Key periosteal elevator, ¼ inch; 1 Key periosteal elevator, ½ inch.



36-3 Top, left to right: 1 Weitlaner retractor, baby, curved; 1 metal ruler, 6 inch. Bottom, left to right: 1 Lucae mallet; 1 Ruskin rongeur, double-action; 1 Ruskin-Liston bone-cutting forceps; 2 Volkmann retractors, 2 prong, sharp; 2 Army Navy retractors, front view and side view.


139CHAPTER 37 Power Saws and Drills, Battery Powered

Power Saws and Drills, Battery Powered

Power saws and power drills are commonly used equipment. Power saws are used to remove or shape bone. The blades of an oscillating saw move back and forth in a swinging motion, whereas the blades of a reciprocating saw move back and forth in a straight line. The power source may be a battery pack, compressed nitrogen, or electricity. When setting up the saw, it is important to attach the power cord to the saw before attaching it to the power source.

Power drills are used to make holes for the insertion of wires or screws or for reaming long bones. Some drill bits are attached by a chuck that requires a key, whereas others may be tightened with a keyless chuck. Drill bits may be cannulated so wires can be used as guides for the drill. Power drills include the Stryker system 5 battery drills, Synthes small battery system, Stryker Mini Driver, and Stryker REM B.

CHAPTER 37



37-1 Stryker System 5 in case: drills, batteries, and most of the attachments are shown in the top right of the case. Far right, top: Pin collet.




37-2 Top to bottom: Oscillating saw and battery.

37-3 Left, top to bottom: ¼ inch Key-less drill attachment; drill; ¼ inch drill; chuck key. Right, top to bottom: Dual-trigger rotary hand piece; battery.



37-4 Top: 1 Synthes Small Battery Drive II hand piece. Bottom, left to right: 1 Synthes Small Battery Drive casing; 1 Synthes battery insertion shield; 1 Synthes 14.4-volt battery.

37-5 Synthes Small Battery attach-ments. Top, left to right: 3 Synthes AO quick coupling chucks: 1 ream attachment, up to 7.3 mm; 1 chuck drill attachment, up to 7.3 mm; 1 chuck drill attachment, up to 4.0 mm; 1 chuck key; 1 Synthes quick coupling for K wires; 1 saw blade; 1 Synthes sagittal saw attachment. Bottom, left to right : 1 Synthes mini quick coupling; 1 burr attachment; 1 screw attachment; 1 Hudson quick coupling; 1 AO quick coupling.



37-6 Stryker Mini 4200 Driver in case.

37-7 Left, top to bottom: Dual-trigger rotary hand piece; battery. Middle: Pin collet. Right, top to bottom: Jacobs chuck attachment; chuck key; oscillat-ing saw attachment; Synthes chuck.



37-8 Top, left to right: 1 Stryker REM B cord; 1 hand piece; 1 wire collet; 1 pin collet. Bottom, left to right: 1 Chuck key; 1 Jacobs chuck, 5⁄32 inch; 1 Jacobs drill, ¼ inch; 1 drill adapter; 1 micro drill long; 1 micro drill and hand switch; 1 sagittal saw and hand switch.



Small Joint Arthroscope Set

Arthroscopy is the visualization of a joint via a scope. The diameter and length of the scope vary according to the size of the joint.

Possible equipment needed for the procedure includes 1 Bard-Parker knife handle #3; 1 Adson tissue forceps with teeth (1 × 2); 1 Mayo dissecting scissors, straight; 1 Halsted mosquito hemostatic forceps, curved; and 1 Webster needle holder.

CHAPTER 38

38-1 Left to right: 1 Trocar sleeve, 2.7 mm; 1 pyramidal trocar; 1 blunt obturator; 1 probe; 1 telescope lens, 25-degree.

38-2 In case, left: 1 Blunt probe; 1 hook probe; 1 straight rasp; 1 angled-down rasp; 1 angled-up rasp; 1 lateral-release knife; 1 retrograde knife; 1 serrated banana knife; 1 meniscecto-my knife, right; 1 meniscectomy knife, left; 1 handle. In case, right top: 1 Blunt obturator; 1 pyramidal trocar. Right bottom: 2 Trocar sleeves; telescope lens, 30-degree. Right, top to bottom, not in case: 1 Cup forceps; 1 scissors; 1 grasper.





145CHAPTER 39 Arthroscopic Carpal Tunnel Instruments

Arthroscopic Carpal Tunnel Instruments

Carpal tunnel syndrome is the narrowing of the space where the median nerve enters the hand from the wrist. An arthroscope is used for the arthroscopic carpal tunnel release pro-cedure. Lactated Ringer’s solution or saline is often used to distend the joint for visualiza-tion.

Possible carpal tunnel instruments needed for the procedure include a small joint arthro-scope set, 1 Bard-Parker knife handle #3; 1 Mayo dissecting scissors, straight; 1 Adson tis-sue forceps with teeth (1 × 2); and 1 Crile-Wood needle holder.

A brief description of the arthroscopic carpal tunnel release procedure follows: 1. A small arthroscope is inserted with the usual attachments into the carpal tunnel. 2. A retrograde knife incises the flexor reticulum with the aid of the arthroscope.

A brief description of the open carpal tunnel release procedure follows: 1. A Bard-Parker scalpel handle #3 with a #10 blade is used to make a small incision in the

palm of the hand. 2. A probe is inserted along the carpal tunnel narrowing. 3. A #3 Hegar dilator may be inserted to open the space. 4. A blunt dissector may be used to release the stricture.

CHAPTER 39

39-1 Left to right: 1 Ridged obturator; 1 straight blunt dissector; 1 curved blunt dissector; 1 right-angle probe; 3 Hegar dilators (3, 4, and 5). Right, top to bottom: 1 Carpal tunnel video endo-scope, 30 degrees; 1 slotted cannula; 2 gold handles for disposable carpal tunnel blades.






Small/Minor Joint Replacement

Small joints are replaced with Silastic prosthetics to relieve pain and improve function.Possible equipment needed for the procedure includes a small bone set; a prosthesis; and

a mini drill with bits and burrs.A brief description of the procedure follows:

1. A Bard-Parker scalpel handle #3 with a #15 blade is used to make an incision on the dorsal side of the joint.

2. A weitlaner retractor is placed to expose the joint. 3. A Ruskin-Liston bone cutter is used to cut the distal and proximal ends of the bones of

the joint. 4. An Adson rongeur is used to round the bone ends. 5. The mini drill is used to ream both bone canals. 6. The caliper is used to measure the length of the bone for sizing the prosthesis. 7. The Silastic prosthesis is inserted. 8. The ligaments and tendons are reattached as needed. 9. The incision is closed.

CHAPTER 40

40-1 Top to bottom, left to right: 1 Metzenbaum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, straight; 1 bandage scissors, 8 inch; 1 Mayo dissecting scissors, curved. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Bard-Parker knife handle #4; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Ferris Smith tissue forceps, front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), 8 inch, front view and side view; 6 paper drape clips; 2 Backhaus towel forceps; 6 Crile hemostatic forceps, 5½ inch; 2 tonsil hemostatic forceps; 2 Ochsner hemostatic forceps, long; 2 Allis tissue forceps, long; 2 Crile-Wood needle holders, 7 inch.





147CHAPTER 40 Small/Minor Joint Replacement

40-2 Top, left to right: 2 Adson suction tubes with finger valve controls: 1 straight, 1 curved, with stylets; 1 metal ruler, 6 inch; 1 caliper, inside/outside. Bottom, left to right: 2 Weitlaner retractors, sharp, medium; 2 Volkmann retractors, 2 prong, sharp; 2 Volkmann retractors, 2 prong, dull; 2 Army Navy retractors, side view and front view.

40-3 Top, left to right: 1 Heath mallet; 1 pliers. Bottom, left to right: 3 Spratt curettes: long curved, 2-0, and 3-0; bone hook; 1 Ruskin-Liston bone- cutting forceps, double-action; 1 Adson rongeur, double-action; 1 Luer bone rongeur.



Total Ankle Prosthesis

The most frequent cause of debilitating ankle pain is arthritis. Three of the most common causes of joint damage are (1) osteoarthritis, (2) rheumatoid arthritis, and (3) trauma-related arthritis.

CHAPTER 41

41-1 Preoperative: post-traumatic left ankle arthritis.





149CHAPTER 41 Total Ankle Prosthesis

41-2 Postoperative: left Agility LP total ankle arthroplasty.

41-3 Postoperative: left Agility total ankle arthroplasty with custom stem talar component and subtalar joint fusion.



Arthroscopy of the Knee/Shoulder

Possible equipment needed to perform surgery through an arthroscope includes: 1. Joint arthroscopic instrumentation. 2. Arthroscopic linear punch used to grasp tough tissue, such as periosteum or cartilage. 3. Arthroscopic biters and baskets to remove tissue and cartilage. 4. Arthroscopic shaver and shaver tips. 5. A specialty suture passer may be used to secure a repair.

CHAPTER 42

42-1 Top, right: Large bandage scis-sors. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 self-locking trocar sleeve, 4 mm; 1 blunt obturator, 4 mm; 1 LUMINA telescope, 25 degrees, 4 mm; 1 egress cannula, 4.5 mm; 1 pyramidal trocar, 3.7 mm; 1 conical obturator, 3.7 mm; 2 probes; 1 Adson tissue forceps with teeth (1 × 2); 1 Crile-Wood needle holder, 6 inch; 1 Mayo dissecting scis-sors, straight.





151CHAPTER 42 Arthroscopy of the Knee/Shoulder

42-2 Left to right: Tips: 1 Acufex duckbill biter, right; 1 Acufex duckbill biter, left. 1 Acufex duckbill biter, upbite; 1 Acufex duckbill biter, straight bite. Tips: 4 Acufex duckling bill biters: right; upbite; straight; left.

42-3 Acufex biter tip.



42-4 Left to right: 1 Grasper. Tips: 1 Acufex upbiting linear punch, 1.3 mm; 1 Acufex upbiting linear punch, 1.5 mm; 1 Acufex basket, 90 degrees, 2.2 mm, left; 1 Acufex basket, 90 degrees, 2.2 mm, right.

42-5 Left to right: Stryker arthros-copy shaver; 1 sheath; 1 shaver; 1 sheath; 1 shaver.


153CHAPTER 42 Arthroscopy of the Knee/Shoulder

42-6 Arthrex scorpion suture passer, 16 mm.

42-7 Scorpion suture passer: A, Closed; B, open with needle.A B



Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon Bone Graft Instruments

In addition to arthroscopic joint instrumentation, possible equipment needed for the pro-cedure includes: 1. Acorn cannulated drill bits used for femoral drilling. 2. Acufex cannulated drill bits used for tibial drilling. 3. Rasps used to smooth bone. 4. Arthrex tips used as graft pushers to push the tendon into position; a femoral tun-

nel notcher for graft attachment; and a femoral positioning drill guide for placing guidewires.

5. An Isotac screwdriver used with suture to secure the graft.

CHAPTER 43

43-1 Top, left to right: 1 Tonsil he-mostatic forceps, straight; 1 Webster needle holder, 5 inch; 1 small sharp scissors. Middle: 1 Jacobs chuck. Bot-tom, left to right: 7 Acufex graft sizers, 6-12 mm; 3 Acufex isometric centering guides, 7-8 mm, 9-10 mm, 11 mm; 1 parallel drill guide, 5 mm; 1 isometric positioner; 6 acorn cannulated drill bits for femoral drilling; 6 Acufex can-nulated drill bits for tibial drilling.





155CHAPTER 43 Arthroscopic Anterior Cruciate Ligament Reconstruction

43-2 A, Left to right: 1 Arthrex graft pusher; 1 Arthrex femoral tunnel notcher; 1 Arthrex over-the-top femoral positioning drill guide, 6 mm; 1 Arthrex over-the-top femoral positioning drill guide, 7 mm; 1 osteotome, thin, ¼ inch; 1 Isotac screwdriver with su-ture and Isotac in place; 3 chamfering rasps, convex, concave, half-round; 2 gouges, ¼ inch, straight and curved; 1 osteotome, ¼ inch, curved. B, Left to right: 4 Arthrex tips: graft pusher; femoral tunnel notcher; over-the-top femoral positioning drill guide, 6 mm; over-the-top femoral positioning drill guide, 7 mm; osteotome, ¼ inch, thin; Isotac screwdriver with suture and Isotac in place. C, Left to right: 3 Rasp tips: convex, concave, and half-round; 2 gouges, ¼ inch; tips: curved and straight; 1 osteotome, ¼ inch, curved.

A

B

C



43-3 Top to bottom: 2 Hyperflex guidewires; 2 Beath passing pins; 1 Kirschner wire (K-wire); 1 drill bit, 1⁄16 inch. Bottom, left to right and top to bottom: 3 Templates: 8 and 9, side view; 10, front view; 1 Beyer rongeur, curved; 1 Ferris Smith rongeur, cup jaw (Martin); 1 pituitary rongeur.

43-4 Left to right: 2 Tibial aiming hooks, right and left, for Arthrex tibial aiming guide; 1 Kirschner wire (K-wire) sleeve for Concept precise tibial aim-ing guide; 1 K-wire sleeve for Arthrex tibial aiming guide; 1 notchplasty gouge. Right, top to bottom: 1 Concept precise tibial aiming guide; 1 Arthrex tibial aiming guide.


157CHAPTER 44 Total Knee Replacement

Total Knee Replacement

A total knee replacement is the removal of the distal end of the femur and the proximal end of the tibia. A prosthesis is used to reestablish the joint.

Possible equipment needed for the procedure includes a total joint replacement set and battery powered drills.

A brief description of the procedure follows: 1. A positioning device may be used. The De Mayo knee positioner assists in the stabili-

zation of the patient’s leg during surgery. The spring loaded lever allows for control of flexion, extension, tilt, and rotation.

2. A Doane retractor is used to protect the medial collateral ligament. 3. An alignment guide is placed lateral to the tibial tubercle. 4. A power saw is used to resect the proximal end of the tibia. 5. Spacer/alignment blocks are used to check for valgus alignment. 6. The AP cutting guide is used to determine where to cut the femur. 7. The saw is used to resect the distal end of the femur. 8. Tibial and femoral ends are checked for size. 9. The trial components are placed and secured. 10. The joint is evaluated and the trials are removed. 11. A prosthesis is chosen and placed. Both a femoral impactor and a tibial impactor are

needed. A mallet is used to seat each component.

CHAPTER 44

44-1 Sigma total knee, base femur and tibia pan #1.






44-2 Sigma total knee, base femur and tibia pan #2.

44-3 Sigma total knee, fixed REF femur prep pan #1.

44-4 Sigma total knee, fixed REF femur prep pan #2.



44-5 Sigma total knee, patella inser-tion pan #1.

44-6 Sigma total knee, patella inser-tion pan #2.

44-7 Sigma total knee, femoral trials pan.



44-8 Sigma total knee, FB tibia prep pan.

44-9 Sigma total knee, spacer blocks pan #1.

44-10 Sigma total knee, spacer blocks pan #2.



44-11 Sigma total knee, MBT prep pan.

44-12 De Mayo knee positioner: Top : Base. Bottom, left to right : Universal distractor, single lever clamp, and foot holder.



44-14 Left to right: 1 Depuy cement mixer. Right, top to bottom: 1 Cement gun; 1 cement restrictor; 1 nozzle; 1 spatula; 2 cement scrapers.

44-13 Stryker cement gun.



44-15 Left to right: 1 Impactor; 2 Doane retractors, side view and front view.

44-16 NexGen system. Left to right: 1 Patella button; 1 femoral component; 1 articulating surface; 1 stem–tibial base plate.



Shoulder Surgery Instruments

Possible equipment needed for a shoulder procedure includes specialized retractors, files, punches, and forceps.

A brief description of the open surgical procedure follows: 1. Retractors are placed to help visualize the joint and hold structures out of the operative

field. These include the humeral head retractor, the glenoid self-retaining retractor, the Bankart shoulder retractor, and the Bateman glenoid retractor.

2. A bone file is used to shape the bone. 3. A glenoid punch is used to grasp the cartilage. 4. Joplin bone forceps are used to grasp and stabilize bone.

CHAPTER 45

45-1 Left to right: 2 Humeral head retractors, side view and front view; 2 Richardson retractors, small, side view and front view; 2 Richardson retractors, medium, side view and front view; 2 Hibbs laminectomy retractors, side view and front view.





165CHAPTER 45 Shoulder Surgery Instruments

45-2 Left to right: 1 Glenoid self-retaining retractor with 4 blades: 2 short, 2 long, front view and side view; 1 glenoid (Bateman) retractor, narrow; 1 glenoid (Bateman) retractor, medium; 1 shoulder retractor, angled, short; 1 Bankart shoulder retractor; 1 shoulder retractor, angled, long.

45-3 Left to right: 1 Shoulder ligature carrier; 2 bone hooks; 1 double-ended blunt elevator; 1 Foman rasp, double-ended; 1 glenoid punch; 1 Joplin bone forceps.



Hip Fracture

A hip fracture is usually a break in the neck of the femur. The fracture may be pinned with a nail, a screw, or a screw and plate.

Possible equipment needed for the procedure includes hip retractors.A brief description of the hip-pinning procedure follows:

1. An Israel retractor is used for muscle retraction. 2. A Hibbs retractor is used for visualization of the hip joint. 3. A Bennett elevator is used to raise the femur into position. 4. A Scott-McCracken elevator is used to remove periosteum. 5. A Hohmann retractor is used to hold soft tissue back from the operative site. 6. An Adson suction tip with tubing is used for visualization. 7. A drill guide is used to show the angle of drilling. 8. A drill is used to make a hole for the nail or the screw. 9. A depth gauge is used to determine the length of the dynamic hip screw (DHS). 10. A nail is inserted. 11. If a plate is needed, it is chosen to fit the femur. A drill is used to start the screw holes;

a depth gauge is used to determine the screw length; and a screwdriver is used to tighten the screws.

CHAPTER 46

46-1 Top to bottom: 1 Yankauer suction tube with tip; 2 Adson suction tubes with finger valve controls and stylets, large. Bottom, left to right: 1 Metal ruler, 6 inch; 1 pliers; 6 paper drape clips; 2 Backhaus towel forceps; 6 Crile hemostatic forceps, 6½ inch; 2 tonsil hemostatic forceps; 4 Ochsner hemostatic forceps, 8 inch; 2 Crile-Wood needle holders, 8 inch.





167CHAPTER 46 Hip Fracture

46-2 Top, left to right: 2 Mayo dis-secting scissors, straight; 1 Metzen-baum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, curved. Bottom, left to right: 2 Bard-Parker knife handles #4; 2 Adson tissue for-ceps with teeth (1 × 2), front view and side view; 2 thumb tissue forceps with teeth (1 × 2), front view and side view; 2 thumb tissue forceps with multiteeth (4 × 5), front view and side view; 2 Ferris Smith tissue forceps, front view and side view.

46-3 Left to right: 2 Bone hooks; 2 Army Navy retractors, front view and side view; 2 Volkmann retractors, 2 prong, sharp; 2 Volkmann retractors, 6 prong, sharp, front view and side view; 2 Israel retractors, front view and side view.

46-4 Left to right: 2 Weitlaner retrac-tors, medium, sharp; 2 Bennett bone elevators and retractors, side view and front view; 2 Hibbs laminectomy retractors, medium, side view and front view.



46-5 Left to right: 1 Scott-McCracken elevator; 1 Key periosteal elevator, ¾ inch; 1 Heath mallet; 1 Luer bone rongeur; 2 Lowman bone-holding clamps, front view.


169CHAPTER 47 Hip Retractors

Hip Retractors

Hip retractors are made to be used in the various angles of the hip joint.

CHAPTER 47

47-1 Left to right: 1 Antler retractor, front view; 1 double Cobra retractor, side view; 2 blunt Cobra retractors, side view; 1 Hohmann retractor, front view; 1 bone hook.

47-2 Top: 1 Flexible depth gauge. Bottom, left to right: 2 Anterior retrac-tors, left and right; 1 superior retractor; 3 Hohmann retractors, narrow, 1 side view and 2 front views; 1 posterior/inferior retractor; 1 femoral retractor.






Total Hip Replacement

A total hip replacement is the removal of the acetabulum and the head of the femur, which are replaced with prosthetic implants.

Possible equipment needed for the procedure includes power saws and blades; power drill, bits, and reamers; a hip prosthesis; total hip instruments; and hip retractors.

A brief description of the procedure follows: 1. Bennett and Hibbs retractors are used for visualization and stabilization of the hip joint. 2. A power saw is used to remove the head of the femur. 3. A power drill is used to ream the shaft of the femur. 4. An acetabular reamer set is used to prepare the acetabulum. 5. The sizer sets are used to determine the size of the acetabular component. 6. A trochanter reamer set is used to prepare the proximal femur. 7. A reamer tray with drill is used to prepare the femoral shaft. 8. A rasp tray with a mallet is used to prepare the femur for the femoral component. 9. The complete set of hip prostheses is used to select the correct size of the prosthetic to be

used.

CHAPTER 48

48-1 Top: 2 Volkmann retractors, 2 prong, sharp. Bottom, left to right: 2 Bard-Parker knife handles #4; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 1 thumb tis-sue forceps with teeth (1 × 2); 2 Ferris Smith tissue forceps, front view and side view; 1 Mayo dissecting scissors, curved; 1 Mayo dissecting scissors, straight; 4 paper drape clips; 2 Back-haus towel forceps; 2 Crile hemostatic forceps, 6½ inch; 2 tonsil hemostatic forceps; 1 Mayo-Péan hemostatic for-ceps; 2 Ochsner hemostatic forceps; 1 Foerster sponge forceps; 2 Crile-Wood needle holders, 8 inch.





171CHAPTER 48 Total Hip Replacement

48-2 Top, left to right: 2 Yankauer suction tubes with tips; 2 Volkmann retractors, 6 prong, sharp. Bottom, left to right: 1 Bard-Parker knife handle #4, long; 1 Russian tissue forceps, long; 1 Mayo dissecting scissors, curved, long; 1 bandage scissors, large; 1 Spratt curette, straight, short; 1 Spratt curette, angled, long; 2 weitlaner retractors, medium.

48-3 Top left: 1 Metal mallet. Right, top to bottom: 1 Metal ruler, 12 inch; 1 Townley femur caliper; 2 Steinmann pins, 9⁄64 inch. Bottom, left to right: 3 Cobb spinal elevators: small, medium, and large; 1 Key periosteal elevator, 1 inch; 1 bone hook; 1 pliers; 1 Smith-Petersen laminectomy rongeur, double-action; 1 Luer bone rongeur.



48-4 Top right: 1 Prosthesis driver. Bottom, left to right: 3 Richards bone curettes, long, assorted sizes; 1 tapered T-handle femoral shaft reamer; 1 Buck cement restrictor inserter; 1 Stryker cement restrictor inserter; 1 Murphy bone lever or skid; 1 impactor; 1 cork-screw femoral head remover.

48-5 Initial incision retractor with two blades: long and short.


173CHAPTER 48 Total Hip Replacement

48-6 Top: 1 Hohmann retractor, large. Bottom, left to right: 1 Hohmann retractor, small; 1 Cobra retractor, straight, front view; 1 Cobra retractor, angled, side view; 1 Cobra retractor, slightly angled, side view; 1 Taylor spinal retractor, black finish, short; 1 Taylor spinal retractor, black finish, long; 3 Hibbs laminectomy retractors: small, medium, and large.



Total Hip Instruments (Zimmer-VerSys)

Possible equipment needed for the total hip replacement procedure includes a basic total hip set, hip retractors, and total hip prosthesis.

CHAPTER 49



49-1 Instruments (Trilogy acetabular).

49-2 Hall surgical acetabular reamer set.



175CHAPTER 49 Total Hip Instruments (Zimmer-VerSys)

49-3 Shell provisionals and acetabular instruments.

49-4 Shell provisionals and acetabulars.

49-5 Linear provisionals.



49-6 General instruments: stem.

49-7 General instruments: femoral.

49-8 Rasp tray.


177CHAPTER 49 Total Hip Instruments (Zimmer-VerSys)

49-9 Reamer tray 2A.

49-10 Top, left to right: V-Lign instrument tray; intramedullary taper reamers. Bottom, left to right: Stabilizer; 1 Crile template.



49-11 Cone provisionals. A, Size options. B, Porous and enhanced taper. C, Left, Cemented. Right, Cemented extended offset. A

B

C

49-13 Left to right: Prosthesis: Midcoat porous stem; prosthesis: fully porous stem.

49-12 Left to right: 1 Acetabular prosthesis; 1 femoral head prosthesis; 1 femoral stem prosthesis, plain; 1 femoral stem prosthesis, cemented.


179CHAPTER 50 Spinal Fusion with Rodding

Spinal Fusion with Rodding

A spinal fusion with rod attachment is performed to correct curvature of the spine. The fusion may use bone from the iliac crest or bone from a bone bank. The soft tissue around the vertebra is removed and the bone graft is placed for the fusion.

Possible instrumentation and equipment needed for this procedure includes basic spine instruments including retractor systems, fluoroscopy to verify placement of pedicle screws, a high-speed drill with burring attachments, dural repair microinstruments, and a micro-scope. There are a wide variety of spinal systems. Texas Scottish Rite Hospital (TSRH) is a system using crosslinks to stabilize rods and is presented in this chapter.

A brief description of how a spinal construct could be inserted is as follows: 1. Decompression of the spine and cleaning out of the disc space for a graft. 2. Shaving, sizing, and trialing for an interbody disc spacer made of allograft, poly-ether

ether ketone (PEEK) plastic, or titanium. 3. Measuring and tapping for titanium pedicle screws on one side of the spine or bilaterally. 4. Sizing and insertion of a titanium rod between the screws. 5. Placing locking caps on the screw heads of the screws to hold the rod in place. 6. Distracting the screw rod construct to reduce the amount of kyphosis, lordosis, or sco-

liosis present in the spine. 7. Optional placement of cross-connectors between the rods to provide additional stability.

CHAPTER 50

50-1 TSRH implant tray (labeled).






50-2 TSRH top tightening implant tray (labeled).

50-3 TSRH bending tray (labeled).

50-4 TSRH rod tray (labeled).



50-5 TSRH pediatric instrument, bottom tray (labeled).

50-6 TSRH pediatric instrument, top tray (labeled).

50-7 TSRH hook trials (labeled).



50-8 TSRH cross-link tray (labeled).

50-9 TSRH wrench tray (labeled).

50-10 Left, top to bottom: Holt probe set: curved probe, T-handle probe, round/straight probe. Bottom, left to right: 1 T-handle wrench; 2 probes (DePuy AcroMed); 1 anterior awl, straight.



50-11 Left to right: 2 Mini–hook hold-ers with attachments; 3 hook holders without pegs; 2 hook holders with rod movers, front view and side view; 1 hook inserter.

50-12 Left to right: 1 Harrington outrigger (3 pieces), assembled; 1 Harrington outrigger nut, pin, wrench; 1 large compressor; 1 curved spreader (Sofamor); 1 large distractor.

50-13 Rod cutter.



50-14 Postoperative. Postposterior fusion at L4-L5 with normal alignment.


185CHAPTER 51 Long Bone Rodding for Fracture Fixation

Long Bone Rodding for Fracture Fixation

Possible equipment needed for the procedure includes an Association for the Study of Internal Fixation (ASIF) basic set.

A brief outline of the procedure follows: 1. A small dissection set is needed to make a small incision on the proximal end of the bone

to be reduced. 2. A cannulated drill bit is placed through a drill sleeve with the aid of fluoroscopy. 3. A calibrated guidewire is placed down the shaft across the fracture site. 4. The size and length of the rod (nail) is determined. 5. A slide hammer is attached to the rod. 6. A mallet drives the rod down the shaft. 7. Screws may be placed on either end of the rod for stabilization.

CHAPTER 51

51-1 Top: Tray that includes reamer heads, flexible shafts and reamer, ram, and cannulated guide rod. Middle: Wrench. Bottom: 1 Awl and 3 hand reamers.






51-2 Top: 2 Plastic medullary tubes. Bottom, left to right: 1 Diameter gauge; 1 awl; 1 socket wrench for conical bolts. Middle, top to bottom: 3 Threaded conical bolts; 1 guide handle for nails; 1 quick-coupling adapter; 4 reamer heads, assorted sizes; 1 holder for reaming rod and guide shaft. Right, top to bottom: 1 Tissue protector; 1 curved driver (2 pieces).


187CHAPTER 52 ASIF Universal Femoral Distractor Set

ASIF Universal Femoral Distractor Set

The distractor is applied directly to the bone allowing for reduction of the fracture and aid-ing in stabilization prior to the final fixation of the fracture site. This can also be used for fractures involving the tibial plateau and pelvic fractures.

CHAPTER 52

52-1 Top, left to right: Universal T-handle and shank pin; 1 drill bit; 3 drill guides; 1 pin wrench. Bottom, left: Stationary pin bar on distractor bar; traveling pin bar on right.






Synthes Retrograde/Antegrade Femoral Nail

Femoral nails are placed to align and stabilize a femoral long bone fracture. The type of nail (antegrade vs. retrograde, reamed vs. unreamed) is dependent on the type of fracture, loca-tion, accessibility of the fracture, and physician’s preference.

CHAPTER 53



53-1 Synthes retrograde/antegrade femoral nail pan #1.




189CHAPTER 53 Synthes Retrograde/Antegrade Femoral Nail




Synthes Unreamed Tibial Nail Insertion and Locking Instruments

CHAPTER 54



54-1 Synthes unreamed tibial nail insertion and locking set (labeled). Bottom: 5 Sizes of locking bolts.

54-2 Synthes unreamed tibial nail set, assorted sizes.



191CHAPTER 55 External Fixation of Fractures

External Fixation of Fractures

External fixation is the attachment of a framework outside the body to stabilize complex fractures.

Possible equipment needed for the procedure includes an Association for the Study of Internal Fixation (ASIF) basic set.

A brief description of the procedure follows: 1. A small incision is made at each insertion and each exit of the pins. 2. A periosteal elevator is used for blunt dissection to the bone. 3. The drill sleeve is placed to protect the soft tissue. 4. Pins are drilled through the bone above and below the fracture or fractures. 5. This process is repeated for every bone fragment that must be stabilized. 6. Universal joints are placed over the ends of each pin. 7. The frame is placed. 8. A wrench is used to tighten the frame. 9. A pin cutter is used to cut the pins as needed.

CHAPTER 55

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

55-1 The Evolution Tray has the instruments to put together the Taylor Spatial framework. (The Evolution Tray was prepared by Dr. Douglas N. Beaman.)




55-2 Left to right: Pin cutter; wire; tensioner; wrench; box wrench; drill. (The Evolution Tray was prepared by Dr. Douglas N. Beaman.)

55-3 Left, top to bottom: Taylor Spa-tial rings with struts in place; Taylor Spatial foot plate. Right, top to bottom: 2 Struts; 1 Taylor Spatial ring.


193CHAPTER 55 External Fixation of Fractures

55-4 Taylor Spatial frame on patient. (Courtesy Lynn Scott, Gaston, Ore.)

55-5 ASIF external fixator miniset.



ASIF Pelvic Instrument Set

Pelvic stabilization is needed due to the traumatic nature of pelvic fractures. This may include acetabular restructure or stabilization of the iliac, ischium, and pubic bones.

Possible equipment needed for the procedure includes a soft tissue set, basic orthopedic instrumentation, and pelvic fixation.

CHAPTER 56

56-1 Left to right: 1 Plate bender; 2 pelvic plate-bending templates, long; 1 small hexagonal screwdriver; 1 drill guide, long, 2.5 mm; 1 drill guide, long, 3.5 mm; 1 small hexagonal screw-driver, long, large handle; 1 small hexagonal screwdriver, regular; 1 depth gauge; 4 drill bits, 2.5 × 180 mm; 4 drill bits, 3.5 × 170 mm; 2 taps, 3.5 × 180 mm.

56-2 ASIF pelvic implant set.





195CHAPTER 56 ASIF Pelvic Instrument Set

56-3 Pelvic external fixator. Top to bottom: 3 Straight black carbon tubes with attaching clamps on each side; 1 curved black carbon tube with Schanz pins attached on each side.



Universal Screwdriver/Broken Screw Set

The universal screw set allows you to have multiple types and sizes of screwdrivers avail-able when you may not know what type of hardware was previously implanted, whereas the broken screw set allows you to extract stripped or broken screws.

CHAPTER 57

57-1 Shukla Universal Screwdriver Set. 1 Cannulated silicone ratcheting screwdriver with various sized screw-driver attachments including flexible and solid hex drivers, torx drivers, flat-tip drivers, and Phillips-tip drivers.





197CHAPTER 57 Universal Screwdriver/Broken Screw Set

57-2 Top, left to right: 1 Broken screw caddy and 1 stripped screw caddy. Bottom, left to right: 1 Extension driver, 8 inch; 1 extension driver, 6 inch; 1 stripped screw extractor breaker bar with cannulated ratcheting T-handle; 1 extension driver, 4 inch; 1 power drill adapter.


198 UNIT 6 Eye, Ear, Nose, and Throat Surgery

Basic Eye Set

The basic eye set is used for the initial preparation of the eye. Examples include placement of the Lancaster speculum, Beaver knife handles with blades, and iris scissors. In this chap-ter we have also included a chalazion set and a pterygium set, both of which include basic eye instrumentation that is seen throughout this unit.

The chalazion set is used for the excision of a chalazion, a lipogranuloma of either the meibomian or Zeiss gland.

A brief description of the procedure follows: 1. An appropriate size chalazion clamp is applied to evert the lid and to control bleeding. 2. A #11 knife blade on a #9 Bard-Parker knife handle is used to make a 2- to 3-mm incision. 3. An appropriate size chalazion curette is used to remove contents including any cyst lining. 4. Pressure is applied for a few minutes to achieve hemostasis. 5. Occasionally, a Castroviejo needle holder is used to place stitches. 6. McPherson forceps, straight and curved, are used to tie the suture.

The pterygium set is used for excision of pterygium with autograft or amniotic mem-brane placement. Pterygium is a noncancerous growth on the conjunctiva. Possible equip-ment needed for the procedure includes an ophthalmic microscope.

CHAPTER 58 UNIT SIX: EYE, EAR, NOSE, AND THROAT SURGERY

58-1 Top, left to right: 1 Plastic scissors, straight, sharp, 5½ inch; 1 Lancaster speculum; 4 Edwards holding clips. Bottom, left to right: 1 Bard-Parker knife handle #9; 2 Beaver knife handles, knurled, one insert above; 1 iris scissors, straight, 4½ inch; 1 Stevens tenotomy scis-sors; 4 Halsted mosquito hemostatic forceps, curved; 2 Halsted mosquito hemostatic forceps, straight.





199CHAPTER 58 Basic Eye Set

58-2 Chalazion set. Top, left to right: 2 Blue clips; 1 Jeweler’s bipolar forceps; 1 Desmarres chalazion forceps; 1 Francis chalazion forceps; 1 Baird chalazion forceps; 1 Lambert chalazion forceps; 1 Hunt chalazion forceps; 1 Vital Mayo dissecting scissors. Bottom, left to right: 1 Bard-Parker knife handle, #9; 1 Beaver blade handle; 1 Meyerhoeffer chalazion curette, 1.5-mm cup; 1 Castroviejo needle holder, locking, curved, 11 mm; 1 Westcott tenotomy scissors, curved, blunt tip; 1 Stevens tenotomy scissors, straight; 1 Castroviejo suturing forceps, 0.12 mm; 1 Castroviejo suturing forceps, 0.3 mm; 1 McPherson tying forceps, straight; 1 McPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.9 mm; 1 Halsted mosquito forceps, curved; 1 Skeele curette, 2.0-mm cup; 1 Meyerhoeffer chalazion curette, 2.5-mm cup; 1 chalazion curette, 3.0-mm cup.

58-3 Curette tips. Left to right: 1 Meyerhoeffer curette, 1.5 mm; 1 Skeele curette, 2.0 mm; 1 chalazion curette, 2.5 mm; 1 chalazion curette, 3.0 mm.



58-4 Pterygium set. Top, left to right: 2 Blue chips; 2 Halsted mosquito forceps, straight, smooth; 1 Halsted mosquito forceps, curved, smooth; 1 Mayo dissecting scissors, straight; 1 Castroviejo caliper; 1 Lieberman eye speculum; 1 Kratz-Berraquer wire eyelid speculum. Bottom, left to right: 1 Beaver knife handle; 1 Castroviejo suturing forceps, 0.9 mm; 1 Fechtner micro ring forceps; 1 Harms-Tubingen tying forceps, straight; 1 MacPherson tying forceps, straight; 1 MacPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.12 mm; 1 Stevens tenotomy scissors, straight, 3½ inch. 1 Vannas capsulotomy scissors, straight, 31⁄8 inch; 1 Westcott tenotomy scissors, curved; 1 Barraquer needle holder, locking, curved, 9 mm; 1 Barraquer needle holder, nonlocking, curved; 1 Castroviejo needle holder, locking, straight, 12 mm; 1 Castroviejo needle holder, locking, curved, 11 mm; 1 Jeweler’s bipolar forceps.


201CHAPTER 59 Clear Corneal Set

Clear Corneal Set

The clear corneal cataract procedure is performed with the use of topical anesthetics, fold-able intraocular lenses (IOLs), and diamond or disposable knives. This allows the surgeon to make microincisions that are self-healing and may not need stitches.

Possible instruments and equipment needed for the procedure include an ophthalmic operating microscope and a phacoemulsifier. For this procedure to be performed, it is imperative that the patient can hear and is able to follow specific directions.

A brief description of the procedure follows: 1. A Lieberman speculum is placed to retract the eyelids. 2. A fine Thornton fixation ring or a 0.12 Castroviejo suturing forceps is used to stabilize

the cornea. 3. A disposable 1-mm sideport blade is used to make paracentesis. 4. After local anesthesia and viscoelastic are placed in the anterior chamber, Utrata for-

ceps is used to make a capsulorrhexis. 5. Balanced salt solution (BSS) in a 3-cc syringe with a 27-gauge disposable cannula is

used to hydrodisect the lens nucleus. 6. The phacoemulsifier is used to remove the nucleus with a nucleus manipulator or IOL

hooks of surgeon’s choice. 7. A 1/A tip and hand piece are used to remove lens cortex. 8. After filling a capsule with viscoelastic, the IOL is inserted with an Alcon Monarch III

IOL injector and disposable cartridge. 9. The Lester IOL manipulator is used to position the IOL accurately. 10. A 1/A tip and hand piece is used to remove the viscoelastic. 11. BSS in a 3-cc syringe with a 27-gauge disposable cannula is used to hydroseal the incision.

CHAPTER 59



59-1 Top, left to right: 1 Lieberman speculum; 4 needle cannulas, 1 30-gauge, 1 27-gauge, 1 Chang, and 1 27-gauge. Bottom, left to right: 1 Halsted mosquito hemostatic for-ceps, fine tip; 3 Edwards holding clips; 1 paper drape clip.




59-2 Left to right: 1 Gaskin fragment forceps, angled; 1 Kelman-McPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.12 mm; 1 Utrata forceps; 1 iris scissors, straight.

59-3 Left to right: Enlarged tips: A, Gaskin fragment forceps, angled; B, Kelman-McPherson suture-tying forceps, angled; C, Castroviejo suturing forceps, 0.12 mm; D, Utrata forceps, angled.

A B

C D


203CHAPTER 59 Clear Corneal Set

59-4 Left to right: 1 Fine Thornton swivel fixation ring, 13 mm; 1 Graether collar button; 1 Bechert nucleus rota-tor; 1 Nagahara Phaco chopper; 1 Seibel nucleus chopper; 1 Hirschman iris hook, titanium; 1 Lester IOL manipulator; 1 Kuglen iris hook ma-nipulator, angled round; 1 Sinsky lens hook, straight; 1 Castroviejo cyclo-dialysis spatula, double-ended; 1 iris spatula. Top to bottom, going across: 1 Disposable 27-gauge cannula; 1 Jensen capsule polisher; 1 Connor anesthesia cannula; 1 Jensen capsule polisher; 1 disposable cannula, 19-gauge.

A

E F G H

B C D

59-5 Enlarged tips: A, Bechert nucleus rotator; B, Nagahara Phaco chopper; C, Seibel nucleus chopper; D, Hirschman iris hook; E, Lester IOL manipulator; F, Kuglen iris hook manipulator; G, Sinsky lens hook; H, iris spatula.



59-6 Left to right, top to bottom: 1 Alcon Monarch III IOL injector; 1 0.9-mm MicroSmooth l/A sleeve; 1 wrench; 1 0.3-mm 45-degree bend l/A tip; 1 0.3-mm small bore l/A tip (attached to hand piece); 1 Alcon l/A UltraFlow SP hand piece, threaded; 1 Intrepid 0.3-mm bend l/A tip; 1 test-ing chamber; 1 wrench; 1 Phaco tip (attached); 1 Alcon OZil torsional hand piece; 1 0.9-mm MicroSmooth Phaco sleeve.

59-7 Left to right: 1 Duckworth & Kent cionni toric reference marker; 1 Gimbel Mendez fixation and guide ring (handle mounted at 90 degrees); 1 Bores two-ray corneal meridian marker.


205CHAPTER 60 Corneal Transplant

Corneal Transplant

Corneal transplant is the replacement of a damaged cornea with a cornea from a human donor’s eye.

Possible equipment and instruments needed for the procedure include an operating microscope, a disposable trephine, a Teflon block, and a basic eye set.

A brief description of the procedure follows: 1. The Schott eye speculum is placed to retract the eyelids. 2. The Flieringa fixation ring is placed to stabilize the eyeball. 3. A disposable trephine is used to cut a button from the cornea of the donor’s eye. 4. The trephine is used to cut a slightly smaller button from the recipient’s eye. 5. The Polack forceps is used to place the donor’s button in the space in the recipient’s

cornea. 6. The Troutman-Barraquer needle holder with suture and Sinskey tying forceps are used

to secure the cornea in place. 7. Irrigating cannulas are used to lubricate the eye with solution as needed.

CHAPTER 60



60-1 Top, left to right: 2 Barraquer wire speculums; 1 Flieringa fixation ring (double ring); 1 McNeil-Goldman scleral ring (with wings); 2 single-wire Flieringa fixation rings; 1 Lancaster speculum. Bottom, left to right: 1 Schott eye speculum; 1 Castroviejo caliper.




60-2 Left to right: 1 Jeweler’s forceps, straight; 1 Elschnig fixation forceps; 1 Lester fixation forceps; 1 serrated forceps, fine; 1 Castroviejo suturing forceps, 0.5 mm; 1 Castroviejo suturing forceps, 0.12 mm; 1 McPherson tying forceps, angled; 1 Troutman-Barraquer forceps (Colibri type); 1 Polack double-tipped, corneal forceps (Colibri type); 1 Maumenee corneal forceps; 1 Clay-man lens-holding forceps.

60-3 Left to right: Enlarged tips: A, Jeweler’s forceps, straight; B, Elschnig fixation forceps; C, Lester fixation forceps.

A B C

60-4 Left to right: Enlarged tips: A, Castroviejo suturing forceps, 0.5 mm; B, Troutman-Barraquer for-ceps (Colibri type); C, Polack double-tipped corneal forceps (Colibri type).

A B C



60-5 Left to right: Enlarged tips: A, Clayman lens-holding forceps; B, Maumenee corneal forceps, side view.

A B

60-6 Top, left to right: 1 Sheets irrigating vectis, 27-gauge; 2 irrigat-ing cannulas, 23- and 27-gauge. Bottom, left to right: 1 Beaver knife handle, knurled, with insert; 1 corneal scleral marker; 1 Shepard iris hook; 1 Bechert nucleus rotator, Y-shaped tip; 1 Sinskey iris and IOL hook; 1 Culler iris spatula; 1 Jameson muscle hook; 1 lens loop; 1 Paton spatula, double-ended; 1 Castroviejo needle holder with lock, curved; 1 titanium needle holder with stop, no lock, curved; 1 Sinskey tying forceps, straight; 1 Troutman-Barraquer microneedle holder, curved.



60-7 Left to right: Enlarged tips: A, Corneal scleral marker; B, Shepard iris hook; C, Bechert nucleus rotator, Y-shaped tip; D, Sinskey iris and IOL hook; E, Culler iris spatula.

A B C

D E

60-8 Left to right: Enlarged tips: A, Jameson muscle hook; B, lens loop; C, Paton spatula, double-ended.

A B C



60-9 Left to right: Enlarged tips: A, Titanium needle holder with stop, no lock, curved; B, Castroviejo needle holder with lock, curved; C, Troutman-Barraquer microneedle holder, curved; D, Sinskey tying forceps, straight.

A B C D

60-10 Left to right: 2 Halsted mos-quito hemostatic forceps; 2 blunt scis-sors, straight; 2 Castroviejo corneal section scissors, left and right; 1 Van-nas capsulotomy scissors, straight; 2 transplant microscissors, right and left; 1 Westcott tenotomy scissors.

60-11 Left to right: Enlarged tips: A, Castroviejo corneal section scissors, left; B, Castroviejo corneal section scissors, right; C, Westcott tenotomy scissors; D, Vannas capsulotomy scissors, straight.

A B C D



Deep Lamellar Endothelial Keratoplasty

Deep lamellar endothelial keratoplasty (DLEK) is a split-thickness (lamellar transplant) form of corneal transplantation. When this procedure is performed, a smaller incision is used, and only the diseased tissue is removed. The remainder of the patient’s cornea remains intact. This procedure involves the replacement of the back layers of the cornea rather than the front layers. It is performed through a small pocket incision, which avoids any changes in the front surface of the cornea. In the DLEK procedure, one to three tiny sutures are placed, rather than the 16 regular sutures or one to two long looping sutures in a circle that are used in penetrating keratoplasty (PK). In the DLEK procedure, the cornea has a smoother surface and a clearer transplant, which allows many of the patients to see better in a matter of weeks instead of the months or years in a standard full-thickness corneal transplant.

Possible instruments needed for the procedure include a cataract removal set. Today there are disposable kits available for both the donor and the recipient.

CHAPTER 61

61-1 Left to right: 1 8-mm Corneal marker; 1 Charlie insertion forceps; 2 Devers dissectors, curved; 1 Cindy scissors; 1 Cindy 2 scissors; 1 reverse Sinskey hook; 1 Nick pick; and 1 Terry scraper.





211CHAPTER 61 Deep Lamellar Endothelial Keratoplasty

61-2 Left to right: Enlarged tips: A, 8-mm Corneal marker; B, Charlie insertion forceps; C, Terry scraper, Nick pick, and reverse Sinskey hook; D, Devers dissectors; E, Cindy scissors and Cindy 2 scissors.

A B C

D E



Glaucoma

Glaucoma is a condition of increased intraocular pressure because of obstructed aqueous humor outflow.

Possible instruments and equipment needed for the procedure include a basic eye set, an operating microscope, and a shunt.

A brief description of the procedure follows: 1. A Lancaster speculum is placed to retract the eyelids. 2. A Beaver knife handle with blade is used to incise the conjunctiva. 3. A Jameson muscle hook is used to isolate the rectus muscles. 4. The device plate is sutured to the sclera using the Barraquer needle holder and

Kelman-McPherson tying forceps. 5. A Kelly Descemet membrane punch is used to create a tunnel into the anterior chamber. 6. The device tube is inserted into the anterior chamber and anchored with suture. 7. The conjunctiva is closed.

CHAPTER 62

62-1 Left to right: 1 Kelman- McPherson tying forceps, straight, front view; 1 Kelman-McPherson tying forceps, angled, side view; 2 Mc-Cullough utility forceps, front view and side view; 1 McPherson tying forceps, straight; 1 McPherson tying forceps, curved; 1 Chandler (Gills) forceps; 2 Hoskins forceps, straight and curved.





213CHAPTER 62 Glaucoma

62-2 Top right: 1 Irrigation cannula, 19-gauge. Bottom, left to right: 2 Vannas scissors, straight and curved; 1 Westcott corneal miniscis-sors, sharp; 1 Westcott tenotomy scissors, blunt; 1 Kelley Descemet membrane punch; 1 Elschnig cyclo-dialysis spatula; 2 Halsted mosquito hemostatic forceps, curved.



Eye Muscle Surgery

Eye muscles are released and tucked to treat the condition called strabismus or “cross-eyes.” Possible instruments needed for the procedure include a basic eye set.

A brief description of the procedure to loosen the inferior oblique muscle follows: 1. A Cook speculum is used to retract the lids. 2. Westcott tenotomy scissors are used for incision into the tenon capsule. 3. A Jameson or Green muscle hook is used to isolate and lift the muscle. 4. A Beaver knife handle with blade is used to bisect the muscle. 5. Jameson recession forceps are used to grasp the ends of the muscle. 6. A cautery is used for hemostasis. 7. A Castroviejo caliper is used to measure how much to relax the muscle.

A brief description of the procedure to tuck the superior rectus muscle follows: 1. Follow steps 1 through 3 above. 2. A Castroviejo caliper is used to measure how big a tuck to make. 3. Jameson recession forceps are used to grasp the muscle. 4. A Von Graefe strabismus hook is used to elevate the tendon to be doubled into a loop. 5. A Troutman-Barraquer needle holder is used for attaching the loop to the sclera. 6. A titanium needle holder is used for closing the conjunctiva. 7. Kelman-McPherson tying forceps are used to tie the suture.

CHAPTER 63



63-1 Left to right: 2 Jameson muscle recession forceps, right, front view and side view; 2 Castroviejo tying forceps, wide handles, without tying platforms, 0.5-mm teeth (1 × 2), front view and side view; 2 McCullough utility forceps, cross-serrated; 1 Jameson muscle hook; 1 Von Graefe strabismus hook; 1 Stevens tenotomy hook; 1 Desmarres lid retractor.



215CHAPTER 63 Eye Muscle Surgery

B C

D E F

A63-3 Left to right: Enlarged tips: A, Jameson muscle recession forceps, right; B, McCullough utility forceps, cross-serrated; C, Jameson muscle hook; D, Stevens tenotomy hook; E, Desmarres lid retractor; F, Green muscle hook.

63-2 2 Green muscle hooks, 7 mm wide.



63-4 Top, left to right: 1 Castroviejo caliper; 1 Cook eye speculum, child-sized; 1 Lancaster speculum. Bottom, left to right: 4 Serrephines; 1 strabis-mus scissors, straight; 1 Westcott tenotomy scissors, curved; 1 Stevens tenotomy scissors, curved; 1 Castro-viejo needle holder with lock, curved; 1 Castroviejo needle holder with lock, straight; 1 Erhardt chalazion clamp; 1 metal ruler, small.


217CHAPTER 64 Retinal Detachment

Retinal Detachment

A retinal detachment is the separation of the retina from the internal wall of the eye.Possible instruments needed for repair of a detachment include a basic eye set.A brief description of the possible methods of repairing a detached retina follows:

1. Scleral buckling. In this procedure a silicone band, sponge, or other device is placed against the outside of the eye at the area of the detachment. This presses the wall of the eye into the retina to encourage reattachment.

2. Pneumatic retinopexy. This procedure uses gas, which is injected into the posterior chamber. By positioning the patient, the gas bubble is forced against the wall of the eye where the detachment is. The gas used will expand and later diffuse in 7 to 10 or 30 to 50 days, depending on which gas is used.

3. Laser photocoagulation. This procedure uses a laser beam to treat the retinal hole. The laser may be used in conjunction with scleral buckling or pneumatic retinopexy.

CHAPTER 64

64-1 Left to right: 4 Castroviejo sutur-ing forceps, wide handles, with tying platforms: 0.3-mm front view, 0.5-mm side view, 0.12-mm front view, 0.12-mm side view; 1 Bonn suture forceps; 1 Wills Hospital utility forceps, straight; 1 Elschnig fixation forceps; 1 Harms tying forceps; 2 McCullough utility forceps, front view and side view; 1 Watzke sleeve-spreader forceps.






64-3 Left to right: 1 Stevens tenotomy scissors; 1 Westcott tenotomy scis-sors; 1 Green needle holder and forceps; 1 Castroviejo needle holder, straight, without lock; 2 Castroviejo needle holders, straight, with locks; 1 Thorpe calipers; 1 Castroviejo calipers.

64-4 Top, left to right: 2 Barraquer wire speculums; 5 Mira diathermy tips, assorted. Bottom, left to right: 4 Serre-phines; 1 Beaver knife handle, knurled, with insert above; 1 Schepens orbital retractor; 1 Jameson muscle hook; 1 Von Graefe strabismus hook; 1 Gass retinal detachment hook.

A B C

D E

64-2 Left to right: Enlarged tips: A, Bonn suture forceps; B, Wills Hospital utility forceps, straight; C, Elschnig fixation forceps; D, Harms tying forceps, straight; E, Watzke sleeve-spreading forceps.


219CHAPTER 65 Vitrectomy

Vitrectomy

Vitrectomy is the removal of the vitreous humor in the posterior chamber of the eye. This may be done when there is a retinal detachment to gain better access to the posterior por-tion of the eye. Vitrectomy may also be done if blood in the vitreous humor (hemorrhage) does not clear on its own. This generally occurs from trauma to the eye.

CHAPTER 65

65-1 Left to right: 1 Barraquer wire speculum; 1 iris scissors, straight; 1 Castroviejo suturing forceps, 0.12 mm; 1 Westcott tenotomy scissors; 1 Paton forceps; 1 Troutman-Barraquer needle holder, with lock; 1 Castroviejo needle holder, with lock; 1 Vannas capsu-lotomy scissors.

65-2 Top, left to right: 1 19-Gauge irrigating cannula; white sponge; 1 27-gauge Bishop-Harmon irrigating cannula; 1 20-gauge and 1 19-gauge cannula. Bottom, left to right: 1 Cas-troviejo caliper; 2 scleral plug forceps; 1 flat Machemer irrigating lens with attached silicone tubing; 1 Minus irrigating lens with attached silicone tubing; 1 Schocket scleral depres-sor, doubled-ended; 1 Von Graefe strabismus hook; 2 Castroviejo needle holders, curved, straight.






65-4 Left to right: Tips: Scleral plug forceps, side view and front view.

65-3 Left to right: Tips: Minus and Machemer irrigating lens.


221CHAPTER 66 Oculoplastic Instrument Set

Oculoplastic Instrument Set

Oculoplastic means plastic surgery on or about the eye.

CHAPTER 66

66-1 Top, left to right: 1 Lancaster speculum; 2 Edwards holding clips. Bottom, left to right: 1 Castroviejo caliper; 1 Bard-Parker knife handle #3; 1 Mayo dissecting scissors, straight, 6 inch; 1 Westcott tenotomy scissors; 1 Stevens tenotomy scissors; 1 Adson tissue forceps with teeth (1 × 2); 2 Halsted mosquito hemostatic forceps, curved and straight.

66-2 Left to right: Westcott scissors, sharp and dull.






66-3 Left to right: 1 Mueller clamp; 1 lacrimal sac retractor, 4 prong, blunt; 1 double fixation hook, 2 prong; 1 iris scissors, sharp; 2 Bishop-Harmon tissue forceps, 0.5 mm; 2 Paufique suture forceps with teeth (1 × 2); 1 Desmarres lid retractor; 2 Castroviejo needle holders with locks, straight and curved.

66-5 3 Serrephines.

A B66-4 Left to right: Enlarged tips: A, 2 Bishop-Harmon tissue forceps, with teeth 1 × 2 and smooth; B, Paufique suture forceps with teeth 1 × 2.


223CHAPTER 67 Eye Enucleation

Eye Enucleation

Enucleation is the removal of the eyeball.Possible instruments needed for the procedure include a basic eye set.

CHAPTER 67

67-1 Top: 2 Serrephines. Bottom, left to right: 1 Enucleation scissors, sharp, curved; 1 Stevens tenotomy scissors; 1 Castroviejo suturing forceps with tying platforms, 0.5-mm teeth (1 × 2); 1 Wells enucleation spoon; 2 tonsil hemostatic forceps; 1 Westphal hemo-static forceps.






Basic Ear Set

The basic ear set is used for the preparation of the ear, the initial incision if needed, and placement of a retractor (handheld or self-retaining) to perform the surgery.

CHAPTER 68



68-1 Top, left to right: 2 Paper drape clips; 2 Backhaus towel forceps, small. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Adson tissue forceps, without teeth; 1 Adson tissue forceps, with teeth (1 × 2); 1 Brown-Adson tissue forceps with teeth (7 × 7); 1 Sheehy ossicle-holding forceps; 1 strabismus scissors, curved; 2 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps; 1 Mayo dissecting scissors, straight; 1 Johnson needle holder, 7 inch.

68-2 Upper left, top to bottom: 1 Weitlaner retractor, dull prongs, angled; 3 Baron ear suction tubes with finger valve control: 3, 5, and 7 Fr; 2 stylets. Upper right, top to bottom: 9 Richards ear speculums, assorted sizes, 4-8 mm, one side view. Bottom, left to right: 1 Cottle elevator, double-ended; 1 Lempert elevator (converse periosteal); 2 Johnson skin hooks; 2 Senn-Kanavel retractors, side view and front view; 1 House Teflon block; 1 House Gelfoam press or Sheehy fascia press; 2 metal medicine cups, 2 oz.



225CHAPTER 69 Tympanoplasty

Tympanoplasty

A tympanoplasty is the repair of the tympanic membrane (eardrum).Possible equipment and instruments needed for the procedure include an operating

microscope for visualization, an ototome (Saber drill) with microbits and microburrs, and a basic ear set. A Skeeter drill (a finer microdrill) may be used if performing procedure farther into the middle ear (i.e., stapedectomy).

A brief description of the procedure follows: 1. A Richards speculum of appropriate size is placed in the ear canal. 2. A Crabtree wax curette is used to remove wax from the canal. 3. A Jordan oval knife may be used to incise the tympanomeatal junction. 4. A Rosen needle is used to elevate the skin of the canal. 5. Richards cup forceps are used to clean all epithelium from the eardrum perforation. 6. An ototome drill with microburrs may be needed if the perforation is not clearly

visible. 7. A House pick is used to explore the middle ear for ossicle mobility. 8. Richards alligator forceps are used to remove any epithelium in the middle ear. To

harvest a graft from the temporalis muscle, a Lempert elevator may be used to sepa-rate fascia from the temporalis muscle. A strabismus scissors is used to cut the fascia, and a Sheehy fascia press is used to thin the fascia before placement.

9. Richards alligator forceps are used to place the graft over the perforation. 10. A Rosen needle is used to position the graft securely.

An ossicular reconstruction may be performed; a brief description of the procedure follows: 1. A Bellucci scissors is used to cut soft tissue. 2. A Mueller malleus nipper is used to loosen the bones. 3. A House sickle knife is used to free the incus from the stapes. 4. Richards alligator forceps are used to remove the bones or fragments. 5. A partial ossicular replacement prosthesis (PORP) is needed to replace several bones. 6. A total ossicular replacement prosthesis (TORP) is needed when all middle-ear bones

are removed.

CHAPTER 69






69-1 A, Rack No. 1 of delicate ear instruments with labels. B, Left to right: Tips of delicate ear instruments: House sickle knife; Austin sickle knife; House tympanoplasty knife. C, Left to right: Tips of delicate ear instruments: Jordan oval knife; House joint knife; drum elevator; angled pick #6; angled pick #7; straight needle; House-Rosen needle.

A

B

C



69-2 A, Rack No. 2 of delicate ear instruments with labels. B, Left to right: Tips of delicate ear instruments: curved needle, large curve; curved needle, small curve. C, Left to right: Tips of delicate ear instruments: straight needle; Austin 25-degree pick; House pick, 1 mm; House pick, 3 mm; oval window pick; whirleybird pick, left; whirleybird pick, right.

A

B

C



69-3 A, Rack No. 3 of delicate ear instruments with labels. B, Left to right: Tips of delicate ear instruments: small double-end curette #3; House double-end curette #1; House double-end curette; Black double-end J curette; House double-end J curette. C, Left to right: Tips of delicate ear instruments: Crabtree; ring curette; wax curette #1; wax curette #2.

A

B

C



69-4 A, Rack No. 4 of delicate ear instruments with labels. B, Left to right: Tips of delicate ear instruments: measuring rod; House measuring rod, 4 mm; House measuring rod, 4.5 mm; House measuring rod. C, Left to right: Tips of delicate ear instruments: measuring rod; Derlacki; angled pick. D, Left to right: Tips of delicate ear instruments: delicate hook #14; Buckingham footplate hand drill; Rosen knife.

A

B

C

D



A

B C

D

69-5 A, Tray No. 1 of delicate ear forceps with labels. B, Delicate ear forceps out of tray. C, Left to right: Tips of delicate ear forceps: small alligator, serrated; Bellucci scissors; left-cup forceps. D, Left to right: Tips of delicate ear forceps: straight-cup forceps; right-cup forceps; large-cup forceps.



69-6 A, Tray No. 2 of delicate ear forceps with labels. B, Left to right: Tips of delicate ear forceps: large crimper; small crimper; malleus nipper.

A

B

69-7 Blunt needles attached to tubing for suction tips, assorted sizes, 15- to 24-gauge.



69-8 Left to right: 6 House suction/ irrigators with finger valve control and 1 stylet; 1 metal suction connector; 6 Baron ear suction tubes with finger valve control and 1 stylet.

69-9 Left, top to bottom: 2 Irrigation clips; 1 straight attachment; 1 angled attachment. Right: 1 Saber drill.



69-10 Left to right: 1 Medtronic Skeeter Ultra-Lite oto tool and 1 ruler.



Tonsillectomy and Adenoidectomy

Tonsillectomy is the removal of the palatine tonsils in the oropharynx. Adenoidectomy is the removal of the lymph tissue on the posterior wall of the nasopharynx (pharyngeal tonsils).

Possible equipment and instruments needed for the procedure include an electrosurgical unit and a tonsil snare.

A brief description of a tonsillectomy follows: 1. A McIvor mouth gag with blade is placed in the mouth for visualization. 2. A Wieder tongue depressor is placed and held on the tongue to expose the tonsils. 3. An AndrewsPynchon suction tip with tubing is used for removing secretions

and blood. 4. A long curved Allis tissue forceps is used to grasp the tonsil. 5. A BardParker scalpel handle #7 with a #11 blade is used to incise the tonsil capsule. 6. A Fisher knife may be used to extend the incision. 7. A Hurd spoon (tonsil dissector) is used to bluntly dissect the tonsil. 8. Tonsil hemostatic forceps are used to clamp the main blood supply. 9. Metzenbaum dissecting scissors are used to excise the tonsil. 10. A Ballenger sponge forceps with tonsil sponge is placed in the tonsil fossa to apply

pressure for hemostasis. 11. A Hurd tonsil dissector and pillar retractor may be used to check for bleeding. 12. Electrocautery may be used for hemostasis.

A brief description of an adenoidectomy follows: 1. A Lothrop uvula retractor is placed at the back of the throat for exposure of the adenoids. 2. A LaForce adenotome is inserted and cuts out the adenoid. 3. A Meltzer adenoid punch may be needed to remove any adenoid tags.

CHAPTER 70





235CHAPTER 70 Tonsillectomy and Adenoidectomy

70-1 Left to right: 1 Bard-Parker knife handle #7; 1 Metzenbaum dissecting scissors, 7 inch; 2 paper drape clips; 2 Crile hemostatic forceps, 6½ inch; 1 Westphal hemostatic forceps; 4 tonsil hemostatic forceps; 1 Allis tissue forceps, long, curved; 3 Allis tissue forceps, long; 3 Ballenger sponge forceps, curved; 1 Crile-Wood needle holder, 8 inch.

70-2 Top to bottom: 1 Andrews- Pynchon suction tube with tip; 1 adenoid suction tube, tip connected. Bottom, left to right: 2 Weder tongue depres-sors; 1 Hurd tonsil dissector and pillar retractor; 1 Fisher tonsil knife and dis-sector; 1 LaForce adenotome, small, front view; 1 LaForce adenotome, large, side view. Right, top to bottom: 1 Lothrop uvula retractor; 1 Meltzer adenoid punch, round, with basket.



70-3 Mouth set. Top to bottom: 1 Andrews-Pynchon suction tube with tip; 2 bite blocks: child and adult. Left to right: 1 McIvor blade, long; 1 McIvor mouth gag frame with blade; 1 McIvor blade, medium; 3 Weder tongue depressors, 2 side views and 1 front view; 1 side mouth gag.


237CHAPTER 71 Transoral Surgery

Transoral Surgery

The FK retractor is mainly used for transoral robotic surgery (TORS). This retractor may also be used in general transoral surgeries to provide the most versatility for achieving ideal exposure of the hypopharynx, larynx, and base of the tongue. The Bruening injection set is utilized to inject the vocal cords.

CHAPTER 71

71-1 Top, left to right: 1 FK retractor custom frame L-shaped; 1 FK frame adapter, 45 degrees; 1 FK-WO TORS basic frame; 1 smoke suction tube; 1 light clip with lateral cable connection. Bottom, left to right: 1 Mandible blade, 11 cm; 2 cheek retractors, curved; 1 tongue blade, curved; 1 TORS blade, right, small; 1 tongue blade, curved, left side open (posterior view); 1 tongue blade, curved, right side open (poste-rior view); 1 TORS blade, right, large; 1 TORS blade, left, large; 1 TORS blade, left, small; 1 laryngeal blade, concave, 17 cm.

71-2 Top to bottom, left to right: 1 Ar-nold needle, 20.5 cm/18-gauge tip with wire pusher inserted; 1 wire pusher; 1 Arnold needle, 20.5 cm/19-gauge tip; 1 Bruening syringe extension; 1 Bruening syringe with syringe plunger attached; 1 Bruening wrench.






Tracheotomy

A tracheotomy is an incision into the trachea below the cricoid cartilage in the anterior neck.

A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #3 with a #15 blade is used to make a small incision above

the suprasternal notch. 2. Halsted mosquito hemostatic forceps are used to clamp bleeders. 3. A Senn retractor is placed to hold the skin edges. 4. A short curved Metzenbaum dissecting scissors is used to extend the incision to the

trachea. 5. A baby weitlaner retractor is placed for exposure. 6. A Bard-Parker scalpel handle with a #11 blade is used to incise between the cartilaginous

rings of the trachea. 7. A Jackson tracheal tenaculum holds the trachea. 8. A Trousseau-Jackson tracheal dilator is inserted to enlarge the opening for placement of

the tracheostomy tube.

CHAPTER 72

72-1 Top left: 1 Blue clip. Left to right: 1 Bard-Parker knife handle, #3; 2 Adson tissue forceps with teeth (1 × 2), 4¾ inch; 1 tissue forceps with teeth (2 × 3), 6 inch; 2 DeBakey vascu-lar atraugrip tissue forceps, 7¾ inch. On stringer: 4 Halsted mosquito for-ceps, curved, 5 inch; 4 Crile forceps, curved, 5½ inch; 2 Allis forceps (5 × 6), 6 inch; 2 right-angle forceps, 7 inch; 1 Crile-Wood needle holder, 6¼ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum dis-secting scissors, 5¾ inch; 1 Joseph scissors, curved, 6¼ inch; 2 Backhaus towel forceps.





239CHAPTER 72 Tracheotomy

72-2 Top left: 1 Medicine cup, 2 oz. Left to right: 2 Senn retractors; 2 Army Navy retractors, front view and side view; 1 Jackson tracheal tenaculum, 5¼ inch; 1 skin hook, single; 1 baby weitlaner retractor, dull; 1 Trousseau-Jackson tracheal dilator, 53⁄8 inch; 1 Frazier suction tube; 1 Andrews suction tube, 3-mm tip, 9½ inch; 1 Andrews-Pynchon suction tube, 9½ inch.

72-3 Left to right: Tips: A, Tracheal hook; B, sharp tip of Senn retractor, double-ended; C, Trousseau-Jackson tracheal dilator, adult.

A B C



Septoplasty and Rhinoplasty

In a septoplasty, a submucous resection (SMR) is performed to correct a deviated septum of the nose. A rhinoplasty is the reconstruction of the bony and cartilaginous parts of the nose.

Possible equipment needed for the procedures includes a power drill with burrs and an electrosurgical unit.

A brief description of the septoplasty procedure follows: 1. A Vienna nasal speculum is inserted into the naris for visualization. 2. A Bard-Parker scalpel handle #7 with a #15 blade is used to incise into the septum. 3. A Freer elevator is used for blunt dissection to separate and elevate tissue layers. 4. A Freer knife is used to incise the cartilage. 5. A Cottle septum elevator is used to elevate the mucous membrane. 6. A Becker scissors may be used to trim the deviated cartilage. 7. A Kerrison rongeur is used to remove any bony, thickened structures. 8. A Converse guarded osteotome with mallet is used to trim bony spurs. 9. Frazier suction tips of various sizes with tubing are used to remove drainage to aid in

visualization.A brief description of the rhinoplasty procedure follows:

1. A Bard-Parker scalpel handle #3 with a #15 blade may be used to make an incision in the tip of the nose.

2. Joseph hooks are placed to retract the skin. 3. A McKenty elevator may be used to elevate the skin from underlying structures. 4. A Cottle septum elevator is used to free up the periosteum and perichondrium. 5. A Ballenger chisel with a mallet is used to break the nasal bones. 6. A curved Metzenbaum dissecting scissors may be used to trim the upper lateral

cartilage. 7. A Converse osteotome with a mallet may be used to shape the bony dorsal hump. 8. An Aufricht rasp may be used to smooth the hump. 9. A Cottle dorsal angular scissors may be used to remove a cartilaginous hump. 10. A Becker septum scissors may be used to remove the septal cartilage. 11. A Cottle osteotome with a mallet is used to remove bony spurs.

CHAPTER 73





241CHAPTER 73 Septoplasty and Rhinoplasty

73-2 Left to right: 1 Bauer rocking chisel; 1 Lewis rasp; 1 Maltz rasp; 1 Aufricht rasp, large; 1 Aufricht rasp, small; 1 Wiener antrum rasp; 2 Ballenger swivel knives; 1 Ballenger chisel, 4 mm; 2 Converse guarded osteotomes; 1 Cottle osteotome, round corners, curved, 6 mm; 4 Cottle osteo-tomes, straight: 4, 7, 9, and 12 mm; 1 mallet, lead-filled head.

73-1 Top: 5 Ludwig wire applicators. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard-Parker knife handle #7; 1 Cottle columella forceps; 1 Brown-Adson tissue forceps with teeth (7 × 7); 1 Beasley-Babcock tissue forceps; 1 Jansen thumb forceps, bayonet shaft, serrated tips; 1 Joseph button-end knife, curved; 1 Freer sep-tum knife; 1 Cottle nasal knife; 1 McKenty elevator; 1 Cottle septum elevator; 1 Freer elevator; 2 Joseph skin hooks; 1 Cottle knife guide and retractor.

73-3 Left to right: Tips: 1 Cottle colu-mella forceps; 1 Freer septum knife; 1 Joseph button-end knife; 1 Aufricht rasp, small, front view; 1 Aufricht rasp, large, side view; 1 Cottle knife guide and retractor, side view; 2 Ballenger swivel knives, side view and front view.



73-4 Top, left to right: 1 Fomon lower lateral scissors; 1 Metzenbaum dis-secting scissors. Bottom, left to right: 1 Metzenbaum dissecting scissors, 4 inch, straight; 1 Metzenbaum dis-secting scissors, 4 inch, curved; 1 Mayo dissecting scissors, straight; 1 Cottle spring scissors; 1 Cottle dorsal angular scissors; 1 Becker septum scissors.

73-5 Top: 1 Andrews-Pynchon suc-tion tube with tip. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard-Parker knife handle #7; 1 Beasley- Babcock tissue forceps; 1 Brown-Adson tissue forceps with teeth (7 × 7); 2 Frazier suction tubes with stylets, 7 Fr; 2 Frazier suction tubes with stylets, 12 Fr; 2 Backhaus towel forceps, small; 2 paper drape clips; 12 Halsted mosquito hemostatic forceps, curved; 2 Allis tissue forceps; 2 tonsil hemostatic forceps; 1 Johnson needle holder (hidden).


243CHAPTER 73 Septoplasty and Rhinoplasty

73-6 Top, left to right: 1 Ferris Smith fragment forceps; 1 mastoid articu-lated retractor; 1 Cottle bone crusher, closed; 1 Aufricht retractor. Bottom, left to right: 1 Kerrison rongeur, upbite; 1 Killian nasal speculum, 2 inch, front view; 1 Killian nasal speculum, 3 inch, side view; 1 Vienna nasal speculum, 1⅜ inch, front view; 1 Vienna nasal speculum, 11⁄8 inch, side view; 1 Asch septal forceps; 2 Army Navy retrac-tors, side view and front view.



Nasal Polyp InstrumentsNasal polyps are small, rounded, elongated growths that project from the mucous mem-brane surface in the nose.

CHAPTER 74



74-1 Left to right: 1 Killian nasal speculum, 3 inch; 1 Druck-Levine antrum retractor with blade (2 parts); 6 Coakley antrum curettes, assorted sizes, #1 to #6; 1 Bruening nasal snare, bayonet (disposable wire).

74-2 Left to right: A, Tips: Coakley antrum curettes, 7.5 × 9.5 mm; oval tip #1, 30-degree angle; oval tip #2, 60-degree angle; oval tip #3, 100-degree angle. B, Coakley antrum curettes, 6 × 7.5 mm, oval tip #4, 30-degree angle; oval tip #5, 60-degree angle; Coakley antrum curette, #6, 6 × 6 mm, triangular tip, 30-degree angle.

A

B



245CHAPTER 75 Nasal Fracture Reduction

Nasal Fracture Reduction

Nasal fracture reduction is a correction of a traumatic injury to the nose.A brief description of the procedure follows:

1. A Gillies elevator is inserted to align the bones and cartilage. 2. Asch forceps may be inserted to maintain alignment during packing insertion.

CHAPTER 75



75-1 Left to right: 1 Gillies elevator; 3 Asch forceps; assorted angles.




Sinus Surgery

The paranasal sinuses may need drainage improved or may need diseased membranes removed.

The endoscopy approach may be used. The instruments are introduced alongside the scope. Possible equipment and instruments needed for the procedure include a light source and a nasal set. For irrigation, cysto tubing, a bag of normal saline, and suction tubing may be used.

A brief description of the procedure follows: 1. A Vienna speculum may be needed to dilate the nares. 2. The scope is inserted through the nose. 3. An axial suction/irrigator is used for secretions and for visualization. 4. Blakesley-Weil ethmoid forceps are used to enlarge the maxillary sinus ostium. 5. A Coakley antrum curette may also be used to enlarge the maxillary sinus opening. 6. Gruenwald nasal forceps are used to grasp polyps. 7. Struycken nasal forceps are used to cut the polyps. 8. A Stammberger antrum punch may be used to remove diseased tissue.

CHAPTER 76



A

B

76-1 A, Left to right: Pediatric and small nasal Blakesley-Weil forceps: 1 pediatric straight; 1 pediatric 45 degrees; 1 45-degree small; and 1 90-degree small. B, Left to right: Tips: Pediatric and small Blakesley-Weil nasal forceps: 1 pediatric straight; 1 pediatric 45 degrees, 1 45-degree small; 1 90-degree small.



247CHAPTER 76 Sinus Surgery

76-2 A, Top, left to right: 1 Stamm-berger antrum punch (backbiter); 1 axial suction/irrigation handle. Bottom, left to right: 1 Sickle knife, sharp; 1 sickle knife, blunt; 1 sheath for 0 and 25 degrees, 4-mm lens; 1 maxillary sinus seeker; 1 Von Eicken antrum wash tube, 11 Fr; 2 antrum curettes, sizes 2 and 1. B, Left to right: Tips: Sickle knife, sharp; sickle knife, blunt; maxillary sinus seeker; 2 antrum curettes, sizes 2 and 1; Stammberger antrum punch (backbiter).

A

B

76-3 A, Left to right: 1 Gruenwald nasal forceps, size 2, 1 straight, cutting; 1 Struycken nasal forceps, 1 straight, cutting; 1 90-degree upward-bent nasal forceps; 1 45-degree upward-bent nasal forceps. B, Left to right: 1 Gruenwald nasal forceps tip; 1 Struycken nasal forceps tip; 1 90-degree upward-bent nasal forceps tip; 1 45-degree upward-bent nasal forceps tip.

A

B



76-4 A, Left to right: Blakesley-Weil nasal forceps: 1 straight, size 0; 1 straight, size 1; 1 straight, size 2. B, Left to right: Blakesley-Weil nasal forceps, tips: 1 straight, size 0; 1 straight, size 1; 1 straight, size 2.

A

B

76-5 A, Left to right: 1 Kuhn-Bolger giraffe forceps, 90 degrees (frontal sinus punch); 1 Kuhn-Bolger giraffe forceps, 110 degrees (frontal sinus punch); 1 Stammberger antrum punch, left; 1 Stammberger antrum punch, right. B, Left to right: Tips: 1 Kuhn-Bolger giraffe forceps, 90 degrees; 1 Kuhn-Bolger giraffe forceps, 110 degrees; 1 Stammberger antrum punch, left; 1 Stammberger antrum punch, right.

A

B


249CHAPTER 76 Sinus Surgery

76-6 A, Left to right: 1 Frontal sinus curette, 90 degrees; 1 Coakley antrum curette, straight with triangle tip; variety of Coakley antrum curettes with various angles and sizes, 1 to 6. B, Left to right: Tips: Frontal sinus curette and a variety of Coakley antrum curettes with various angles, sizes 1 to 6.

A

B

76-7 Left to right: 1 Beaded measur-ing probe; 1 maxillary sinus ostium seeker; 1 frontal ostium seeker; 1 Ostrom-Terrier ostium forceps, retrograde.



76-8 Left to right: 1 Small nasal scis-sors, straight; tips: small nasal scis-sors, curved left; small nasal scissors, curved right.

76-9 Top to bottom: 3 Telescope lenses, 4 mm: 0 degrees, 25 degrees, 70 degrees.


251CHAPTER 77 Facial Fracture Set

Facial Fracture Set

Facial fracture is a traumatic injury in which the continuity of the bone tissue of one or more facial bones is broken.

CHAPTER 77UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL SURGERY

77-1 Top, left to right: 1 Stevens tenotomy scissors, curved; 1 plastic scissors, straight, sharp; 3 wire- cutting scissors; 1 Mayo dissecting scissors, straight. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard-Parker knife handle #7; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Adson tissue forceps without teeth, front view and side view; 1 Brown-Adson tissue forceps with teeth (9 × 9), front view; 1 bayonet dressing forceps, 7½ inch; 1 Mayo dissecting scissors, curved; 1 Metzenbaum dissecting scissors; 2 paper drape clips; 2 Backhaus towel forceps, small; 2 Backhaus towel forceps; 6 Halsted mosquito hemostatic forceps, curved; 2 Halsted mosquito hemostatic forceps, straight; 2 Providence Hospital hemostatic forceps, curved; 2 Halsted hemostatic forceps, straight; 4 Crile hemostatic forceps, curved; 2 Allis tissue forceps; 2 Webster needle holders, 4 inch; 2 Crile-Wood needle holders, 6 inch; 2 Johnson needle holders, 6 inch.





252 UNIT 7 Oral, Maxillary, and Facial Surgery

77-3 Left to right: 1 Weder tongue retractor, large, side view; 1 Weder tongue retractor, small, front view; 2 University of Minnesota cheek retrac-tors, front view and side view; 3 ribbon retractors, assorted sizes; 2 Senn-Kanavel retractors, side view and front view.

77-2 Top, left to right: 2 Frazier suc-tion tubes with 1 stylet; 1 Yankauer suction tube with tip; 2 zygomatic arch awls. Bottom, left to right: 2 Joseph skin hooks, single; 2 Joseph skin hooks, double; 1 Kerrison rongeur, 90-degree upbite; 1 Lucas curette #0, short; 2 mandibular awls; 1 Cottle os-teotome, curved; 1 Cottle osteotome, straight; 1 Crane mallet.


253CHAPTER 77 Facial Fracture Set

77-4 Left to right: 1 Cottle nasal speculum #1, side view; 1 Cottle nasal speculum #2, front view; 1 Cottle nasal speculum #3, side view; 1 Friedman rongeur, single action; 1 Asch forceps; 2 Rowe disimpaction forceps, left and right.

77-5 Top, left to right: 3 Dingman bone-holding forceps; 1 Dingman zygoma elevator; 1 Gillies malar eleva-tor; 1 Freer elevator; 2 Langenbeck elevators; 1 Langenbeck perios-teal elevator, straight; 1 Langenbeck periosteal elevator, angled. Bottom left: Tip of Dingman bone-holding forceps.



Orthognathic Surgery

Orthognathic surgery is bony reconstruction of the mandible and/or the maxilla. The pro-cedure can be classified as Le Fort I, Le Fort II, or Le Fort III. Le Fort I is a fracture through the maxilla. Le Fort II is a fracture through the zygomatic arches. Le Fort III is a fracture through the bony orbits of the eye.

Possible instruments and equipment needed for the procedure include small bone instruments, drills and saws, and a mini-fracture fixation system. If arch bars and stainless steel wires are used, a wire cutter will be needed.

A brief description of the procedure follows: 1. A Petri pterygoid retractor is used to retract the cheek and stabilize the jaw. 2. A weitlaner retractor is used to retract the mucous membrane over the jaw. 3. A Bauer retractor is used to elevate the mandible and stabilize it. 4. A pterygomasseteric stripper is used to remove soft tissue from mandible. 5. Mini screws and plates are used to maintain the placement of the bones. 6. Arch bars with wires are applied to prevent movement of the jaw during healing. The

arch bars will be removed at a later time.

CHAPTER 78

78-1 Top right: 1 Burton retractor, double. Left to right: 2 Bauer retrac-tors, left and right; 1 Joseph coronoid self-retaining retractor; 1 Petri ptery-goid retractor; 1 channel retractor; 2 general-purpose retractors; 1 Kent-Wood adjustable retractor.





255CHAPTER 78 Orthognathic Surgery

78-2 Left to right: 1 Piriform rim retractor; 2 Langenbeck retractors, front view and side view; 2 Langenbeck retractors, up-curved tip, front view and side view; 1 pterygomasseteric sling stripper, small; 1 pterygomas-seteric sling stripper, medium; 1 Gillies malar elevator; 1 weitlaner retractor, 5 inch, blunt prong.

78-3 Left to right: 2 Roller compres-sions with metal trocar points, above: small and large; 1 trocar cannula (with trocar); 1 trocar with handle; 1 holding forceps; 2 dental mirrors #5; 2 cheek retractors; 1 mandibular reduction forceps.

78-4 Left to right: 1 Drill guide; 1 ball-end nasal osteotome; 3 osteotomes, straight: 4, 6, and 8 mm; 1 osteotome, angled, 6 mm; 1 osteotome, curved, 8 mm; 1 Parkes osteotome; 1 sagittal splitting osteotome; 1 Crile-Wood needle holder, curved, 6 inch; 1 coronoid match retractor.



78-5 Top: 2 Trocar cannulas. Bottom, left to right: 1 Caliper; 1 condylar strip-per; 1 Byrd screw; 2 zygomatic arch awls; 1 Freer elevator, double-ended; 1 periosteal elevator; 1 chisel.

78-6 Top to bottom, left to right: 1 MMF set lid; 2.0 × 8 mm MMF self-drilling screws and 2.0 × 12 mm MMF self-drilling screws (in set); ligature wire, blunt 22-gauge and 24-gauge (in set); 1 twist drill, 1.6 × 58 mm; 1 screw-driver ratchet handle with screwdriver blade and grasping sleeve; 1 2.0 × 8 mm MMF self-drilling screw.


257CHAPTER 79 Titanium 2.0-mm Microfixation System

Titanium 2.0-mm Microfixation System

The titanium 2.0-mm microfixation system is used for fixation of facial bones.

CHAPTER 79

79-1 Titanium 2.0-mm microfixation system instrumentation, trays 1 and 2 of 3 (labeled).

79-2 Titanium 2.0-mm microfixation system instrumentation, tray 3 of 3 (labeled).





258 UNIT 8 Plastic Surgery

Minor Plastic Set

Plastic surgery is performed to mold, alter, and restore visible parts of the body.

CHAPTER 80 UNIT EIGHT: PLASTIC SURGERY

80-1 Top, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 1 Brown-Adson tissue forceps with teeth (9 × 9), front view. Bottom, left to right: 2 Bard-Parker knife handles #3; 2 DeBakey vascular atraugrip tissue forceps, short; 2 Cushing tissue forceps with teeth (1 × 2); 4 paper drape clips; 6 Halsted mosquito hemostatic forceps, curved; 1 Halsted mosquito hemostatic forceps, straight; 8 Crile hemostatic forceps, curved, 5½ inch; 1 Halsted hemostatic forceps, straight; 6 Crile hemostatic forceps, curved, 6½ inch; 4 Allis tissue forceps; 4 Babcock clamp tissue forceps; 4 Ochsner hemostatic forceps, straight; 1 Westphal hemo-static forceps; 2 tonsil hemostatic forceps; 1 Foerster sponge forceps; 1 Johnson needle holder, 6 inch; 2 Crile-Wood needle holders, 6 inch.

80-2 Top, left to right: 2 Army Navy retractors, front view and side view; 2 Miller-Senn retractors, side view and front view. Bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzen-baum scissors, 7 inch; 1 Metzenbaum scissors, 5 inch; 2 Goelet retractors, front view and side view; 2 Richardson retractors, small, side view and front view.


259CHAPTER 80 Minor Plasic Set

80-3 Left, top to bottom: 1 Metal medicine cup, 2 oz; 1 weitlaner retractor, small. Right, top to bottom: 1 Yankauer suction tube with tip; 1 Poole abdominal suction tube with shield; 1 Ochsner malleable retractor, medium; 1 Ochsner malleable retractor, narrow; 1 Deaver retractor, medium.



Micro Plastic Set

A Micro Plastic Set is used in microvascular surgery. Possible equipment includes a surgical microscope and micro plastic instrumentation.

CHAPTER 81

81-1 Left to right, top to bottom: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 1 strabismus scissors, curved, 4½ inch; 1 tenotomy scissors, curved, 41⁄8 inch; 1 plastic scissors, sharp, straight, 4¾ inch; 1 Weck scissors; 1 Stevens tenotomy scissors, straight; 1 round handle scis-sors, straight, 18 cm; 1 round handle dissecting scissors, curved, 15 cm; 1 round handle scissors, curved, 18 cm; 1 Potts scissors, angled 25 degrees; 1 Freer elevator, double ended; 2 Cottle hooks, single, small, deep.

81-2 Left to right: 2 Bishop-Harmon tis-sue forceps, straight, with teeth 1 × 2, front and side view; 2 dilator forceps, tip angled 10 degrees, 43⁄8 inch, front and side view; 1 Adson micro forceps, 4¾ inch; 1 micro tying forceps, straight, 12 cm; 2 Gerald-DeBakey tissue forceps, 7¼ inch, 1-mm tip; 2 Delicate Touch Gerald-DeBakey tissue forceps, straight, titanium, 7 inch; 1 Delicate Touch micro forceps, round handle, titanium, 7¼ inch, 1-mm ring tips; 1 Delicate Touch Dennis micro forceps, round handle, titanium, 1-mm ring tips; 2 Mills proximal ring forceps, micro diamond jaw, round handle, 8¼ inch; 2 Delicate Touch micro forceps, straight, 71⁄8 inch; 1 Jeweler’s forceps, straight, flat handle, 7 inch.


261CHAPTER 81 Micro Plasic Set

81-3 Enlarged tips: 2 Ring forceps.

81-4 Top right corner, left to right: 1 Approximator vein clamp, double, 0.4-1.0 mm; 1 COAMPS vein clamp, single 0.4-1.0 mm; 1 approximator vein clamp, double, 0.6-1.5 mm; 2 vein clamps, single, 0.6-1.5 mm. Bottom, left to right: 2 Harmon mosquito forceps, curved, 4 inch; 1 Delicate Touch micro needle holder, titanium, locking, 7 inch; 1 Castroviejo eye needle holder, locking, straight, 5½ inch; 1 Barraquer micro needle holder, curved; 2 Rizzutti clip appliers.



Plastic Miscellaneous

Lighted breast retractors are used for breast cases such as breast augmentation, mastecto-mies, and breast reconstructions. These provide better visualization and smoke evacuation. The Coleman Infiltration Set is used for fat transplantation, whereas the Byron liposuction, liposcution tulip cannula, and bucket handle are used for liposuction. Depending on the location and extent of treatment, different liposuction cannulas may be used.

CHAPTER 82

82-1 Left to right: 1 Tebbetts fiber optic retractor, 9 × 24 cm blade; 1 Luxtec fiber optic light cable; 1 Tebbetts fiber optic retractor, 15 × 36 cm blade.


263CHAPTER 82 Plastic Miscellaneous

82-2 Left to right: 1 Cushing insulated bipolar forceps; 1 Maxwell flap retrac-tor, 4 × 7⁄8 inch; 1 Maxwell flap retrac-tor, 4 × 1½ inch; 1 Gorney-Freeman SuperCut scissors.

82-3 Left to right, top to bottom: 1 Coleman mini cannula, 19-gauge; 1 V-dissector, 7 cm; 1 Coleman mini stylet, 19-gauge; 1 Coleman infiltration cannula, 7 cm; 1 Coleman infiltration cannula, concave curve, 9 cm; 1 Coleman cannula, 9 cm; 1 Coleman aspiration cannula, 1 × 15 cm; 1 Lamis infiltration needle, 16-gauge ×15 cm; 1 Luer-Lok to Luer-Lok, 12-gauge; 1 Blue rack with collection tube.



82-4 Enlarged Coleman infiltration tips, four variations.

82-5 Top to bottom: Byron liposuction cannulas: 14 mm × 26 cm; 15 mm × 32 cm; 14 mm × 32 cm; 13 mm × 30 cm; 12 mm × 15 cm.

82-6 Enlarged Byron tip.


265CHAPTER 82 Plastic Miscellaneous

82-7 Top to bottom: 1 Tulip cannula; 2 liposuction handles, bucket handle, 5-mm and 10-mm tips.

82-8 Left to right: 2 Bucket cannula tips.



Skin Graft

A skin graft is performed when the full thickness of skin has been lost.Possible instruments needed for the procedure include a minor plastic set.A brief description of the procedure follows:

1. An electric dermatome is used to harvest skin. 2. Disposable dermatome blades are used in various widths, depending on the size of the

graft needed. 3. A Dermamesher graft expander is used to enlarge the piece of skin so it will cover a

larger area.

CHAPTER 83

83-1 Padgett dermatome. Top to bottom, left to right: Screwdriver to tighten screws for guards; calibration tool; Padgett dermatome hand piece; electric power cord; three guards.

83-2 Head of Padgett dermatome, adjustable depth level for skin procurement.


267CHAPTER 83 Skin Graft

83-4 Bioplasty Dermamesher, 1:1 ratio. This does not require a carrier for the meshing of the skin. Also comes in 1:2, 1:3, and 1:4 ratios.

83-3 Guards for Padgett dermatome. Top to bottom: 4-inch, 3-inch, and 2-inch.


268 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery

Endarterectomy

Endarterectomy is the surgical removal of the intimal lining of the artery. This procedure is performed to clear a major artery that may be blocked by plaque accumulation. The most common arteries needing endarterectomy are the carotid (neck) and the femoral (groin).

Possible equipment needed for the procedure includes femoral-to-popliteal artery bypass instruments, DeBakey tunnelers, 2 Cooley coarctation clamps, 1 Hollman tunneling forceps, and possibly a synthetic graft.

CHAPTER 84 UNIT NINE: PERIPHERAL VASCULAR, CARDIOVASCULAR, AND THORACIC SURGERY

84-1 Endarterectomy instruments in the sterilization container. (Courtesy Case Medical, Inc., South Hacken-sack, N.J.)

A B

84-2 A, Femoral artery shows blockage in the main artery and deep femoral artery in the groin. B, Following endarterectomy of both arteries, the contrast shows arteries with increased blood supply.





269CHAPTER 85 Artery Bypass Graft

Artery Bypass Graft

Possible equipment needed for the procedure includes a DeBakey tunneler, 2 Cooley coarc-tation clamps, 1 Hollman tunneling forceps, and a synthetic graft.

A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #3 with a #11 blade is used to incise into the popliteal

artery. 2. Potts-Smith scissors (45 degrees) are used to extend the incision in the artery. 3. DeBakey vascular forceps are used to clamp the popliteal artery. 4. A DeBakey tunneler is used to make a passage beneath the sartorius muscle for the

graft from the popliteal artery to the femoral artery. 5. A Bard-Parker scalpel handle #7 with a #11 blade is used to make a small incision into

the femoral artery. 6. Potts-Smith scissors are used to extend the incision. 7. A Cooley coarctation clamp is used to occlude the femoral artery. 8. Hollman tunneling forceps are used to pull the graft into position. 9. An Ayers needle holder is used for the suturing of the graft. 10. DeBakey tissue forceps are used to help with the suturing.

CHAPTER 85

85-1 Top to bottom: 2 Yankauer suc-tion tubes with tips; 1 Frazier suction tube with stylet. Bottom, left to right: 6 Paper drape clips; 10 Halsted mos-quito hemostatic forceps, curved; 6 Crile hemostatic forceps, curved, 5½ inch; 6 Providence Hospital hemo-static forceps (delicate tip), curved, 5½ inch; 4 Crile hemostatic forceps, curved, 6½ inch; 4 Allis tissue forceps; 4 Westphal hemostatic forceps; 6 ton-sil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, long, curved; 2 Carmalt hemostatic forceps, long; 2 Adson hemostatic forceps, long; 2 Mixter hemostatic forceps, long, fine and heavy tips; 2 Foerster sponge forceps; 2 Crile-Wood needle holders, 7 inch; 2 Ayers needle holders, 7 inch, fine tips.






85-2 Top, left to right: 2 Bard-Parker knife handles #7; 2 Miller-Senn retrac-tors. Bottom, left to right: 2 Bard-Parker knife handles #3; 2 Adson tissue forceps with teeth (1 × 2), side view and front view; 2 DeBakey vascular atraugrip tissue forceps, short, side view and front view; 2 Ferris Smith tissue forceps, side view and front view; 2 DeBakey vascular atraugrip tissue forceps, medium, side view and front view; 1 eyed obturator (stylet) for Rumel tourniquet.

85-3 Left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum scis-sors, 5 inch; 1 Metzenbaum scissors, 7 inch; 1 Lincoln-Metzenbaum scissors; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 1 Strully scissors, probe tip.

85-4 Top: 2 Army Navy retractors, side view and front view. Bottom, left to right: 2 weitlaner retractors, sharp, medium; 2 vein retractors, side view and front view; 2 Richardson retrac-tors, small, side view and front view; 2 Richardson retractors, medium, side view and front view; 1 Deaver retractor, small, side view.


271CHAPTER 86 Endovascular Abdominal Aortic Aneurysm Repair

Endovascular Abdominal Aortic Aneurysm Repair

An aneurysm is the abnormal bulging of an artery.Possible equipment and instruments needed for the procedure include an angiocath for

an arteriogram, an endoluminal synthetic graft, a small dissection set, 2 Rumel tourniquets, and a skin stapler.

A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #7 with a #11 blade is used to make small incisions over

both femoral arteries in the groins. 2. Femoral cutdown instrumentation may be needed for additional exposure. 3. Halsted mosquito hemostatic forceps are placed for hemostasis and blunt dissection. 4. A snare is introduced through the left femoral artery up through the descending aorta to

above the aneurysm. 5. A pull wire is introduced through the right femoral artery and right iliac artery to the

descending aorta. 6. The pull wire is snared and pulled into the left iliac artery to the femoral artery. 7. The endoluminal graft is introduced through the right femoral artery above

the bifurcation. 8. The graft is inflated, which secures it to the walls of the descending aorta and the iliac

arteries. 9. The small incisions are closed with staples with the aid of Adson tissue forceps with teeth.

CHAPTER 86



86-1 Graphic diagram of a descend-ing aortic aneurysm. (Courtesy VAS Communications, Phoenix, Ariz.)




86-2 Graphic diagram of an endolu-minal graft postoperatively. (Courtesy VAS Communications, Phoenix, Ariz.)

86-3 Top, left to right: 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 1 Dennis forceps, 8½ inch; 1 DeBakey tissue forceps, 2-mm tip, 7¾ inch; 1 tissue forceps, 1 × 2 teeth, 6¾ inch. Bottom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 1 Metzenbaum dissecting scissors, curved, 7 inch; 1 Metzenbaum, curved, sharp, 7 inch; 1 Diethrich scissors, 25-degree angle; 1 Potts scissors, reversed. On stringer: 6 Halsted mos-quito clamps, curved, 5 inch; 6 Crile forceps, curved, 5½ inch; 2 right-angle clamps, fine, 7 inch; 2 Mayo-Hegar needle holders, 7¼ inch; 2 Crile-Wood needle holders, 6 inch; 2 Fogarty stealth clamps, straight, 6½ inch; 2 Fogarty stealth clamps, angled, 6 inch; 1 Gregory Profunda vascu-lar clamp, medium; 2 Gregory Profunda vascular clamps, small; 2 DeBakey clamps, short, 40 degrees; 1 titanium micro clamp, 41⁄8 inch (blue).


273CHAPTER 86 Endovascular Abdominal Aortic Aneurysm Repair

86-4 Enlarged tip: Potts scissors, reversed.

86-5 Left to right: 2 Weitlaner retrac-tors, blunt, 3 × 4, 6½ inch; 1 Army Navy retractor; 1 Richardson-Eastman retractor, double-ended, 10 inch; 1 Richardson retractor, narrow, 9½ inch; 1 Andrews suction tube; 1 heparin needle, short; 1 heparin needle, medium, angled; 1 eyed obturator for Rumel tourniquet, 111⁄8 inch; 1 hemoclip applier, medium; 1 petri dish; 1 hemo-clip applier, small.



Abdominal Vascular Set (Open Procedure)

CHAPTER 87

87-2 Top to bottom: 2 Bard-Parker needle holders #4; 2 Bard-Parker needle holders #7. Bottom, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Hayes Martin tissue forceps with multiteeth, short, front view and side view; 2 Ferris Smith tissue forceps, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, medium, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 Russian tissue forceps, long, front view and side view.

87-1 Top, left to right: 2 Backhaus towel forceps; 6 paper drape clips. Bottom, first stringer, left to right: 2 Ochsner hemostatic forceps, straight, long; 2 Mayo-Péan hemostatic forceps, long; 4 tonsil hemostatic forceps; 1 Westphal hemostatic forceps; 4 Providence Hospital hemostatic forceps (delicate tip), 5½ inch, curved; 4 Crile hemostatic forceps, 5½ inch, curved; 4 Halsted mosquito hemostatic forceps, curved. Second stringer, left to right: 4 Halsted mosquito hemostatic forceps, curved; 6 Crile hemostatic forceps, 5½ inch, curved; 1 Westphal hemostatic forceps; 4 tonsil hemostatic forceps; 4 Carmalt hemo-static forceps, long; 2 Adson hemostatic forceps, long; 2 Allis tissue forceps, long; 4 Ochsner hemostatic forceps, long, straight; 3 Mixter hemostatic forceps, long, heavy tip; 2 Mixter hemostatic forceps, long, fine tip; 4 Foerster sponge forceps; 2 Ayers needle holders, 8 inch; 2 Crile-Wood needle holders, 8 inch.





275CHAPTER 87 Abdominal Vascular Set (Open Procedure)

87-3 Top, left to right: 1 Metzen-baum scissors, 5 inch; 1 Lincoln-Metzenbaum scissors; 1 Metzenbaum scissors, 7 inch. Bottom, left to right: 1 Strully scissors, probe tip; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 2 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, long, sharp; 1 Snowden-Pencer scissors, curved; 1 Snowden-Pencer scissors, straight.

87-4 Top to bottom: 2 Vein retractors; 1 metal ruler. Bottom, left to right: 1 Eyed obturator (stylet) for Rumel tourniquet; 2 weitlaner retractors, sharp, medium; 2 Army Navy retrac-tors, side view and front view; 1 Poole abdominal suction tube with shield; 2 Yankauer suction tubes with tips.



87-5 Top: 2 Ochsner malleable re-tractors: large and small. Bottom, left to right: 1 Richardson retractor, small; 1 Richardson retractor, medium; 2 Richardson retractors, large, side view and front view; 3 Deaver retractors: small, medium, and large.

87-6 Left to right: Tips: A, Adson hemostatic forceps, curved, 8½ inch; B, Mixter forceps, delicate, longitu-dinal serrations, 10¾ inch; C, Mixter forceps, full curve, heavy, 10½ inch; D, comparison of the three tips of the above instruments.

A B C D


277CHAPTER 88 Thoracoscopy

Thoracoscopy

A thoracoscopy visualizes inside the chest cavity via a laparoscope.Possible instruments needed for the procedure include a laparoscope, a minimally

invasive surgery (MIS) adult set, and a minor instrument set.A brief description of the procedure follows:

1. Thoracoports, including obturators and cannulas are used for scope insertion. 2. A fan retractor is used for visualization. 3. Roticulating Babcock tissue forceps are used to gently handle tissue. 4. A Duval lung clamp is used to stabilize tissue that is being removed. 5. Roticulating Metzenbaum dissecting scissors are used to excise the tissue.

CHAPTER 88

88-1 Top to bottom: 1 Articulating lung grasper, 10 mm; 1 roticulating Metzenbaum scissors, 5 mm × 33 cm, angled shaft; 1 roticulating Babcock tissue forceps, 5 mm × 33 cm, angled shaft.

88-2 Left to right: Tips: A, Roticulating Metzenbaum scissors, 5 mm, 33-cm length, angled shaft; B and C, roticulat-ing Babcock tissue forceps, 5 mm, 33-cm length, angled shaft; B, closed; C, open.

A B C






88-3 Top to bottom: Duval clamp, 10 mm, open; Duval clamp, 10 mm, closed; fan retractor, 10 mm (two parts, together).

A B88-4 A, Tip of Duval clamp, 10 mm, closed; B, tip of Duval clamp, 10 mm, open.

88-5 Top: 2 5-mm Thoracoports, includes 1 blunt obturator, 1 cannula. Middle: 2 10-mm Thoracoports, includes 1 blunt obturator, 1 cannula. Bottom: 1 12-mm Thoracoport, includes 1 blunt obturator, 1 cannula; 1 15-mm Thoraco-port, includes 1 blunt obturator, 1 cannula.


279CHAPTER 88 Thoracoscopy

*Video position change per physician preference

AS

SIS

TA

NT

ANESTHESIA

THORACOSCOPY (LEFT)

CA

ME

RA

HO

LDE

R

SC

RU

B

SU

RG

EO

N

VIDEO2*VIDEO

1

BACKTABLE

5, 10, or 12Variable; depends

on surgery

__10_5 _5

88-6 Position for thoracoscopy.



Thoracic Instruments

A thoracotomy is an incision into the chest cavity.Possible instruments needed for the procedure include an abdominal vascular set and

cardiovascular instruments.A brief description of the procedure follows:

1. A Matson rib stripper is used to remove muscle and periosteum from ribs. 2. A Giertz rib cutter is used to resect a rib. 3. A Semb rongeur is used to trim bone ends. 4. A Burford retractor is placed to retract the ribs. 5. A Semb retractor is used to expose the lung. 6. A Duval lung clamp is placed for gentle maneuvering of the lobes of the lungs. 7. A Sarot clamp is used for clamping the bronchus. 8. A Bailey rib contractor is used during chest closure.

CHAPTER 89

89-1 Top, left to right: 1 Malleable T retractor; 1 Giertz (first rib) (rib guil-lotine) rongeur; 1 Matson rib stripper and elevator. Bottom left: Burford rib spreader with shallow blade attached; 1 shallow blade; 2 deep blades.





281CHAPTER 89 Thoracic Instruments

89-2 Top to bottom: Bethune (rib) rongeur; 1 Sauerbruch (rib) rongeur, double-action.

89-3 Left to right: 2 Doyen rib eleva-tors and raspatories, left and right; 1 Alexander rib raspatory (periosteo-tome), double-ended; 1 Semb lung retractor; 1 Semb gouging rongeur, double-action; 1 Bailey rib contractor.



89-4 Top: 2 Crile-Wood needle hold-ers, 11 inch. Bottom, left to right: 1 Sarot bronchus clamp, angled; 1 Lee bronchus clamp, angular; 4 Allis tissue forceps, long; 3 Duval lung forceps, 2 front views and 1 side view.

A B

DC

89-5 Left to right: Tips: A, Sarot bron-chus clamp, angled; B, Lee bronchus clamp, angled; C, Duval lung forceps; D, Semb lung retractor.


283CHAPTER 90 Cardiac Surgery

Cardiac Surgery

Cardiac surgery relates to surgery of the heart. Some heart surgeries include a coronary artery bypass graft (CABG); replacement of the heart valves (valvular annuloplasty); or repair of the wall between the chambers of the heart (septal repair).

Specialty instrumentation needed for open cardiac procedures include sternal saws, microinstruments, and cardiac specific clamps.

A brief description of the procedure follows: 1. A sternal knife or saw is used to open the chest. 2. A sternal retractor is used to expose the pericardial sac. 3. Stay sutures are used to hold the pericardium open and expose the heart. 4. The necessary procedure is performed. 5. The pericardium, sternum, soft tissue, and skin are then closed.

CHAPTER 90

90-1 Left to right: 1 Vital Metzenbaum scissors; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum scissors, fine, curved, blunt, 9 inch; 1 Metzenbaum scissors, fine, 8 inch (hidden); 2 DeBakey needle holders, serrated, 9 inch; 6 Julian needle holders, serrated, 8 inch; 6 Mayo-Hegar needle holders, 7 inch; 3 wire twisting forceps; 6 Crile forceps, curved, 5½ inch (1 hidden); 2 Boettcher tonsil clamps, 7½ inch; 1 Mayo-Péan hemo-static forceps, 8 inch; 2 Kocher clamps, 1 × 2 teeth, 8 inch; 1 Foerster sponge stick, straight; 1 DeBakey tangential oc-clusion vascular forceps, 7¾ inch; 1 Cooley forceps, curved, 8 inch; 1 Semb ligature-carrying forceps, fully curved, 9 inch; 1 Lambert-Kay aortic clamp, 8 inch; 1 Fogarty Hydragrip clamp, an-gled, 8½ inch; 1 Fogarty Hydragrip clamp, angled, curved shank, 9¼ inch; 1 Stealth aortic cross clamp, angled, 9 inch.






90-2 Enlarged tips: A, DeBakey tangential occlusion vascular forceps. B, Cooley forceps. C, Semb ligature-carrying forceps, fully curved tip. D, Semb ligature-carrying forceps, top of tip. E, Lambert-Kay aortic clamp. F, Left to right: Fogarty Hydragrip clamps, angled without inserts and with inserts.

A B C

D E F

90-3 Top, left to right: 16 Kocher clamps, 1 × 2 teeth, 6¼ inch. Bot-tom, left to right: 1 Vital Metzenbaum scissors; 6 Halsted mosquito clamps, curved, 5 inch; 8 Crile forceps, curved, 5½ inch; 2 Boettcher tonsil clamps, 7½ inch; 1 Kantrowitz forceps, 8 inch; 1 Carmalt hemostatic forceps, right angle, heavy duty, 9 inch; 1 Mayo-Péan hemostatic forceps, 8 inch; 4 tubing clamps (for tubing with OD, 5⁄8 inch), 7½ inch; 1 Fogarty stealth applicator forceps; 2 hemoclip appliers, small; 2 hemoclip appliers, medium; 2 Mayo dissecting scissors, 6¾ inch.


285CHAPTER 90 Cardiac Surgery

90-5 Left to right, top to bottom: 1 Bard-Parker knife handle, #4; Bard-Parker knife handle, #7; 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 2 fixation forceps, 7 × 8 teeth, 6 inch; 1 Baker tis-sue forceps, 1 × 2 teeth, serrated, 7½ inch; 1 DeBakey-Diethrich coronary artery forceps, 1.0-mm tip, 9½ inch; 1 DeBakey tissue forceps, 2-mm tip, 9½ inch; 1 Russian forceps, 10 inch; 1 DeBakey vascular forceps, angled, 9½ inch; 1 Backhaus towel forceps, small; 1 Backhaus towel forceps, large; 1 Lorna towel forceps, nonperforating, 5¼ inch.

90-4 Enlarged tip: Fogarty stealth applicator forceps.

90-6 Left to right: 1 Bandage scissor; 1 Pemco suction tip; 1 Yankauer suc-tion tip; 1 Codman wire cutter; 2 Greene retractors, 8½ inch; 2 eyed obturators (stylet) for Rumel tourniquets, 11½ inch; 1 Penfield dissector, #4; 1 myocardial dilator, 5¾ inch; and 1 Finochietto rib spreader, pediatric.



90-7 Enlarged tip: Eyed obturator (stylet) for Rumel tourniquet.


287CHAPTER 91 Open Heart Microinstruments

Open Heart Microinstruments

Open heart microinstrumentation is used for coronary artery bypass grafting. These deli-cate instruments allow the surgeon to handle very fine needles and work in very small areas of the heart.

CHAPTER 91

91-1 Top, left to right: 1 Frazier suction, 7 Fr, 7½ inch; 1 Frazier suction stylet; 2 Parsonnet epicardial retractors, 2 inch, 1½ inch, 1¼ inch. Bottom, left to right: 1 Beaver knife handle, round, 6 inch; 1 Prince-Metzenbaum scissors; 1 Strully scissors, 8 inch; 1 microvas-cular scissors, angled, 120 degrees, 7 inch; 1 microvascular scissors, angled, 25 degrees, 7 inch; 1 Weary nerve hook, fine; 3 coronary artery probes, 1.0 mm, 1.5 mm, 2.0 mm; 1 micro forceps, titanium 0.5 mm tip, 8½ inch; 1 micro forceps, titanium-toothed, 0.5-mm tip, 8¼ inch; 1 Castroviejo micro needle holder, titanium, 8¼ inch; 1 Castroviejo micro needle holder, titanium, 7¼ inch; 1 Jacobson needle holder, titanium, fine, 8½ inch.






A B C

D E

91-2 Enlarged tips: A, Microvascular scissors, angled, 120 degrees, 7 inch; B, microvascular scissors, angled, 25 degrees, 7 inch; C, 3 coronary artery probes (Garrett dilators), 1.0 mm, 1.5 mm, 2.0 mm; D, Parsonnet epicardial retractor, 3 × 3 sharp prongs, 1½ inch; E, Strully scissors.


289CHAPTER 92 Sternal Saws and Sternum Knife

Sternal Saws and Sternum Knife

The sternal knife and sternal saws are used to expose the pericardium and the heart. The incision is made through the skin, subcutaneous tissue, and muscle to expose the sternum. A sternotomy is then performed.

CHAPTER 92

92-1 Left to right: 1 Stryker hand piece with battery separate; 1 blade; 1 Stryker sternal saw attachment with safety guard.






92-2 Left to right: Power cord; Hall sternal saw. Right, top to bottom: 1 Saw blade; 1 saw guide; 1 wrench.

92-3 Surgeons’ preference instead of sternal saw. Top to bottom: Lebsche sternum knife and mallet.


291CHAPTER 93 Open Heart Extras

Open Heart Extras

Open heart extras include internal defibrillator paddles, sternal plating systems, and beating heart retractors and stabilizers. Internal defibrillator paddles are used to reverse fibrillation and initiate cardiac contractions. Sternal plating systems are used to reapproximate and fix-ate the sternum after a sternotomy. Beating heart retractors attach to the sternal retractor proximally, and the stabilizers attach to the heart to immobilize the coronary artery to be grafted. The stabilizer will compress or use suction on the tissue around the arteriotomy to immobilize the anastomosis site.

CHAPTER 93

93-1 Left to right: 1 Ankeney sternal retractor; 1 Himmelstein sternal retractor.






93-2 Morse sternal retractor.

A B

93-3 Left to right: A, Horizon clip appliers, 2 small, 2 medium; B, enlarged tips of Horizon clip appliers, small, medium.



93-4 Internal defibrillator paddles and handles with cable.

93-5 Octopus retractor with dispos-able tissue stabilizers.



93-6 Top, left to right: 1 Sternal crimper; 1 tensioning handle. Bottom, left to right: 1 Crimp passer; 3 sternal cables with needles attached and 3 crimpers in the middle; cable cutter.

93-7 Top, left to right: 2 SternaLock power driver units (cords not included); 1 bone reduction forceps; plate and wire cutter. Bottom, left to right: 1 Tray containing plates, screws, and blades; 1 Beuse plate-holding forceps; 1 SternaLock screw sizer; 1 plate-holding wand, 2.4 mm; 1 ratcheting screwdriver with SternaLock blade attached; 1 ratcheting screwdriver; 1 SternaLock blade; 1 double-action rongeur, small.



93-8 Pericardial window. Top, left to right: 1 Bandage scissors; 1 double-action ronguer, small; 1 Richardson retractor, narrow; 1 Army Navy retrac-tor. Bottom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 2 Adson forceps, 1 × 2 teeth; 1 fixation forceps, 7 × 8, 6 inch; 1 Baker tissue forceps, 1 × 2, serrated 7½ inch; 1 Russian forceps, 10 inch; 1 atraugrip forceps, 9½ inch. On stringer: 4 Halsted mosquito clamps, curved, 5 inch; 4 Crile hemostatic forceps, curved, 6½ inch (1 hidden); 2 Boettcher tonsil clamps, curved, 7½ inch; 2 Allis clamps; 2 Ochsner-Kocher, 8 inch (1 hidden); 1 sponge forceps; 1 Mayo-Péan hemostatic forceps; 2 Mayo-Hegar needle holders, 7¼ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Vital Metzenbaum scissors; 1 Nelson scissors, curved, 9 inch; 1 4-prong rake, sharp, 8½ inch.



Cardiovascular Instruments

Cardiovascular instruments are used on the vessels because, when clamped on them, the instrument tips do not damage the vessels.

These instruments needed for the procedure are often found within open heart sets.

CHAPTER 94

94-1 Left to right: A, Cooley clamp, angled jaw, straight shank, 5¼ inch, front view and tip; B, DeBakey bulldog clamp, ring handle, 45-degree angle, 4¾ inch, front view and tip; C, DeBakey peripheral vascular clamp, angular, 7 inch, front view and tip.

A B C





297CHAPTER 94 Cardiovascular Instruments

94-2 Left to right: A, Fogarty clamp-applying forceps, angled, front view and tip; B, Fogarty clamp-applying forceps, straight, front view, and tip; C, renal artery clamp, 7¼ inch, front view and tip.

A B C

94-3 Left to right: A, Potts-Smith tissue forceps, Carb-Bite tip, front view and tip; B, Lee bronchus clamp, 9¼ inch, front view and tip; C, Cooley coarctation clamp, straight handle, 8¾ inch, front view and tip.

A B C



94-4 Left to right: 1 DeBakey aortic exclusion clamp, acute S-shape, medium, 7¼ inch; 1 DeBakey aortic exclusion clamp, acute S-shape, long; 1 DeBakey multipurpose vascular clamp, obtuse angle, 60 degrees, 8¼ inch; 1 Semb ligature-carrying forceps, 9 inch.

94-5 Top: 1 Andrews-Pynchon suc-tion tube. Bottom, left to right: 1 Metal ruler, 6 inch; 1 Freer double-ended elevator; 1 Penfield dissector, single-ended, #4; 1 Hoen nerve hook; 1 Adson hemostatic forceps, angled, fine tip; 2 Ryder needle holders, 7 inch, fine tip.

A B94-6 Left to right: Tips: A, DeBakey aortic exclusion clamp, S-shape; B, Hoen nerve hook, straight.


299CHAPTER 95 Open Heart Valve Extras

Open Heart Valve Extras

Instrumentation needed for a heart valve repair or replacement includes a basic open heart set and a valve instrument set.

CHAPTER 95



95-1 Left to right: 6 Backhaus towel forceps, small; 1 Providence Hospital hemostatic forceps; 2 Ayers needle holders, 11 inch; 2 Heaney needle holders; 2 tonsil hemostatic forceps; 2 tonsil hemostatic forceps, long; 2 Allis tissue forceps, long; 1 Allis tissue forceps, long, curved. Right, top to bottom: 1 Pituitary rongeur, straight bite, 7 inch; 1 pituitary rongeur, upbite, 7 inch; 1 pituitary rongeur, downbite, 7 inch.

95-2 Left to right: 3 Pituitary rongeur tips: straight bite, downbite, upbite.




A B

DC

95-4 Enlarged tips: A, Leaflet retractor; B, Cushing-Brown tissue forceps with teeth (9 × 9); C, Heaney needle holder; D, Allis tissue forceps, curved.

95-3 Left to right: 1 Bard-Parker knife handle #3, long; 1 Cushing-Brown tissue forceps with teeth (9 × 9); 1 Cushing tissue forceps with teeth (1 × 2); 2 Teflon Bardic plugs; 3 leaflet retractors, 2 side view and 1 front view; 1 grafting suction tube.


301CHAPTER 96 Return Open Heart Set

Return Open Heart Set

A return open heart set is used when an unexpected complication (e.g., hemorrhage) occurs following an open heart procedure. Possible equipment needed for the procedure includes open heart instrumentation including retractors and a re-open sternal saw or sternal plating removal instrumentation.

CHAPTER 96



96-1 Top left: 3 Bard-Parker knife handles: #7, #4, and #3. Bottom, left to right: 2 Hayes Martin tissue forceps with multiteeth, front view and side view; 1 Ferris Smith tissue forceps; 1 Cushing tissue forceps with teeth (1 × 2), 7 inch; 2 Reul dressing forceps, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 Russian tissue forceps, long, front view and side view.

96-2 Left to right: 8 Paper drape clips; 6 Crile hemostatic forceps, 6½ inch; 12 Ochsner hemostatic forceps, medium jaw; 2 Ochsner hemostatic forceps, long jaw; 2 Westphal hemostatic forceps, short; 4 tonsil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, long, curved; 1 Adson hemo-static forceps, long; 1 Foerster sponge forceps; 1 Crile-Wood needle holder, 7 inch; 2 Jarit sternal needle holders, 7 inch; 2 Crile-Wood needle holders, 8 inch; 1 Ayers needle holder, 8 inch; 2 Yankauer suction tubes with tips.




96-3 Left to right: 2 Volkmann retrac-tors, 4 prong, dull, front view and side view; 1 Richardson retractor, small; 1 Ochsner malleable retractor, medium; 2 Army Navy retractors, front view and side view; 1 wire cutter, heavy.

96-4 Top, left to right: 1 Wire cutter, small; 1 hemoclip cartridge base. Bottom, left to right: 2 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum scis-sors, 7 inch; 2 Weck EZ Load hemoclip appliers (the new version is the Weck Horizon hemoclip).


303CHAPTER 96 Return Open Heart Set

96-5 Left to right: 1 Lambert-Kay aor-tic clamp; 1 DeBakey multipurpose vascular clamp, obtuse angle, 60 degrees; 1 Beck aorta clamp; 1 Jarit microsurgical needle holder with lock, 7 inch; 2 eyed obturators (stylets) for Rumel tourniquet.



Vein Retrieval Instruments

Vein retrieval instruments are used when veins are taken from one part of the body (usually the legs or arms) and used for a bypass procedure on the heart. Leg procedures for harvest-ing the greater saphenous vein can be performed as an open procedure or as a minimally invasive procedure. A vein harvest kit can be used for the minimally invasive procedure.

CHAPTER 97

97-1 Top, left to right: 2 DeBakey tissue forceps, 6 inch; 2 Adson forceps, 1 × 2, 4¾ inch; 1 weitlaner retractor, 3 × 4 inch, sharp, 6½ inch; 1 Bard-Parker knife handle, #3. Bottom, left to right, on stringer: 2 Metzenbaum scissors, curved, 5½ inch; 1 Vital Metzenbaum scissors; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 tenotomy scissors, 6 inch (hidden); 2 Mayo-Hegar needle holders, 7¼ inch; 2 tubing clamps (for tubing with OD, 5⁄8 inch); 1 Boettcher tonsil clamp, curved, 7½ inch; 1 Lahey gall duct forceps, 7½ inch; 6 Halsted mosquito clamps, curved, 5 inch; 10 mosquito clamps, fine, (1 hidden); 1 Backhaus towel forceps, 3½ inch; 1 Senn retractor, sharp, 6¾ inch; 1 Army Navy retractor; 1 Richardson retractor, 1 × ¾ inch; 1 Castroviejo delicate touch micro needle holder, straight, locking, 75⁄8 inch; 1 hemoclip applier, small; 1 hemoclip applier, medium.





305CHAPTER 97 Vein Retrieval Instruments

97-3 Top to bottom: Olympus 1 chip camera and light cord.

97-2 Top to bottom: 1 Bipolar cord; 1 VasoView harvesting cannula; 1 BiSector bipolar ligating forceps (connects to bipolar cord); 1 Olympus 5-mm 0-degree lens; 1 short port, blunt tip; 1 sealing balloon; 1 20-cc syringe; 1 dissection tip (connects on harvest-ing cannula).



Radial Artery Harvest Set

Radial artery harvest instrumentation is used when the radial artery is harvested from the arm and used for a coronary artery bypass graft procedure.

CHAPTER 98

98-1 Left to right: 1 Andrews-Pynchon suction tube; 1 Bard-Parker knife handle #3; 2 DeBakey vascular atraugrip tissue forceps, medium. Top: 2 Brawley scleral wound retrac-tors. Bottom: 1 Weitlaner retractor; 1 cerebellar retractor, small. On instru-ment stringer: 4 Halsted microline artery forceps; 2 Adson hemostatic forceps, fine, right-angle; 2 Horizon clip appliers, small; 2 Metzenbaum dissecting scissors, 7 inch, 5 inch; 1 Crile-Wood needle holder, 5 inch (hidden).





307CHAPTER 99 Craniotomy

Craniotomy

Craniotomy is an incision made in the head through the skull that allows the performance of surgery on the brain for tumor resection, vascular defect repair, or traumatic injury.

Possible equipment needed for the procedure includes: 1. Midas Rex drill with craniotome blades, used to open the skull. 2. A Cavitron ultrasonic surgical aspirator (CUSA), used for tumor removal. 3. An operating microscope, used for visualization. 4. An electrosurgical unit, used for hemostasis. 5. A neuroplating set of screws and plates, used to repair fractures and to replace the

bone flap. 6. Burr-hole covers, used to cover the burr holes.

A brief description of the procedure follows: 1. Local injection at incision. 2. Incision of skin and galea with skin blade and hemostasis with cautery. 3. Remove scalp from the periosteum with either cautery or a periosteal elevator. 4. Burr holes are created using a high-speed drill with a perforator attachment. 5. Hemostasis of the burr holes use bone wax, followed by separation of the dura using a

Penfield dissector. 6. To create a bone flap, the burr holes are connected with a craniotome attachment to

the high-speed drill. The bone flap is removed using a Penfield dissector. 7. The dura is preserved by cutting with dura or Metzenbaum scissors and tacking up

the dura with sutures to the skull. 8. Hemostasis of brain tissue is achieved using bipolar forceps or irrigating bipolar for-

ceps. Hemostatic agents such as Thrombin and Gelfoam may be used. 9. Exposure to deep brain tissue is achieved by using a Leyla or Greenberg retractor.

Superficial work on the surface or skull may be limited to weitlaner retractors or skin hooks attached to the drape.

10. Tumor resection or dissection of brain tissue may involve microsurgical instruments such as micro Penfield dissectors, scissors, and Rhoton dissectors. An ultrasonic irri-gator/aspirator may be used in larger tumors. All of these instruments will be utilized under a microscope.

11. Craniotomies for aneurysms or arteriovenous malformations utilize specialized clips with appliers to prevent the aneurysm from rupturing.

12. Following hemostasis, the dura is closed and the skull flap replaced using titanium screws and plates to secure the bone flap in place. If swelling of brain tissue is too great to replace the bone flap, the patient’s bone flap is cryopreserved until brain swelling subsides. If the skull flap is not intact, methyl methacrylate can be used in conjunction with titanium mesh for a skull flap substitute, or an artificial skull flap using a poly-ether ether ketone (PEEK) plastic can be constructed and applied in a separate cranioplasty procedure.

CHAPTER 99UNIT TEN: NEUROSURGERY





308 UNIT 10 Neurosurgery

99-1 Top to bottom, left to right: 2 Bard-Parker knife handles #7; 2 Bard-Parker knife handles #3; 1 Cushing bipolar cautery forceps, microtip, insu-lated bayonet shaft; 1 Adson hypophy-seal forceps, bayonet shaft, round-cup tip; 1 Gerald dressing forceps, bayonet shaft, narrow tips, serrated; 1 Adson dressing forceps, bayonet shaft. Bottom, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Gillies tissue forceps with teeth (1 × 2), front view and side view; 2 DeBakey vascular atraugrip tissue forceps, medium, front view and side view; 2 Gerald tissue forceps with teeth (1 × 2), front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), Gutsch handle, front view and side view.

A B C

D E F

99-2 Left to right: Enlarged tips: A, Gillies tissue forceps with teeth (1 × 2); B, Gerald tissue forceps with teeth (1 × 2); C, Adson dressing forceps, bayonet shaft; D, Gerald dressing forceps, bayonet shaft, narrow tips, serrated; E, Adson hypophyseal forceps, bayonet shaft, round-cup tip; F, Cushing bipolar cautery forceps, microtip, insulated bayonet shaft.



99-3 Top to bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Metzenbaum dissecting scissors, 7 inch; 1 Metzenbaum dissecting scis-sors, 5 inch; 1 Strully scissors, 8 inch; 1 Adson ganglion scissors, straight, 6¼ inch. Bottom, left to right: 2 Raney scalp clip appliers; 3 paper drape clips; 2 Ligaclip appliers, small/short; 4 Backhaus towel forceps; 6 Back-haus towel forceps, small; 6 Cairns hemostatic forceps; 6 Crile hemostatic forceps, curved; 2 Allis tissue forceps; 2 Ochsner tissue forceps; 2 Ligaclip appliers, medium/medium; 1 Westphal hemostatic forceps; 1 Adson hemo-static forceps, fine tip; 2 DeBakey needle holders, 7 inch; 2 Webster needle holders, 6 inch; 2 Crile-Wood needle holders, 7 inch.

99-4 Left to right: Tips: A, Strully scissors; B, Adson ganglion scissors, straight; C, Samii scissors (tip); D, dura scissor (tip).

A B C D

99-5 Top to bottom, left to right: 1 Dura scissors, 1 Samii scissors, 3 micro suctions.



99-6 Top, left to right: 6 Frazier suc-tion tubes, sizes 6 to 12. Bottom, left to right: 5 Silicone spatula retractors, 6, 9, 13, 16, and 22 mm; 1 metal ruler; 5 Davis brain spatulas, various widths.

99-7 Top to bottom, left to right: 5 Ventricular needles with stylets, 3½ inch, 12, 14, 16, 18, and 20 gauge; 1 10-cc glass syringe (2 parts). Bottom, left to right: 2 Jarit crossing-action retractors, 4 inch, blunt prongs; 2 Raney scalp clip appliers, side view; 2 vein retractors, side view and front view.



99-8 Left to right: 1 Acra scalp clip applier, unloaded; 1 scalp clip car-tridge; 1 scalp clip; 1 Acra scalp clip applier, loaded.

99-9 Left to right: 1 Dura hook; 1 Woodson dura separator and packer, 7 inch; 1 Brun oval-cup curette, an-gled, 3-0; 3 Penfield dissectors, #1, #2, and #3, 7¼ inch; 1 Penfield dissector, #4, 8 inch; 1 Adson dura hook, sharp; 1 nerve hook, dull, flat; 1 Freer elevator; 1 Kistner probe; 1 Adson periosteal elevator (joker), curved, blunt, 6¾ inch; 1 Hoen periosteal elevator, narrow; 1 Hoen periosteal elevator, wide.



A B C D

E F

G H J

K L M

I

99-10 Left to right: Enlarged tips: A, Frazier dura hook, 5 inch; B and C, Woodson dura separator and packer, double-ended, 7 inch; B, packer end; C, separator end; D, Brun oval-cup curette, angled, 3-0; E and F, Penfield dissectors, #1, #2, and #3; E, side view, dissector end; F, front view, spoon and wax-packer end; G and H, Penfield dissector #4, 8 inch; G, side view; H, front view; I, Adson dura hook, sharp, 8 inch; J and K, Freer double-ended elevator, 7¾ inch; J, side view; K, front view; L and M, Adson periosteal elevator (joker), curved, blunt, 6¾ inch; L, side view; M, front view.



99-11 Top to bottom: 1 Gigli blade with attached saw handles; 1 passer.



Neurologic Bone Pan Instruments

Bone instrumentation consists of instrumentation to be used on bone and tougher tissues. It may also consist of handheld and self-retaining retractors.

CHAPTER 100



100-1 Top, left to right: 1 Adson rongeur; 1 cup rongeur, 6 mm. Bottom, left to right: 1 Ruskin double-action rongeur, small, straight; 1 Ruskin double-action rongeur, small, curved; 1 Leksell rongeur, side-curved; 1 Leksell rongeur, curved; 1 Smith-Petersen laminectomy rongeur.



315CHAPTER 100 Neurologic Bone Pan Instruments

100-2 A, Top: 1 Kerrison rongeur, 45-degree, 1 mm. Bottom, left to right: 4 Kerrison rongeurs, 45-degree: 2, 3, 4, and 5 mm. B, Left to right: Tips: 5 Kerrison rongeurs, 45-degree, 1, 2, 3, 4, and 5 mm.

B

A

100-3 Left to right: 2 Senn retrac-tors, side view and front view; 2 Army Navy retractors, side view and front view; 2 Green goiter retractors, side view and front view; 1 metal mallet. Top to bottom, left to right: 2 weitlaner retractors, baby, angled; 2 weitlaner retractors, small, angled.



100-4 Left to right: 2 Weitlaner retractors, small; 2 weitlaner retractors, medium; 2 Adson retractors, sharp, medium, angled.


317CHAPTER 101 Neurologic Retractors

Neurologic Retractors

Neurologic retractors generally are flexible and have numerous attachments in various sizes allowing the retractor to be positioned to gain the best exposure.

CHAPTER 101

101-1 Left to right: 1 Leyla holding arm, angled; 1 Leyla ball and socket joint clamp; 1 Leyla holding arm, straight. (Flexible Lone Star retractor hooks in Figure 31-8 may be attached to Leyla retractor for retraction.)






101-2 Tapered malleable brain retractors that are often used with the Leyla retractor.

101-3 Top to bottom, left to right: Greenberg Universal retractor: hand rest with flexible bar to clamp; 2 pri-mary bars; 1 long retractor arm. Right side: 4 Secondary bars.


319CHAPTER 101 Neurologic Retractors

101-4 Greenberg Universal retractor, continued: 2 flexible retractor bars, long. Middle, top to bottom: 8 Metal brain spatulas, various widths; 10 plastic-coated blades, various widths. Right: 2 Flexible retractor bars, short.



Medtronic Midas Rex Electric Drill

The Midas Rex drill has numerous attachments to cut and drill bone as needed.

CHAPTER 102



102-1 Top: Midas Rex cord and hand piece. Bottom, left to right: Midas Rex hand piece attachments: 1 perforator; 8 B small bone attachment; 9 M large bone attachment; AM-14 large bone attachment; F1 B5 footed attachment; TT 12 telescoping attachment; AT 10 telescoping attachment.



321CHAPTER 102 Medtronic Midas Rex Electric Drill

102-3 1 Midas perforator tip.

102-2 3 Midas tips.



Rhoton Neurologic Microinstrument Set

Rhoton microinstruments are dissection instruments used in aneurysms, tumors, and acoustic neuroma resections. Each instrument is made of light-weight titanium for balance and durability. These instruments are often referred to by number.

CHAPTER 103

103-1 A, Left to right: 2 Beaver blade handles with insert, knurled; 1 microscissors, straight; 1 microscis-sors, curved; 1 microneedle holder, straight; 1 microneedle holder, curved; 1 micrograsping forceps. B, Left to right: Tips: Microscissors, straight; microscissors, curved; microneedle holder, straight; microneedle holder, curved; micrograsping forceps.

B

A





323CHAPTER 103 Rhoton Neurologic Microinstrument Set

103-2 Rhoton dissectors #1 to #19 in numbered rack for identification.

103-3 Tips: 3 Round microdissec-tors: 1, 2, and 3 mm; 2 general-purpose microelevators: curved and angled; 3 spatula microdissectors: small, medium, and large; 2 microhooks, 90-degree: semisharp and blunt.

103-4 Tips: Microhook, 45-degree, semisharp; microneedle point, straight; 2 microcurettes: straight and angled; 4 ball microdissectors: straight; 40-degree, 4 mm; 90-degree, 5 mm; 40-degree, 8 mm; 1 arachnoid microknife.



103-5 Left to right: Enlarged tips: 3 Round microdissectors: 1, 2, and 3 mm; 1 general-purpose microeleva-tor, angled.

103-6 Left to right: Enlarged tips: 4 Spatula microdissectors: large, small, medium, and medium straight.

103-7 Left to right: Enlarged tips: 2 Microhooks, 90 degrees: Semisharp and blunt; 1 general purpose microel-evator, curved; 1 microneedle point, straight.

103-8 Left to right: Enlarged tips: 2 Microcurettes: straight and angled; 1 ball microdissector, 90-degree angle tip.


325CHAPTER 104 Ultrasonic Handpieces

Ultrasonic Handpieces

Ultrasonic aspirators use ultrasound technology to dissect and aspirate targeted tissues with minimal transmitted movement to adjacent normal neural structures and with minimal blood loss.

CHAPTER 104

104-1 Top to bottom, left to right: 1 Selector 24 KHz flue; 1 Selector metal extension, angled; 1 Selector black plastic shroud, angled; 1 Selector hand piece with cord; 1 hand piece support with wrench.






Neurologic Shunt Instruments

A shunt is a tube or device implanted in the body to redirect body fluid from one cavity or vessel to another. Generally, a neurological shunt redirects cerebrospinal fluid from the ven-tricles in the brain to another cavity, often the abdomen. A valve and catheter combination is placed. The neurosurgeon will place the valve and catheters, and a general surgeon may assist with placement of a catheter into the abdomen laparoscopically.

CHAPTER 105

105-1 Top, left to right: 1 Frazier suction, angled 10 Fr; 1 Green bipolar bayonet forceps, 1.5 mm × 8.5 inch; 1 Kerrison ronguer, 2 mm, 7 inch. Bot-tom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 1 DeBakey vascular tissue forceps, 7¾ inch; 1 bayonet forceps, Gutsch handle, 7¾ inch; 1 Crile forceps, curved, 6¼ inch; 1 Heiss skin retrac-tor, blunt, 4 × 4 prongs; 1 weitlaner retractor, sharp; 1 Penfield dissector, #1; 1 curette, straight, 3-0; 1 Penfield dissector, #4; 1 Codman cranial perfo-rator; 1 Midas Rex perforator driver; 1 Péan clamp, curved, 10 inch.





327CHAPTER 105 Neurologic Shunt Instruments

105-2 Shunt passer.



MINOP Neuroendoscopy Set

MINOP is a neuroendoscopy system used primarily for intraventricular indications, although it can be used for endoscope-assisted neurosurgery. It consists of endoscopes, trocars, instruments, and electrodes for diagnostic and therapeutic purposes.

CHAPTER 106



106-1 Top to bottom: 2 Guidewires; 1 endoscope lens, 0 degrees × 2.7 mm; 1 endoscope lens, 30 degrees × 2.7 mm; 1 sheath, 6 mm; 1 sheath, 4.6 mm; 1 trocar, 4.6 mm; 1 trocar, 6 mm; 1 sheath (no working channel), 3.2 mm; 1 trocar, 3.2 mm.



329CHAPTER 106 MINOP Neuroendoscopy Set

106-2 Top to bottom in rack: 2 Micro-scissors, B/B, S/S; 1 biopsy forceps; 1 fixation and dissecting forceps; 1 surgical microforceps; 2 suction tips.

106-3 Left to right: 1 Monopolar cord; 1 hook electrode; 1 needle electrode; 3 hook electrodes; 1 blunt electrode. Top to bottom: 1 Silastic tubing; in center of tubing: 2 Light cord adaptors; 1 bipolar cord. Right: 1 Bipolar fork electrode.



Intracranial Pressure Monitoring Tray

An Intracranial Pressure (ICP) monitoring tray contains equipment used to monitor intra-cranial pressure. The monitoring device may be a fiber optic catheter or a bolt-shaped sensor that connects to a machine that measures ICP. A disposable cranial access kit is generally used to place the monitor, as this procedure is most frequently performed at the bedside or in the emergency department.

CHAPTER 107

107-1 All contents of the Codman cranial access kit are disposable. Top, left to right: 1 Codman cranial hand crank drill; 2 medicine cups; 1 drill bit with stop, 2.7 mm; 1 Allen wrench; 1 drill bit with stop, 5.8 mm. Tray con-tents: 2 25-gauge Needles; 1 18-gauge needle; 1 spinal needle; 1 ventricular needle; 1 culture tube with screw cap; 1 razor; 2 syringes, 12 cc. Bottom, left to right: 1 #15 Scalpel; 1 #11 scalpel; 1 ruler; 1 skin marker; 1 suture scissors, sharp; 1 Adson forceps with teeth; 1 Adson forceps, smooth; 1 Heiss skin retractor, blunt, 4 × 4 prongs; 2 mosquito forceps, curved; 1 needle holder.





331CHAPTER 108 Yasargil Aneurysm Clips with Appliers

Yasargil Aneurysm Clips with Appliers

Yasargil aneurysm clips are used on either side of an aneurysm, which is a localized dilation of the wall of a blood vessel.

CHAPTER 108

108-1 Aneurysm clip trays and 2 non-locking aneurysm clip appliers.






Synthes Low-Profile Cranial Plating Set

At closure, the skull flap is replaced using titanium screws and plates to secure the bone flap in place. If swelling of brain tissue is too great to replace the bone flap, the patient’s bone flap is cryopreserved until brain swelling subsides. If the skull flap is not intact, methyl methacrylate can be used in conjunction with titanium mesh for a skull flap substitute, or an artificial skull flap using a poly-ether ether ketone (PEEK) plastic can be constructed and applied in a separate cranioplasty procedure. Both of these are secured with titanium screws and plates.

CHAPTER 109



109-1 Synthes low-profile cranial plating set. Left side: 2 Screwdriver handles and a variety of drill bits, 4 mm, 6 mm. Right side: 1.5-mm Screws.



333CHAPTER 109 Synthes Low-Profile Cranial Plating Set

109-2 Variety of Synthes low-profile implant cranial plates. Right side: 2 Burr hole covers, 12 mm, 17 mm.



Laminectomy

A laminectomy is an incision in the back to remove the lamina so as to expose the spinal column.

Possible instruments and equipment needed for the procedure include a neurologic soft tissue set; an operating microscope for visualization; an electrosurgical unit; and an electric drill, bits, and burrs.

A brief description of the procedure follows: 1. A Beckman-Adson retractor is used to expose the vertebrae. 2. A Hibbs retractor is used if deeper retraction is needed. 3. A Cobb elevator is used to remove periosteum from the laminae. 4. A Smith-Petersen rongeur is used to remove the spinous processes. 5. Cushing bayonet forceps with teeth are used to grasp the ligamentum flava. 6. A Bard-Parker scalpel handle #7 with a #15 blade is used to incise close to the mid-

line. 7. A Mellon curette is used to remove lateral gutter ligaments. 8. A Brun curette is used to define the laminae edges. 9. A Leksell rongeur is used to remove the laminae and expose the spinal cord. 10. An Adson blunt nerve hook is used to explore nerve roots and extradural space. 11. A Love retractor is used to protect nerves from injury. 12. A Cushing disk rongeur is used to remove disk material.

CHAPTER 110



110-1 Top, left to right: 4 Cushing intervertebral disk rongeurs, 2 mm: straight, 6 inch; upbiting, 6 inch; narrow, straight, 7 inch; straight, 7 inch. Bottom, left to right: 1 Cushing intervertebral disk rongeur, 3 mm, 7 inch, upbiting; 1 Ferris Smith pituitary rongeur, 6 mm, 7 inch; 1 Cushing inter-vertebral disk rongeur, 4 mm, 7 inch.



335CHAPTER 110 Laminectomy

110-2 Middle, top to bottom: 4 Frazier suction tubes: 12, 10, 8, and 6 Fr. Bot-tom, left to right: 1 D’Errico nerve root retractor; 1 Love nerve root retractor, straight; 1 Love nerve root retractor, 90-degree angle; 1 Scoville nerve root retractor, angular.

A B110-3 Left to right: Tips: A, D’Errico nerve root retractor; Love nerve root retractor, straight; B, Love nerve root retractor, 90-degree angle; Scoville nerve root retractor, angular.



110-4 A, Left to right: 4 Spurling- Kerrison rongeurs, 40 degrees: 2, 3, 4, and 5 mm. B, Left to right: Tips: 4 Spurling-Kerrison rongeurs, 40 degrees: 2, 3, 4, and 5 mm.

A

B

110-5 Top: 2 Adson cerebellar retractors, medium. Bottom, left to right: 2 Weitlaner retractors, straight, long; 2 Taylor spinal retractors: short, front view; long, side view; 2 Hibbs laminectomy retractors: narrow, front view; wide, side view.


337CHAPTER 110 Laminectomy

110-6 A, Top: 1 Mellon curette, long, large. Bottom, left to right: 3 Curettes, size 4-0: reverse-angled, angled, and straight; 3 curettes, size 2-0: reverse-angled, angled, and straight; 3 curettes, size 3-0: reverse-angled, angled, and straight; 3 curettes, size 0: reverse-angled, angled, and straight; 1 Cobb spinal elevator, narrow; 1 Cobb spinal elevator, wide. B, Left to right: Curette tips: 1 size 4-0, straight; 3 size 2-0: reverse-angled, angled, and straight; 3 size 3-0: reverse-angled, angled, and straight; 2 size 0: reverse-angled and straight.

A

B

110-7 Left to right: 1 Backward-an-gled curette; 1 forward-angled curette.



Williams Laminectomy Microretractors

Williams laminectomy microretractors are utilized to retract tissue away from a bony sur-face. The pointed hook side is placed aside bone while the blade retracts tissue.

CHAPTER 111

111-1 Left to right: Williams lami-nectomy microretractors: short blade, right-handed, back view; long blade, right-handed, front view; long blade, left-handed, front view.





339CHAPTER 112 Minimally Invasive Spine Surgery

Minimally Invasive Spine Surgery

Minimally invasive spine surgery is spine surgery through a small incision utilizing a retrac-tor system that allows visualization of the anatomy. Specially designed instrumentation is utilized to enhance this visualization.

A brief description of the procedure follows: 1. Local injection is placed at the skin incision site. 2. K-wire is inserted at the intended level of the spine and verified under fluoroscopy. 3. A small stab skin incision is made and a dilator is placed over the K-wire. 4. A succession of increasing-in-size dilators is placed over one another while under fluo-

roscopy.The dilators split the muscle and fascia versus dissection with cautery or Cobb elevators.

The last dilator is short with an attachment to a retractor arm to the side of the surgical bed. Verification of the correct spinal level occurs after final adjustment of the retractor tube, removal of dilators, and before work on the lamina begins with either a high-powered drill with specialized minimally invasive attachments or Kerrison rongeurs.

CHAPTER 112

112-1 Left to right: 1 Boss titanium bed rail clamp; 1 guidewire; 9 Boss titanium-colored dilating tubes; 3 Boss titanium tubular retractors; 1 Boss flex-arm retractor.






112-2 Top to bottom, left to right: 1 Kerrison rongeur, bayonet, 2 mm; 1 Kerrison rongeur, bayonet, 3 mm; 1 suction nerve root retractor; 1 knife handle, bayonet, #11; 1 MIS bone curette, bayonet, straight, 6-0; 1 MIS bone curette, bayonet, forward angle, 6-0; 1 MIS bone curette, bayonet, reverse angle, 6-0; 1 MIS bone curette, bayonet reverse angle, 3-0; 1 MIS bone curette, bayonet, forward angle, 3-0; 1 Penelope, bayonet; 1 nerve hook, bayonet; 1 Penfield dissector, bayonet, #4; 1 micro Penfield dissector, bayonet, #4; 1 Woodson elevator, bayonet.


341CHAPTER 113 Anterior Cervical Fusion

Anterior Cervical Fusion

An anterior cervical fusion is performed to relieve pain and stabilize the neck by fusing the cervical vertebrae. The patient is placed in the supine position. Bone from the iliac crest or from a bone bank may be used for the fusion.

Possible instruments needed for the procedure include a neurologic soft tissue set. A brief description of the anterior cervical fusion procedure follows: 1. A Cloward cervical retractor with one long and one short blade is used to separate the

carotid sheath, trachea, and esophagus. 2. A Ferris Smith pituitary rongeur is used to remove the disk. 3. A Cloward vertebra spreader is used to widen the space. 4. A Cloward double-ended impactor is used to seat the bone graft between the vertebrae. 5. Plates and screws are used to stabilize the fusion.

CHAPTER 113

113-1 Left to right: 1 Twist drill; 1 screwdriver with 14-mm disposable distraction screw; 1 Teflon mallet; 1 vertebral body distractor, right; 1 Cloward blade retractor with lip, 17 mm; 1 Cloward blade retractor without lip, 13 mm; 1 Cloward blade retractor, 20 mm.






113-2 Top, left to right: 6 Sets of blunt cervical retractor blades, small to large. Middle, left to right: 1 Cloward cervical retractor handle, small; 1 Cloward cervical retractor handle, large. Bottom, left to right: 6 Sets of 4-pronged cervical retractor blades, small to large.

113-3 Shadow ACF retractor blades of various lengths, widths, and tip ends; 2 retractor handles; 1 color depth gauge.


343CHAPTER 113 Anterior Cervical Fusion

113-4 Top: 1 Shadow ACF transverse retractor with blades attached; 1 Shadow ACF longitudinal retractor with blades attached. Bottom: Tray containing long and short teeth retrac-tor blades.



ASIF Anterior Cervical Locking Plating Instruments

CHAPTER 114



114-1 ASIF anterior cervical locking plating instruments in tray, with names marked.



345CHAPTER 114 ASIF Anterior Cervical Locking Plating Instruments

114-2 Drill guide with axillary bin with names marked.

114-3 Top, left to right: 3 Sizes of cervical plates taken out of trays. Bottom, left to right: 3 Marked trays: 1 of screws and 2 of various sizes of cervical plates.


This page intentionally left blank


347Index

Index

AAAMI. See Association for the Advancement

of Medical Instrumentation (AAMI)Abdomen, aortic aneurysm in, 271–273Abdominal vascular set, 274–276Acetabular prosthesis, 178fAcra scalp clip applier, 311fAcufex basket, 152fAcufex duckbill biter, 151fAcufex duckbill biter (tip), 151fAcufex upbiting linear punch, 152fAdair breast clamp, 87fAdair breast clamp (tip), 87fAdenoidectomy, 234–236Adson cerebellar retractor, 336fAdson dura hook, 311fAdson dura hook (tip), 312fAdson ganglion scissors, 309fAdson ganglion scissors (tip), 309fAdson hemostatic forceps, 116fAdson hemostatic forceps (tip), 116f, 276fAdson hypophyseal forceps, 308fAdson hypophyseal forceps (tip), 308fAdson periosteal elevator, 311fAdson periosteal elevator (tip), 312fAdson rongeur, 147fAdson suction tube, 137fAdson tissue forceps, 20f, 34f–35f, 45Adson tissue forceps (tip), 20f, 35fAER. See Automated endoscope reprocessor

(AER)Agility LP total ankle arthroplasty, 149fAlbarrán bridge, 121fAlcohol, instrument cleaning with, 10Alcon I/A UltraFlow SP hand piece, 204fAlcon Monarch III IOL injector, 204fAlcon OZil torsional hand piece, 204fAlexander rib raspatory, 281fAlligator forceps, 230fAllis-Adair tissue forceps (tip), 104fAllis clamp, 20Allis tissue forceps, 20, 20f, 32, 36f, 45Allis tissue forceps (tip), 20f, 36f, 104fAmerican Iron and Steel Institute, 3Amines, instrument staining from, 11Ammonia, instrument spotting from, 11AMS Quick Connect assembly tool, 135fAndrews-Pynchon suction tube, 235fAndrews suction tube, 239fAnesthesia, introduction of, 2Aneurysm clip tray, 331fAnkeney sternal retractor, 291fAnkle prosthesis, 148–149Anterior cervical fusion, 341–343Anterior cruciate ligament reconstruction,

154–156Antler retractor, 169fAORN. See Association of periOperative

Registered Nurses (AORN)Aortic aneurysm, repair of, 271–273Appendectomy, position for, 59fApple needle holder, 75f, 78f

Apple needle holder (tip), 58f, 78fApplied Medical Alexis protractor, 63fArmy Navy retractor, 19, 32, 34f, 46f, 87fArnold needle, 237fArtery

aorta, repair of, 271–273bypass graft of, 269–270femoral, blockage of, 268fradial, 306

Arthrex femoral tunnel notcher, 155fArthrex femoral tunnel notcher (tip), 155fArthrex graft pusher, 155fArthrex graft pusher (tip), 155fArthrex over-the-top femoral positioning

drill guide, 155fArthrex over-the-top femoral positioning

drill guide (tip), 155fArthrex scorpion suture passer, 153fArthrex scorpion suture passer (tip), 153fArthrex tibial aiming guide, 156fArthritis, ankle, 148Arthroplasty, ankle, 149fArthroscopy

anterior cruciate ligament, 154–156carpal tunnel, 145definition of, 144instrument set for, 144knee, 150–153shoulder, 150–153

Articulating lung grasper, 277fAsch forceps, 245fAsch septal forceps, 243fASIF anterior cervical locking plating

instruments, 344–345ASIF external fixator miniset, 193fASIF pelvic instrument set, 194–195ASIF universal femoral distractor set, 187Association for the Advancement of Medical

Instrumentation (AAMI), 4–5Association of periOperative Registered

Nurses (AORN), 4sterilization container system maintenance

and, 30Atrial retractor (tip), 82fAufricht rasp, 241fAufricht rasp (tip), 241fAustin pick (tip), 227fAustin sickle knife, 226fAutomated endoscope reprocessor (AER), 10Auvard weighted vaginal speculum, 89f, 94f,

104f

BBabcock clamp, 20Babcock clamp grasping forceps (tip), 58fBabcock forceps, 20Babcock tissue forceps, 32, 36f, 45Babcock tissue forceps (tip), 36f, 277fBack table, setup for, 31fBackhaus towel forceps, 21f, 224fBailey rib contractor, 281fBaird chalazion forceps, 199f

Baker tissue forceps, 285fBalfour abdominal blade, 42f–43fBalfour abdominal retractor, 125F, 41fBalfour blade, 39fBalfour-Mayo blade, 43fBalfour retractor, 19, 32Ballenger knife, 241fBallenger knife (tip), 241fBanana knife, 144fBandage scissors, 285fBankart shoulder retractor, 165fBard-Parker knife handle, 86fBard-Parker scalpel handle, 32, 33f, 49Bard-Parker scalpel handle, 32, 33fBard-Parker scalpel handle, 32, 33fBariatric spatula, 77fBariatric surgery, laparoscopic, 72–78Bariatric telescope, 74fBariatrics, 72Baron ear suction tube, 224f, 232fBarraquer needle holder, 131fBarraquer wire speculum, 205fBasket insert, container tray, 26fBateman retractor, 165fBauer retractor, 254fBauer rocking chisel, 241fBeasley-Babcock tissue forceps, 241fBeath passing pin, 156fBeaver knife handle, 130fBechert nucleus rotator, 203f, 207fBechert nucleus rotator (tip), 203f, 208fBeck aorta clamp, 303fBecker septum scissors, 242fBellucci scissors (tip), 230fBennett bone elevator, 167fBethune rongeur, 281fBeuse plate-holding forceps, 294fBiofilm, 6, 10Bioplasty Dermamesher, 267fBiopsy forceps, 63f, 110fBiopsy forceps (tip), 63f, 110fBipolar forceps (tip), 81fBiSector bipolar ligating forceps, 305fBishop-Harmon irrigating cannula, 219fBishop-Harmon tissue forceps, 222fBishop-Harmon tissue forceps (tip), 222fBlack double-end J curette (tip), 228fBlakesley-Weil nasal forceps, 246fBlakesley-Weil nasal forceps (tip), 246f, 248fBlunt elevator, 165fBlunt probe, 144fBoettcher tonsil clamp, 304fBone hook, 165fBone instruments, 314–316Bonn suture forceps, 217fBonn suture forceps (tip), 218fBonney tissue forceps, 48fBookwalter retractor, 39f–40fBookwalter retractor horizontal bar, 39fBookwalter retractor horizontal flex bar, 39fBookwalter retractor oval ring, 39fBookwalter retractor table post, 39fBores two-ray corneal meridian marker, 204f


348 Index

Boss flex-arm retractor, 339fBoss titanium bed rail clamp, 339fBoss titanium tubular retractor, 339fBowel grasper, fenestrated, 77fBowel grasper (tip), 82fBowel resection, 69–70

laparoscopic, 63–68position for, 68f

Box lockexample of, 18finspection of, 12

Bozeman uterine forceps, 88fBozeman uterine forceps (tip), 90fBrain retractor, 318fBreast biopsy, 84Bridge channel adapter, 109fBroken screw set, 196–197Bronchoscope, cleaning of, 9Brown-Adson tissue forceps, 86fBruening nasal snare, 244fBruening syringe, 237fBruening wrench, 237fBrun oval-cup curette, 311fBrun oval-cup curette (tip), 312fBuck cement restrictor inserter, 172fBucket cannula (tip), 265fBuckingham footplate hand drill, 229fBugbee cord, 110fBugbee electrode, 110fBurford rib spreader, 280fBurton retractor, 254fByron liposuction cannula, 264fByron liposuction cannula (tip), 264f

CCadiere forceps (tip), 80fCairns hemostatic forceps, 309fCamera, laparoscopic, 50fCannula, for laser laparoscope, 60fCarbon-chrome ratio, 3–4Cardiac probe grasper (tip), 82fCardiac surgery, 283–286Cardiovascular instruments, 296–298Carmalt hemostatic forceps, 69fCarmalt hemostatic forceps (tip), 70fCarpal tunnel instruments, 145Carpal tunnel syndrome, 145Castroviejo caliper, 205fCastroviejo corneal section scissors, 209fCastroviejo corneal section scissors (tip), 209fCastroviejo cyclodialysis spatula, 203fCastroviejo needle holder, 199fCastroviejo needle holder (tip), 209fCastroviejo suturing forceps, 131fCastroviejo suturing forceps (tip), 202f, 206fCataract surgery, 9Cautery cord, nondisposable, 54fCautery hook (tip), 80fCautery spatula (tip), 80fCavernotome, 135fCavitation, ultrasonic cleaning and, 7Centers for Disease Control and Prevention

(CDC), 4, 14Cervical retractor, 342fCervical vertebra, fusion of, 341–343Chalazion set, 198, 199fChamber maintainer, 131fChamfering rasp, 155fChamfering rasp (tip), 155fChandler (Gills) forceps, 212fChannel retractor, 254fCharlie insertion forceps, 210fCharlie insertion forceps (tip), 211f

Cholecystectomydefinition of, 61laparoscopic, 61–62position for, 62f

Chromium oxide, 3Cindy scissors, 210fCindy scissors (tip), 211fClamp, 18f

occluding, 17types of, 17–18

Clayman lens-holding forceps, 206fClayman lens-holding forceps (tip), 207fCleaning

instrument, 5manual, 6–7mechanical, 6–8ultrasonic, 7

Clear corneal instrument set, 201–204Clip applier, 57f, 65fCloward blade retractor, 341fCoagulating electrode, 129fCoagulating electrode (tip), 129fCoakley antrum curette, 244fCoakley antrum curette (tip), 244fCobb spinal elevator, 171fCobra grasper (tip), 80fCobra retractor, 169fCodman cranial access kit, 330fCodman cranial hand crank drill, 330fCodman wire cutter, 285fCohen cannula, 99fCohen cone, 99fColeman cannula, 263fColeman cannula (tip), 264fColonic insufflator, 71fComprehensive Guide to Steam Sterilization

and Sterility Assurance in Health Care Facilities, 4, 15

Cone provisionals, 178fConnor anesthesia cannula, 203fContainer system. See Sterilization container

systemContour curved cutter, 66fCook eye speculum, 216fCooley clamp, 296fCooley clamp (tip), 296fCooley coarctation clamp, 297fCooley coarctation clamp (tip), 297fCooley forceps (tip), 284fCopper, instrument staining from, 11Cornea, transplant of, 210Corneal instrument set, 201–204Corneal marker, 210fCorneal marker (tip), 211fCorneal scleral marker (tip), 208fCorneal transplant instrument set, 205–209Corpus Hippocraticum, 2Corrosion

avoidance of, 12of instruments, 11–12

Cottle bone crusher, 243fCottle columella forceps (tip), 241fCottle dorsal angular scissors, 242fCottle elevator, 224fCottle nasal knife, 241fCottle nasal speculum, 253fCottle osteotome, 241fCovidien Endoscopic Endo GIA tri-stapler,

67fCovidien purse string, 70fCovidien Sonicision cordless ultrasonic

dissection, 68fCovidien Sonicision cordless ultrasonic

dissection (tip), 68f

Crabtree wax currette, 225Crane mallet, 252fCranial tray, 28fCraniotomy, 307–313Creutzfeldt-Jakob disease, 10, 15–16, 22Crile clamp, 17Crile hemostatic forceps, 32, 36fCrile hemostatic forceps (tip), 36fCrile template, 177fCrile-Wood needle holder, 87fCrile-Wood needle holder (tip), 87fCritical instruments, 14Culler iris spatula, 207fCuller iris spatula (tip), 208fCup forceps (tip), 58fCushing bipolar cautery forceps, 308fCushing bipolar cautery forceps (tip), 308fCushing-Brown tissue forceps, 300fCushing-Brown tissue forceps (tip), 300fCushing insulated bipolar forceps, 263fCushing intervertebral disk rongeur, 334fCushing vein retractor, 87fCutting electrode, 129fCutting electrode (tip), 129fCutting instruments, 13, 18–19Cystoscope, 108, 109f, 121fCystoscope lens, 109fCystoscope obturator, 109f, 121fCystoscopy, 108–111

DDa Vinci Surgical System, 79–83

surgeon console for, 83fDavis brain spatula, 134f, 309fDe Mayo knee positioner, 161fDeaver blade, 42f–43fDeaver retractor, 32, 35f, 46f, 73f, 104fDeaver retractor blade, 120fDeBakey aortic exclusion clamp, 298fDeBakey aortic exclusion clamp (tip), 298fDeBakey bulldog clamp, 296fDeBakey bulldog clamp (tip), 296fDeBakey-Diethrich coronary artery forceps,

48f, 285fDeBakey multipurpose vascular clamp, 298fDeBakey peripheral vascular clamp, 296fDeBakey peripheral vascular clamp (tip), 296fDeBakey tangential occlusion vascular

forceps (tip), 284fDeBakey tissue forceps, 77fDeBakey tissue forceps (tip), 80fDeBakey vascular Atraugrip tissue forceps,

34f–35fDeBakey vascular Atraugrip tissue forceps

(tip), 35fDecontamination, instrument, 1–2, 5–6Deep lamellar endothelial keratoplasty

(DLEK), 210–211Defibrillator, internal, 293fDelicate Touch micro forceps, 260fDelicate Touch micro needle holder, 261fDepth gauge, 169fDePuy AcroMed probe, 182fDePuy cement mixer, 162fD’Errico nerve root retractor, 335fD’Errico nerve root retractor (tip), 335fDesmarres chalazion forceps, 199fDesmarres lid retractor, 214fDesmarres lid retractor (tip), 215fDetergent

corrosion and pitting caused by, 11–12enzymatic, 8instrument cleaning with, 6


349Index

Detergent (Continued)for mechanical cleaning, 8for sterilization container systems, 26–27

Devers dissector, 210fDevers dissector (tip), 211fDeviated septum, repair of, 240Diameter gauge, 186fDilatation and curettage, 88–90Dingman bone-holding forceps, 253fDingman zygoma elevator, 253fDisinfectant, instrument cleaning with, 10Disinfection, 14–16Dissection scissors, 18–19Distractor, 183fDLEK. See Deep lamellar endothelial

keratoplasty (DLEK)Doane retractor, 163fDouble fixation hook, 222fDoyen intestinal forceps, 69fDoyen intestinal forceps (tip), 70fDoyen rib elevator, 281fDrill

Jacobs, 143fkeyless, 140fpower, 139–143

Druck-Levine antrum retractor, 244fDrum elevator (tip), 226fDuckworth & Kent cionni toric reference

marker, 204fDura hook, 311fDura scissors, 309fDura scissors (tip), 309fDuval clamp, 278fDuval clamp (tip), 278fDuval lung forceps, 282fDuval lung forceps (tip), 282f

EEar, basic instrument set for, 224Ear forceps, 230f–231fEardrum, repair of, 225–233Edwards holding clip, 198fEEA anvil grasper, 64fElectrode

coagulating, 129fcutting, 129f

Ellik cystoscope evacuator, 129fElschnig cyclodialysis spatula, 213fElschnig fixation forceps, 206fElschnig fixation forceps (tip), 206f, 218fEndarterectomy, 268Endo catch retriever, 61fEndo GIA stapler, 67fEndo power stapler, 66fEndo power stapler (tip), 66fEndoflex protective cover, 63fEndoflex retractor, 63fEndoflex snake retractor, 64fEndoPass delivery instrument (tip), 82fEndoscope

carpal tunnel video, 145fcleaning of, 9–10inspection of, 13

Endoscopy, definition of, 49Endovascular aortic aneurysm repair,

271–273Endoweave grasper, 57fEndoWrist bipolar instruments, 81fEndoWrist clip applier (tip), 82fEndoWrist instruments, 79–83EndoWrist monopolar cautery instruments,

80fEndoWrist needle driver, 81f

EndoWrist stabilizer (tip), 82fEnucleation scissors, 223fEnzymatic detergent, 6, 8

instrument cleaning with, 6Erhardt chalazion clamp, 216fEsophageal retractor, 64fEthicon Echelon Flex Endo GIA power

stapler, 66fEthicon Echelon Flex Endo GIA power

stapler (tip), 66fEthicon endoscopic curved intraluminal

stapler, 67fEthicon Laparoscopic Enseal, 68fEthicon Laparoscopic Enseal (tip), 68fEthicon Laparoscopic Harmonic scalpel, 68fEthicon SecureStrap laparoscopic tacker, 65fEthicon stapler PPH, 70fEthylene oxide, 16Evolution Tray, 191fEye enucleation, 223Eye instruments, 198–200

cleaning of, 9Eye muscle, surgery for, 214–216Eyed obturator (tip), 286f

FFacial fracture instrument set, 251–253Fallopian ring applicator, 106fFallopian ring applicator (tip), 106fFarr spring retractor, 45FDA. See Food and Drug Administration

(FDA)Femoral artery, blockage of, 268fFemoral head prosthesis, 178fFemoral nail, 188–189Ferris Smith fragment forceps, 243fFerris Smith pituitary rongeur, 334fFerris Smith rongeur, 156fFerris Smith tissue forceps, 32, 34f–35fFerris Smith tissue forceps (tip), 20f, 35fFiber optic cord, 71fFiber optic light cable, 49Fiber optic light cord, 13, 50fFilshie clip, 106fFilshie clip applicator, 106fFine tissue forceps (tip), 80fFinochietto rib spreader, 285fFisher tonsil knife, 235fFK retractor, 237fFlash sterilization. See Immediate use steam

sterilization (IUSS)Flexible endoscope, cleaning of, 9–10Flieringa fixation ring, 205fFoerster sponge forceps, 21f, 38f, 88fFoerster sponge forceps (tip), 38fFogarty clamp-applying forceps (tip), 297fFogarty Hydragrip clamp (tip), 284fFogarty stealth applicator forceps (tip), 285fFoman rasp, 165fFomon lower lateral scissors, 242fFood and Drug Administration (FDA), 4

regulation of sterilization container systems by, 24, 30

Forcepsin da Vinci Surgical System, 80fdescription of, 20

Fracture fixationexternal, 191–193long bone, 185–186

Francis chalazion forceps, 199fFrazier dura hook (tip), 312fFrazier suction tube, 21fFreer double-ended elevator, 298f

Freer double-ended elevator (tip), 312fFreer elevator, 137fFreer septum knife, 241fFreer septum knife (tip), 241fFriedman rongeur, 253fFurlow insertion tool, 135f

GGarrigue weighted vaginal speculum, 120fGaskin fragment forceps, 202fGaskin fragment forceps (tip), 202fGass retinal detachment hook, 218fGelpi retractor, 19, 124fGerald dressing forceps, 308fGerald dressing forceps (tip), 308fGerald tissue forceps, 308fGerald tissue forceps (tip), 308fGiertz rongeur, 280fGigli blade, 313fGil-Vernet retractor, 115f, 124fGilles elevator, 245fGillies malar elevator, 253fGillies tissue forceps, 308fGillies tissue forceps (tip), 308fGimbel Mendez fixation and guide ring, 204fGlaucoma, 212–213Glenoid punch, 165fGlenoid (Bateman) retractor, 165fGlenoid self-retaining retractor, 165fGlutaraldehyde, disinfection with, 16Goelet retractor, 34f, 46f, 124fGomey-Freemen SuperCut scissors, 263fGraether collar button, 203fGraptor retractor (tip), 80fGrasper

in da Vinci Surgical System, 80fdouble-action, 55fdouble-action (tip), 58fdouble-fenestrated (tip), 80fsingle action, 57f

Grasper (tip), 58fGrasping forceps (tip), 92fGraves bivalve speculum, 95fGraves vaginal speculum, 89f, 94f, 104fGreen bipolar bayonet forceps, 326fGreen goiter retractor, 87fGreen muscle hook (tip), 215fGreen strabismus hook, 215fGreenberg Universal retractor, 318fGreenwald suture guide, 125f, 125fGruenwald nasal forceps, 247fGruenwald nasal forceps (tip), 247fGuideline for Disinfection and Sterilization in

Healthcare Facilities, 4Guideline for Disinfection and Sterilization

of Prion-Contaminated Medical Instruments, 10

Guyon-Péan vessel clamp (tip), 116f

HHall sternal saw, 290fHall surgical acetabular reamer set, 174fHalsey needle holder, 87fHalsey needle holder (tip), 87fHalsted clamp, 17Halsted hemostatic forceps, 36fHalsted hemostatic forceps (tip), 36fHalsted mosquito hemostatic forceps, 36f,

45, 213fHalsted mosquito hemostatic forceps (tip),

36fHarmonic cord, 76f, 100f


350 Index

Harmonic curved shears (tip), 81fHarmonic scalpel, 76f, 100fHarmonic scalpel (tip), 76fHarms tying forceps, 217fHarms tying forceps (tip), 218fHarrington blade, 43fHarrington outrigger, 183fHarrington retractor, 32Harrington retractor blade, 40fHarrington splanchnic retractor, 125fHasson obturator, 73fHasson trocar, 52f, 73fHayes Martin tissue forceps, 86fHeaney-Ballantine hysterectomy forceps,

96f–97fHeaney-Ballantine hysterectomy forceps (tip),

97f, 104fHeaney hysterectomy forceps, 96f–97fHeaney hysterectomy forceps (tip), 97f, 104fHeaney needle holder, 98fHeaney needle holder (tip), 98f, 300fHeaney retractor, 89f, 104fHeaney-Simon vaginal retractor, 120fHeaney uterine biopsy curette, 89fHeaney uterine biopsy curette (tip), 90fHeart surgery, 283–286

open, 287–288, 291–295Heart valve, repair of, 299–300Heath mallet, 147fHegar dilator, 89fHegar uterine dilator, 134fHem-O-Lok clip applier, 117fHem-O-Lok clip applier (tip), 82f, 117fHem-O-Lok remover, 117fHemoclip-applying forceps, 124fHemostat, types of, 17Hemostatic clamp, 12–13, 17Henle probe, 131fHeparin needle, 273fHerniorrhaphy, position for, 59fHerrick kidney clamp, 116fHerrick kidney clamp (tip), 116fHibbs laminectomy retractor, 164fHimmelstein sternal retractor, 291fHinge, inspection of, 12Hip

fracture of, 166–168total replacement of, 170–173

instruments for, 174–178Hip retractor, 169Hippocrates, 2Hirschman iris hook, 203fHirschman iris hook (tip), 203fHoen nerve hook, 86f, 115fHoen nerve hook (tip), 298fHoen periosteal elevator, 311fHohmann retractor, 169fHoke chisel, 137fHolmium laser fiber, 114fHolt probe set, 182fHook holder, 183fHook scissors, 58fHorizon clip applier, 292fHorizon clip applier (tip), 292fHoskins forceps, 212fHot Shears (tip), 80fHouse double-end curette (tip), 228fHouse Gelfoam press, 224fHouse joint knife (tip), 226fHouse measuring rod (tip), 229fHouse pick (tip), 227fHouse-Rosen needle (tip), 226fHouse sickle knife, 226fHouse suction/irrigator, 232f

House teflon block, 224fHudson quick coupling, 141fHumeral head retractor, 164fHunt chalazion forceps, 199fHunter (Glassman) bowel grasper, 64f, 77fHunter (Glassman) bowel grasper (tip), 65f, 78fHurd tonsil dissector, 235fHydrogen peroxide, disinfection with, 16Hydrogen peroxide gas plasma, 16Hyperflex guidewire, 156fHysterectomy

abdominal, 96–98position for, 102fsupracervical laparoscopic, 99–102vaginal, 103–104

Hysteroscopy, 91–93

IICP monitoring tray, 330Identification systems, 16–17IFU. See Instructions for useImmediate use steam sterilization (IUSS),

9, 16Impactor, 163fIncision retractor, 172fInlet fascia closure device, 75fInstructions for use, 4

for sterilization container systems, 29–30Instrument pan, 54fInstrument rack

laparoscopic, 76ffor tympanoplasty, 226f–228f, 230f

Instrument-tracking software, 22Instruments. See also Microinstruments

accessory, 21ASIF anterior cervical, 344–345cardiac surgery, 283–286cardiovascular, 296–298care and handling, 1–23

resources for, 4–5classification of, 14, 17–21cleaning of, 5–8corrosion of, 11–12craniotomy, 307–313cutting, 18–19decontamination of, 5–6design of, 1evolution of, 2eye, cleaning of, 9finish of, 3grasping, 20–21handheld, 17–21history of, 1holding, 20–21identification systems for, 16–17inspection of, 12–14insulated, 14microscopic, 14neurologic bone pan, 314–316neurologic shunt, 326–327nonpowered, 17–21packaging of, 14–15point of use, 5powered, 17preparation of, for processing, 5prion contamination of, 10–11quality of, 3–4radial artery harvest, 306repair of, 22return open heart, 301–303specialty, cleaning of, 9–10spotting of, 11–12staining of, 11–12

Instruments (Continued)stainless steel, 2–4sterilization of, 15–16, 24–30testing of, 12–14thoracic, 280–282tracking of, 22vein retrieval, 304–305

Insufflation tubing, 53f, 74fInsuFlow heater hydrator insufflation tubing,

74fInsulated instruments, 14Insulation, inspection of, 14Intracranial pressure monitoring tray, 330Intramedullary taper reamer, 177fIntrepid I/A tip, 204fIntuitive Surgical, Inc., 79Iris scissors, 18f, 130fIris spatula (tip), 203fIron, instrument staining from, 11Irrigation cannula, 213fIsotac screwdriver, 155fIUSS. See Immediate use steam sterilization

(IUSS)

JJ-hook cautery electrode, 57fJackson tracheal tenaculum, 239fJacobs chuck, 143fJacobs chuck attachment, 142fJacobs drill, 143fJameson muscle hook, 207fJameson muscle hook (tip), 208f, 215fJameson muscle recession forceps, 214fJameson muscle recession forceps (tip), 215fJansen retractor, 19Jansen thumb forceps, 241fJarit hysterectomy forceps, 98fJarit hysterectomy forceps (tip), 98fJarit microsurgical needle holder, 303fJaw, example of, 18fJaw alignment, inspection of, 12–13Jensen capsule polisher, 203fJeweler’s forceps, 131f, 206fJeweler’s forceps (tip), 206fJohnson needle holder, 224fJohnson skin hook, 224fJoint, inspection of, 12Joint replacement, small, 146–147Joplin bone forceps, 165fJordan oval knife (tip), 226fJorgenson dissecting scissors, 96f, 122–126Jorgenson dissecting scissors (tip), 98fJoseph button-end knife, 241fJoseph button-end knife (tip), 241fJoseph coronoid self-retaining retractor, 254fJoseph skin hook, 84

KK-wire, 156fKelley Descemet membrane punch, 213fKelly retractor blade, 40f, 44fKelman-McPherson tying forceps, 202fKent-Wood adjustable retractor, 254fKeratome, inspection of, 13Keratoplasty, deep lamellar endothelial,

210–211Kerrison rongeur, 243fKerrison rongeur (tip), 315fKevorkian-Younge endocervical biopsy

curette, 89fKevorkian-Younge endocervical biopsy

curette (tip), 90f


351Index

Key periosteal elevator, 137f, 168fKidney, nephrectomy of, 115Killian nasal speculum, 135fKirschner wire (K-wire), 156fKistner probe, 311fKnee

arthroscopy for, 150–153total replacement, 157–163

Knifeinspection of, 13sternal, 289–290

Knife handle, 18Kocher clamp, 32Kocher forceps, 20Kratz-Berraquer wire eyelid speculum, 200fKronner laparoscopic scope holder, 52fKuglen iris hook manipulator, 203fKuglen iris hook manipulator (tip), 203fKuhn-Bolger giraffe forceps, 248f

LL-hook cautery, 56fL-hook cautery (tip), 56fLacrimal probe, 131fLacrimal sac retractor, 222fLaForce adenotome, 235fLahey gall duct forceps, 304fLahey goiter vulsellum forceps, 84fLahey thyroid tenaculum, 84Lahey traction forceps, 87fLahey traction forceps (tip), 87fLambert chalazion forceps, 199fLambert-Kay aortic clamp, 303fLambert-Kay aortic clamp (tip), 284fLaminectomy, 334–337Laminectomy, Williams microretractor, 338Lamis infiltration needle, 263fLancaster speculum, 198f, 205fLangenbeck elevator, 253fLangenbeck periosteal elevator, 253fLangenbeck retractor, 87fLaparoscope, 49

laser, 60lens for, 50fOlympus EndoEye, 51f

Laparoscopic clip applier/remover, 127fLaparoscopic ligating and dividing clip

applier, 65fLaparoscopic set

adult MIS, 54–59minor, 47–48

Laparoscopy, 49–53bariatric surgery, 72–78bowel resection, 63–68cholecystectomy, 61–62definition of, 49instrument rack for, 56f, 58ffor nephrectomy, 117–118position for, 59ffor prostatectomy, 127tubal occlusion, 105–107

Laparotomydefinition of, 32setup for, 31–38

Laparotomy set, small, 45–46Laser, vaginal, 94–95Laser laparoscope, 60Lateral vaginal retractor, 95fLe Fort fracture, 254Leaflet retractor, 300fLebsche mallet, 290fLebsche sternum knife, 290fLee bronchus clamp, 282f, 297f

Lee bronchus clamp (tip), 282f, 297fLeksell rongeur, 314fLempert elevator, 224fLens loop, 207fLens loop (tip), 208fLester fixation forceps, 206fLester fixation forceps (tip), 206fLester IOL manipulator, 203fLester IOL manipulator (tip), 203fLewis rasp, 241fLeyla ball and socket joint clamp, 317fLeyla holding arm, 317fLieberman eye speculum, 200f–201fLigament, anterior cruciate, 154–156LigaSure impact sealer/divider, 101fLigaSure impact sealer/divider (tip), 101fLigaSure laparoscopic sealer/divider, 101fLigaSure laparoscopic sealer/divider (tip),

101fLincoln-Metzenbaum scissors, 115fLinear cutter, 65fLinear provisionals, 175fLinear stapler, 66fLister’s antiseptic technique, 2Lithotripter, stone breaker pneumatic, 111fLittle retractor, 115fLone Star steel retractor, 126fLong tip forceps (tip), 80fLorna towel forceps, 285fLothrop uvula retractor, 235fLove nerve retractor, 115fLove nerve root retractor, 335fLove nerve root retractor (tip), 335fLowman bone-holding clamp, 168fLubrication, of mechanical washer, 8Lucae mallet, 138fLudwig wire applicator, 241fLuer bone rongeur, 147fLuer-Lok adapter, 55fLumen

cleaning, 5, 7inspection of, 12

LUMINA telesope, 150fLumpectomy, 84Lung grasper, 277fLuxtec fiber optic light cable, 262f

MMachemer irrigating lens, 219fMachemer irrigating lens (tip), 220fMalleable retractor blade, 40f, 42fMalleable T retractor, 280fMallet

Crane, 252fHeath, 147fLebsche, 290fLucae, 138f

Malleus nipper, 231fMaltz rasp, 241fManual cleaning, 6–7Marlow knot pusher, 56fMarlow knot pusher (tip), 56fMaryland bipolar dissector, 57f, 64fMaryland bipolar dissector (tip), 58f, 65fMaryland bipolar forceps (tip), 81fMastectomy, 85–87Matson rib stripper, 280fMaumenee corneal forceps, 206fMaumenee corneal forceps (tip), 207fMaxwell flap retractor, 263fMayo dissecting scissors, 33f, 46f

curved, 32, 33f, 46fstraight, 32, 33f, 46f

Mayo-Hegar needle holder, 38fMayo-Hegar needle holder (tip), 38fMayo needle holder, 32Mayo-Péan clamp, 17Mayo-Péan hemostatic forceps, 32, 37fMayo-Péan hemostatic forceps (tip), 37fMayo scissors, 18–19, 18f

inspection of, 13Mayo stand, setup for, 32f, 38fMcCullough utility forceps, 212fMcCullough utility forceps (tip), 215fMcIvor blade, 236fMcKenty elevator, 241fMcNeil-Goldman scleral ring, 205fMcPherson tying forceps, 131fMcPherson tying forceps (tip), 202fMEC. See Minimum effective concentration

(MEC)Mechanical cleaning, 6–8Mechanical washer, 8Medicine cup, 46fMediTray basket insert, 25fMedtronic Midas Rex electric drill, 320–321Medtronic Skeeter Ultra-Lite oto tool, 233fMega needle driver (tip), 81fMega SutureCut needle driver (tip), 81fMellon curette, 337fMellon curette (tip), 337fMeltzer adenoid punch, 235fMeniscectomy knife, 144fMetzenbaum dissecting scissors, 18–19, 18f,

33f, 46fMetzenbaum scissors

inspection of, 13roticulating, 277f

Meyerhoeffer chalazion curette, 199fMeyerhoeffer chalazion curette (tip), 199fMicro Plastic Set, 260–261Microbipolar forceps (tip), 81fMicrocurette, 323fMicrocurette (tip), 324fMicrodissector (tip), 324fMicrofixation system, 257Microforceps (tip), 80fMicrohook, 323fMicrohook (tip), 324fMicroinstruments. See also Instruments

open heart, 287–288Rhoton neurologic, 322–324

Microneedle holder, 131f, 322fMicroscissors, 322fMicroSmooth I/A sleeve, 204fMicroSmooth Phaco sleeve, 204fMicrovascular scissors (tip), 288fMidas Rex electric drill, 320–321Midas Rex electric drill (tip), 321fMiller-Senn retractor, 46f, 87fMinerals, instrument spotting caused by, 11Mini-hook holder, 183fMini-Metzenbaum scissors, 57fMinimally invasive spine surgery, 339–340Minimally invasive surgery (MIS), 1, 49Minimum effective concentration (MEC), 16MINOP neuroendoscopy set, 328–329Minus irrigating lens, 219fMinus irrigating lens (tip), 220fMira diathermy tip, 218fMIS. See Minimally invasive surgery (MIS)MIS bone curette, 340fMixter hemostatic forceps, 37f, 116fMixter hemostatic forceps (tip), 37f, 116fMMF self-drilling screw set, 256fMonopolar scissors, 58fMorse sternal retractor, 292f


352 Index

Mosquito clamp, 17Mueller clamp, 222fMultisociety Guidelines for Reprocessing

Flexible Gastrointestinal Endoscopes, 9Murphy blade, 43fMurphy bone lever, 172f

NNagahara Phaco chopper, 203fNagahara Phaco chopper (tip), 203fNasal fracture reduction, 245Nasal polyp, instruments for, 244Nasal scissors, 250fNathanson liver retractor, 75fNathanson retractor, 75fNeck, cervical fusion for, 341–343Needle, inspection of, 13Needle driver (tip), 81fNeedle holder, 21

inspection of, 13Needle-tip suction, 56fNephrectomy, 115–116

laparoscopic, 117–118Neuroendoscopy set, MINOP, 328–329Neurologic bone pan instruments, 314–316Neurologic retractor, 317–319Neurologic shunt instruments, 326–327NexGen system, 163fNezhat dorsal plug, 54fNezhat-Dorsey cautery, 56fNezhat-Dorsey cautery (tip), 56fNezhat-Dorsey irrigator, 77fNezhat-Dorsey suction, 56fNezhat-Dorsey suction (tip), 56fNezhat suction/irrigator, 64fNezhat suction/irrigator (tip), 65fNick pick, 210fNick pick (tip), 211fNoncritical instruments, 14Notchplasty gouge, 156f

OObturator, 71f

examples of, 73feyed (tip), 286f

Occluding clamp, 17Occupational Safety and Health

Administration (OSHA), 5Ochsner forceps, 20, 20fOchsner forceps (tip), 20fOchsner hemostatic forceps, 32, 38fOchsner hemostatic forceps (tip), 38fOchsner malleable retractor, 32, 35f, 46fOctopus retractor, 293fOculoplastic instrument set, 221–222Olsen clamp (tip), 58fOlympus 1 chip camera, 305fOlympus EndoEye laparoscope, 51fOlympus flexible cystoscope, 111fOlympus flexible ureteroscope, 113fOpen heart microinstruments, 287–288Open heart surgery, 291–295, 299–303Operating room, setup for, 31–38Orthognathic surgery, 254–256Orthopedic surgery, 136–138Orthophthalaldehyde, disinfection with, 16Oscillating saw, 140fOSHA. See Occupational Safety and Health

Administration (OSHA)Osteoarthritis, ankle, 148Osteotome, 155fOsteotome (tip), 155f

Ostium seeker, 249fOstrum-Terrier ostium forceps, 249fO’Sullivan-O’Connor retractor, 19, 19f, 32,

41f, 96fblades for, 41f

Ototome, 225Oval window pick (tip), 227f

PPaddle blade, 79fPadgett dermatome, 266f

guards, 267fhead, 266f

Paper drape clip, 36f, 224fPaper drape clip (tip), 36fParker retractor, 19Parkes osteotome, 255fParsonnet epicardial retractor, 287fParsonnet epicardial retractor (tip), 288fPassivation, instrument manufacture and,

3–4Patient safety, 1–2Paton spatula, 207fPaton spatula (tip), 208fPaufique suture forceps, 222fPaufique suture forceps (tip), 222fPelvic external fixator, 195fPemco suction tip, 285fPenfield dissector, 285fPenfield dissector (tip), 312fPenile prosthesis, 133–135Peracetic acid, disinfection with, 16Perforated tray, 24Pericardial dissector (tip), 82fPersonal protective attire, instrument

cleaning and, 7Petri pterygoid retracor, 254fPhaco tip, 204fPin collet, 142fPin cutter, 192fPiriform rim retractor, 255fPitting

avoidance of, 12instruments affected by, 11–12

Pituitary rongeur, 156fPituitary rongeur (tip), 299fPK dissecting forceps (tip), 81fPlastic surgery, minor, 258–259Plate bender, 194fPolack double-tipped corneal forceps, 206fPolack double-tipped corneal forceps (tip),

206fPolishing, instrument manufacture and, 3Polymers, instruments made from, 1Poole abdominal suction tube, 21f, 34f, 46fPoole suction tube, 21Port, laparoscopic, 52fPort cap, 55fPotts scissors, 79fPotts scissors (tip), 273fPotts-Smith cardiovascular scissors, 115fPotts-Smith tissue forceps, 297fPotts-Smith tissue forceps (tip), 297fPower drill, 139–143Power saw, 139–143PreCise bipolar forceps (tip), 81fPrince-Metzenbaum dissecting scissors, 86fPrions

description of, 10instrument contaminated with, 10–11sterilization and, 15–16

Probe dilator, 115fProGrasp forceps (tip), 80f

Prostateprocedure for, 122–126transurethral resection of, 128–129

Prostatectomy, 122–126laparoscopic, 127

Prosthesisacetabular, 178ffemoral head, 178fpenile, 133–135porous stem, 178f

Prosthesis driver, 172fProvidence Hospital hemostatic forceps, 130fPterygium set, 200fPterygomasseteric sling stripper, 255fPubovaginal sling/anterior repair, 119–121Pyramidal trocar, 144f

RRagnell-Davis retractor, 134fRaney scalp clip applier, 309fRanfac knot pusher, 56fRanfac knot pusher (tip), 56fRasp (tip), 155fRasp tray, 176fRatchet

example of, 18finspection of, 12–13

Reamer tray, 177fRecommended Practices for Sterilization,

for Care and Cleaning of Surgical Instruments and for Selection and Use of Packaging Systems, 4

Regulation, of sterilization container systems, 30Renal artery clamp, 297fRenal artery clamp (tip), 297fResano forceps (tip), 80fResectoscope, 128fResolution chart, 13–14Retinal detachment, 217–218Retractor, 19–20

abdominal self-retaining, 39–44brain, 318fneurologic, 317–319self-retaining, 19f, 39–44upper hand, 42f

Retractor bladefenestrated, 41fmalleable, 40f, 42f

Rheumatoid arthritis, ankle, 148Rhinoplasty, 240–243Rhoton dissector, 323fRhoton neurologic microinstrument set,

322–324Ribbon retractor, 252fRichards alligator forceps, 225Richards bone curette, 172fRichards ear speculum, 224fRichardson-Eastman retractor, 120fRichardson retractor, 19f, 32, 34f, 46f

double-ended, 134fRichardson retractor blade, 44fRidged obturator, 145fRigid endoscope, inspection of, 13Ring forceps (tip), 261fRizzutti clip applier, 261fRobotic instruments, 79–83Rod

for long bone fracture, 185–186spinal fusion with, 179–184

Rod cutter, 183fRongeur, inspection of, 13Rosen knife (tip), 229fRotary hand piece, 142f


353Index

Rowe disimpaction forceps, 253fRuskin double-action rongeur, 314fRuskin-Liston bone-cutting forceps, 147fRuskin ronguer, 138fRusking-Liston bone-cutting forceps, 138fRussian tissue forceps, 34f–35fRussian tissue forceps (tip), 35fRust, instrument staining from, 11Ryder needle holder, 298f

SSaber drill, 225Safety, patient, 1–2Sagittal splitting osteotome, 255fSamii scissors, 309fSamii scissors (tip), 309fSarot bronchus clamp, 282fSarot bronchus clamp (tip), 282fSatinsky atraumatic clamp, 118fSatinsky (vena cava) clamp, 116fSatinsky (vena cava) clamp (tip), 116fSauerbruch rongeur, 281fSaw

Hall sternal, 290foscillating, 140fpower, 139–143Stryker sternal, 289f

Scalpel rigid stricture, 112fSchepens orbital retractor, 218fSchertel grasper (tip), 82fSchocket scleral depressor, 219fSchott eye speculum, 205fSchroeder uterine tenaculum forceps, 88f,

94f, 97f, 99fSchroeder uterine tenaculum forceps (tip),

97f, 104fScissors

in da Vinci Surgical System, 79fdescription of, 18–19examples of, 18finspection of, 13

Scleral plug forceps, 219fScleral plug forceps (tip), 220fScott-McCracken elevator, 168fScoville nerve root retractor, 335fScoville nerve root retractor (tip), 335fSecureStrap tack, 65fSeibel nucleus chopper, 203fSeibel nucleus chopper (tip), 203fSelector hand piece, 325fSemb gouging rongeur, 281fSemb ligature-carrying forceps (tip), 284fSemb lung retractor, 281fSemb lung retractor (tip), 282fSemicritical instruments, 14Senn-Kanavel retractor, 224fSenn retractor, 19Senn retractor (tip), 239fSeptoplasty, 240–243Serrephines, 218f, 222f–223fShadow ACF retractor blade, 342fShadow ACF transverse retractor, 343fShank, example of, 18fSheehy fascia press, 224fSheehy ossicle-holding forceps, 224fSheets irrigating vectis, 207fShell acetabular instruments, 175fShepard iris hook, 207fShepard iris hook (tip), 208fShoulder, arthroscopy for, 150–153Shoulder ligature carrier, 165fShoulder surgery, instruments for, 164–165Shukla Universal Screwdriver Set, 196f

Shunt passer, 327fSickle knife, 247fSickle knife (tip), 247fSigma total knee FB tibial prep pan, 160fSigma total knee femoral trials pan, 159fSigma total knee fixed REF femur prep pan,

158fSigma total knee MBT prep pan, 161fSigma total knee pan, 157fSigma total knee patella insertion pan, 159fSigma total knee spacer blocks pan, 160fSigmoidoscope, 71fSigmoidoscopy, 71Silber vasovasostomy clamp, 131fSims uterine curette (tip), 90fSims uterine sound, 89fSims uterine sound (tip), 90fSinskey iris and IOL hook, 207fSinskey iris and IOL hook (tip), 208fSinskey lens hook, 203fSinskey lens hook (tip), 203fSinskey tying forceps (tip), 209fSinus surgery, 246–250Skeele curette, 199fSkeele curette (tip), 199fSkeeter drill, 225Skin graft, 266–267Skin hook retractor, 19, 19fSmith-Petersen laminectomy rongeur, 171fSnap-fit scalpel instruments, 79fSnowden-Pencer dissecting forceps, 132fSnowden-Pencer dissecting scissors, 33fSnowden-Pencer fixation forceps, 132fSnowden-Pencer scissors, 275fSociety of Gastroenterology Nurses and

Associates, 9Sofamor spreader, 183fSpacer block, knee, 160fSpatula cautery, 56fSpatula cautery (tip), 56fSpatula microdissector (tip), 324fSpinal column, laminectomy for, 334–337Spinal fusion, 179–184

postoperative radiograph of, 184fSpinal tray, 29fSpine, minimally invasive surgery for,

339–340Sponge holder, 21Spotting, of instruments, 11–12Spratt curette, 147fSpurling-Kerrison rongeur, 336fSpurling-Kerrison rongeur (tip), 336fStaining, of instruments, 11–12Stainless steel

composition of, 3corrosion of, 11–12grades of, 3instruments made from, 1–3quality of, 3–4

Stammberger antrum punch, 247fStammberger antrum punch (tip), 247fSteinmann pin, 171fStent grasper, 110fStent grasper (tip), 110fSterilization, 15–16

immediate use steam, 16instrument packaging for, 14–15of instruments, 1–2preparation for, 14–16steam, 15

Sterilization container system, 24–30care and handling of, 26–27instructions for use, 29–30instrument placement in, 28–29

Sterilization container system (Continued)regulation of, 30selection of, 29shelf life of, 27–28storage and sterility maintenance for,

27–28SteriTite Container, 25f–26fSternal crimper, 294fSternal knife, 289–290Sternal saw, 289–290SternaLock blade, 294fSternaLock power driver unit, 294fStevens tenotomy hook, 214fStevens tenotomy hook (tip), 215fStevens tenotomy scissors, 130fStone breaker pneumatic lithotripter, 111fStone extractor, 114fStone grasping forceps, 118fStrabismus scissors, 216fStrully scissors, 275fStrully scissors (tip), 288fStruycken nasal cutting forceps, 247fStruycken nasal cutting forceps (tip), 247fStryker arthroscopy shaver, 152fStryker cement gun, 162fStryker REM B cord, 143fStryker sternal saw, 289fStryker System 5, 139fSuction/irrigator system, 53f, 102fSuction tube, 21Supracervical laparoscopic hysterectomy,

99–102Surgery

cardiac, 283–286evolution of, 2eye muscle, 214–216history of, 2instrument cleaning after, 6–8minimally invasive. See Minimally invasive

surgery (MIS)open heart, 287–288, 291–295, 299–303orthognathic, 254–256orthopedic, 136–138sinus, 246–250spinal, 339–340transoral, 237

Surgical instruments. See InstrumentsSutureCut needle driver (tip), 81fSwitchblade scissors, 77fSynthes AO quick coupling chuck, 141fSynthes low-profile cranial plating set,

332–333Synthes Mini 4200 Driver, 142fSynthes mini quick coupling, 141fSynthes retrograde/antegrade femoral nail,

188–189Synthes sagittal saw attachment, 141fSynthes Small Battery Drive II, 141fSynthes unreamed tibial nail insertion and

locking instruments, 190

TT-handle probe, 182fT-handle wrench, 182fTASS. See Toxic anterior segment syndrome

(TASS)Taylor Spatial framework, 191fTaylor Spatial ring, 192fTaylor spinal retractor, 173fTebbetts fiber optic retractor, 262fTelescope

bariatric, 74finspection of, 13


354 Index

Tenaculum forceps (tip), 80fTendon, patellar, 154–156Tensioner, 192fTerry scraper, 210fTerry scraper (tip), 211fTexas Scottish Rite Hospital (TSRH), 179

bending tray, 180fcrosslink tray, 182fhook trials, 181fimplant tray, 179fpediatric instrument tray, 181frod tray, 180fspinal system, 179top tightening implant tray, 180fwrench tray, 182f

Thomas uterine curette, 89fThomas uterine curette (tip), 90fThompson bariatric post and bar, 42fThompson retractor, 19, 32, 43f

blades for, 43fjoints for, 44frotational blades for, 43f–44f

Thompson retractor holder, 75fThoracic grasper (tip), 80fThoracic instruments, 280–282Thoracoport, 278fThoracoscopy, 277–279

position for, 279fThorpe calipers, 218fThorton fixation ring, 203fTibial aiming hook, 156fTibial nail insertion and locking instruments,

190Tissue forceps (tip), 20fTitanium, instruments made from, 1Titanium 2.0-mm microfixation system, 257Titanium needle holder (tip), 209fTo Err is Human: Building a Safer Health

System, 1–2Tonsil hemostatic forceps, 32, 37fTonsil hemostatic forceps (tip), 37fTonsillectomy, 234–236Tooth forceps, 118fTORS. See Transoral robotic surgery (TORS)TORS blade, 237fTotal hip replacement, 170–178Total knee replacement, 157–163Towel clamp, 21Townley femur caliper, 171fToxic anterior segment syndrome (TASS), 9Tracheal hook (tip), 239fTracheotomy, 238–239Transoral robotic surgery (TORS), 237Transoral surgery, 237Transplant microscissors, 209fTransurethral resection of the prostate

(TURP), 128–129Trilogy acetabular instruments, 174fTrocar

examples of, 73flaparoscopic, 52f–53f

Trocar sleeve, 144fTrousseau-Jackson tracheal dilator, 239fTrousseau-Jackson tracheal dilator (tip), 239fTroutman-Barraquer forceps, 206fTroutman-Barraquer forceps (tip), 206fTroutman-Barraquer microneedle holder, 207fTroutman-Barraquer microneedle holder

(tip), 209fTroutman tier needle holder, 131fTruClear hand piece, 93fTruClear hysteroscopy system, 93fTSRH. See Texas Scottish Rite Hospital

(TSRH)Tubal occlusion

laparoscopic, 105–107position for, 107f

Tubing passer, 135fTulip cannula, 265fTURP. See Transurethral resection of the

prostate (TURP)Tympanoplasty, 225–233

UUltrasonic cleaning, 7Ultrasonic handpiece, 325Universal screwdriver/broken screw set,

196–197University of Minnesota cheek retractor, 252fUpper hand retractor, 42fUreteroscope, rigid, 114fUreteroscopy, 113–114Urethra, cystoscopy of, 108Urethroscopy, 112Urinary bladder, cystoscopy of, 108U.S. Food and Drug Administration. See

Food and Drug Administration (FDA)Uterine manipulation probe, 99fUterine manipulator, disposable, 100fUterine sound, 99fUterus, dilatation and curettage of, 88–90Utrata forceps, 202fUtrata forceps (tip), 202f

VV-Lign instrument tray, 177fVagina, repair of, 119–121Vaginal hysterectomy, 103–104Vaginal laser, 94–95Valve hook, 82fVan Buren sound, 129fVannas capsulotomy scissors, 131f, 209fVannas capsulotomy scissors (tip), 209fVas deferens, 130Vascular bulldog, 127fVasectomy, 130–132Vasovasostomy approximator, 131fVasoView harvesting cannula, 305fVein retractor, 275fVein retrieval instruments, 304–305

Verres needle, 49, 53fVerres needle stylet, 60fVersaPoint hysteroscopic resectascope, 91f

sheath for, 92fVienna nasal speculum, 243fVital Metzembaum scissors, 304fVitallium, instruments made from, 1Vitrectomy, 219–220Volkmann rake retractor, 120fVolkmann retractor, 86fVon Eicken antrum wash tube, 247fVon Graefe strabismus hook, 214f

WWasher-decontaminator/disinfector, 8Watzke sleeve-spreader forceps, 217fWatzke sleeve-spreader forceps (tip), 218fWave grasper, 57fWax curette (tip), 228fWeary nerve hook, 287fWebster needle holder, 154fWeck EZ Load hemoclip applier, 302fWeck Horizon hemoclip, 302fWeck scissors, 260fWeder tongue depressor, 235fWeinberg blade, 42fWeinberg retractor blade, 44fWeitlaner retractor, 19, 19f, 46f, 138fWeitlaner self-retaining retractor, 45Welch Allyn operative sigmoidoscope, 71fWells enucleation spoon, 223fWestcott tenotomy scissors, 18–19, 18fWestcott tenotomy scissors (tip), 209f, 221fWestphal hemostatic forceps, 37fWestphal hemostatic forceps (tip), 37fWhirleybird pick (tip), 227fWiener antrum rasp, 241fWilliams laminectomy microretractor, 338Wills Hospital utility forceps, 217fWills Hospital utility forceps (tip), 218fWire collet, 143fWolf bipolar grasper, 105fWolf optical urethrotome obturator, 112fWoodson dura separator and packer, 311fWoodson dura separator and packer (tip),

312fWoodson elevator, 340f

YYankauer suction tube, 21, 21f, 34f, 46fYankauer suction tube (tip), 34fYasargil aneurysm clip, 331

ZZ clamp, 97fZ clamp (tip), 97fZimmer-VerSys instruments, 174–178Zygomatic arch awl, 252f


Contents—cont’d

UNIT SIX: EYE, EAR, NOSE, AND THROAT SURGERY

58 Basic Eye Set, 198 59 Clear Corneal Set, 201 60 Corneal Transplant, 205 61 Deep Lamellar Endothelial Keratoplasty, 210 62 Glaucoma, 212 63 Eye Muscle Surgery, 214 64 Retinal Detachment, 217 65 Vitrectomy, 219 66 Oculoplastic Instrument Set, 221 67 Eye Enucleation, 223 68 Basic Ear Set, 224 69 Tympanoplasty, 225 70 Tonsillectomy and Adenoidectomy, 234 71 Transoral Surgery, 237 72 Tracheotomy, 238 73 Septoplasty and Rhinoplasty, 240 74 Nasal Polyp Instruments, 244 75 Nasal Fracture Reduction, 245 76 Sinus Surgery, 246

UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL SURGERY

77 Facial Fracture Set, 251 78 Orthognathic Surgery, 254 79 Titanium 2.0-mm Microfixation System, 257

UNIT EIGHT: PLASTIC SURGERY 80 Minor Plastic Set, 258 81 Micro Plastic Set, 260 82 Plastic Miscellaneous, 262 83 Skin Graft, 266

UNIT NINE: PERIPHERAL VASCULAR, CARDIOVASCULAR, AND THORACIC SURGERY

84 Endarterectomy, 268 85 Artery Bypass Graft, 269 86 Endovascular Abdominal Aortic Aneurysm Repair, 271 87 Abdominal Vascular Set (Open Procedure), 274 88 Thoracoscopy, 277 89 Thoracic Instruments, 280 90 Cardiac Surgery, 283 91 Open Heart Microinstruments, 287 92 Sternal Saws and Sternum Knife, 289 93 Open Heart Extras, 291 94 Cardiovascular Instruments, 296 95 Open Heart Valve Extras, 299 96 Return Open Heart Set, 301 97 Vein Retrieval Instruments, 304 98 Radial Artery Harvest Set, 306

UNIT TEN: NEUROSURGERY 99 Craniotomy, 307 100 Neurologic Bone Pan Instruments, 314 101 Neurologic Retractors, 317 102 Medtronic Midas Rex Electric Drill, 320 103 Rhoton Neurologic Microinstrument Set, 322 104 Ultrasonic Handpieces, 325 105 Neurologic Shunt Instruments, 326 106 MINOP Neuroendoscopy Set, 328 107 Intracranial Pressure Monitoring Tray, 330 108 Yasargil Aneurysm Clips with Appliers, 331 109 Synthes Low-Profile Cranial Plating Set, 332 110 Laminectomy, 334 111 Williams Laminectomy Microretractors, 338 112 Minimally Invasive Spine Surgery, 339 113 Anterior Cervical Fusion, 341 114 ASIF Anterior Cervical Locking Plating Instruments, 344

UNIT ON PEDIATRIC SURGERY (ON EVOLVE WEBSITE)


Instrumentation for the operating room a photographic manual.

Documents

Transcript of Instrumentation for the operating room a photographic manual.