SURGICAL INSTRUMENTS
INTRODUCTION
Surgical instruments are very expensive. It represents a major investments of any hospital as
different surgical technique are involved, relative to different operation so also are the tools to
get the job done.
Surgical instruments are now becoming more precise in design and more delicate in structure,
this implies that when abused, misused or subjected to inadequate cleaning or in other cases of
sheer rough handling, the life expectancy of even the finest quality of instrument is reduced. It is
not only that the cost of repair and replacement becomes unnecessary high. A standard
instrument should last for a period of 10 years.
Definition:- Instruments are tools required for the safe performance of surgery. A typical surgical
instrument is made from stainless (metal) with appropriate finish (coating).
NOMENCLATURE
This is the system of naming surgical instrument. Instruments are given names based on the
following:-
1. The maker’s name e.g mayor’s scissors
2. The size e.g. mosquito artery forceps
3. The function e.g. trachea dilator
4. The structure e.g curved/straight artery
CLASSIFICATION
Instruments are basically classified according to their functions. The groups are:-
1. Cutting Instrument: To separate tissue, to cause an intentional break in the continuity of
tissues e.g. amputation knife, osteotome.
2. Haemostatic/clamping instrument: use to appose edges of bleeding vessels
3. Dissecting Instrument:- have various functions like to separate tissues, brings together tinny
tissues
4. Probing Instrument:- basically used to define sinuses or tracts in tissues. it has blunt tips and a
pliable body.
5. Retracting instrument:-This are instrument used to expose and gain access to site of operation
especially a cavity. They are either manual or self retaining.
6. Grasping Instrument:-This is for firm gripping on tissue for better manipulation.
7. Suturing instrument-This are singularly used or in combination with other item or equipment
to bring tissue edges into close apposition
These can be discussed under three headings viz:-
[Link] before surgery
2. Handling during surgery
[Link] after surgery
Handling Before Surgery
The type of surgery to be perform determine the identity of instrument set or pack to be
used e.g. for a mastoidectomy surgery the set will be indicated. Also for a laparotomy a basic set
and lap set will be necessary. Other pre- pack can be supplied as the need arises depending on
the surgery to be done e.g. in thyroidectomy, there is extra instrument to be used e.g. joll’s
retractor.
But in whichever way it is compulsory that :-
1. The sterility of such instruments must be guaranteed before the commencement of surgery
session.
2. The transportation of such set or pack in a way that it is not inadvertently contaminated.
3. The totality of the number of instruments in the pack should be crossed checked between the
scrub/circulating nurse in accordance with kardex.
4. The outcome of the count collected must be documented.
5. The accessory parts to every instrument must be checked and found correct.
6. Instruments with joints and screws should be worked up and found useful.
7. The effectiveness of “sharps” e.g scissors or myringotome must be determined before surgery.
8. Ensure no rust or corrosion on the instruments before surgery.
Handling During Operating
Instruments must be well laid out in order of use. On the extreme left hand we have;
➢ A medium size kidney dish for towel clips(8)
➢ In front of the gallipots are 3 medium size kidney dishes containing diathermy cable and
points as well as quiver,4 needle holders and various sutures required for the surgery.
➢ Beside the 3rd kidney dish is the swab bowl containing about 2-3 bundles of small swabs
depending on type of operation. Instrument at the open edge of the trolley proximal to the
scrub nurse are the following:-
From left to right:-
- 6 sponge holding forceps
- 2-3 bard parker handle with some sizeable blades.
- 2 plain dissecting forceps
- 2 toothed dissecting forceps
- Ferguson's stitch or assistant scissors
- Mayor’s scissors
- Mcindoe’s scissors
- A set of artery forceps on a railing
- 12 mosquito artery forceps
- 12 No 2 straight artery forceps
- 12 No 2 curved artery forceps
- 5 No 3 curved artery forceps
- 2 long lane’s tissue forceps
- 2 short lane’s tissue forcep
- 2 Babcock’s tissue forceps
- 6 Allis tissue forceps
- 1 9inch straight artery forcep
Towards the guarded edge of the trolley distal to the scrub nurse are:-
- 2 small largenbeck retractors
- 2 medium size largenbeck retractors
- suction nozzles
➢ Instruments with joints should be locked up before presenting to the surgeon.
➢ Instruments must be presented to the surgeon in such a way that no manipulation is
required by the surgeon.
➢ Instrument must be given on an exchange basis i.e. give and take.
➢ The sterile field should not be congested with instruments i.e. not more than 5
instruments allowed
➢ Instruments are better handle at the joint midpoint such that the handle will be proximal
to the surgeon .A45 degree elevation may be suggested in this situation
➢ The active end or business end must be ensure that no rust or corrosion
➢ Check for the completeness of the part before presenting to the surgeon
➢ Remove the rubber shod on the business end before giving to the surgeon. The shod is a
protective device that holds the mouth in place.
➢ Instrument with hook/fine teeth should be check before receiving from the surgeon
➢ Instruments with lens should be handle with extra care
➢ Instrument must be count before the closure of cavities to prevent being left in patient
cavity
Handling After Surgery
Instruments should be separated appropriately immediately after completion of surgical
operations.
➢ Blood stained instruments are opened up and separated into the water bowl.
➢ Transfer instruments to disposal room after surgery and wash with a soft brush under
running water
➢ Check joints for stiffness
➢ Check for completeness of working parts
➢ Instruments must be found complete before packing .
➢ Lensed instruments must be separated from others.
➢ Sizeable instrument trays should be used for packing instruments after surgery .This
should be lined with a layer of green towel.
➢ Heavy instruments should come lower while lighter ones arranged on them accordingly .
➢ Instruments in bunches must have mayo’s clips on for securing it. These should be
arranged in orderliness.
➢ Instruments are placed on two layers of wrapping materials(cellulose or fabric
wrappers)which must be color differentiated i.e. the outer most layer of green calico and
an inner green towel which signifies the sterile potion.
➢ There should be a kardex on top of every instrument set which should conform with the
content of the pack. The kardex carries the following information:-
- The identity of the pack
- The content of the set as well as date.
- The instrument should be pack appropriately after an autoclaving tape [BOWIE-DICK
autoclaving tape] has been placed on it.
-The folded edge of the pack is secured with a length of autoclaving tape on which
should be written:-
❖ Identity of the set.
❖ Initial and signature of the packer as well as time and date of packing.
❖ Instrument sets or packs should be autoclaved after use unless contraindicated.
FIBRE OPTIC INSTRUMENTS
These are more delicate and expensive surgical item/equipment .it is used in generating light
from the source which is conducted and transferred through various cables and connectors into
shallow dark cavities for adequate direct or indirect vision as well as any other qualities
derivable from such equipment e.g. operative resections. It is a collection of glass fibres
surrounded by an opaque tube which act as a flexible rod conveying light from a powerful
projector lamp to the spot where it is needed. Some of the accessory parts of fibre optics
includes:-
a fibre light source, fibre light carrier cable, fibre light connector which connect the cable to
the obturator, obturator.
ELECTROMEDICAL EQUIPMENT
This is a broad group of surgical items that are commonly used especially intra-operatively to
give precise care to the surgical patients, the name implies that most of them are basically
powered by electric current. Electro-medical equipment may be used on patients needing
intensive care, such equipment includes but not limited to the following-:
1. Suction machine
2. Diathermy machine
3. Electrocardiogram machine (E.C.G)
4. Defibrillator
5. Ventilator
6. Multiparameter patient monitor
7. Pulse oxymeter
8. Drilling machine
9. Otoscope
10. Head light
11. Anaesthetic machine
12. Endoscopic machine
13. Operating microscope
14. X –ray machine
15. X-ray viewing machine
16. Operating lamp
17. Oxygen concentration
Among all the equipment mentioned above, the suction machine, diathermy machine and head
light are more crucial in the dispensation of the routine intra - operative care in ENT and of
necessity the ENT Nurse should be well versed in the procedure of handling these items.
THE SUCTION MACHINE
According to Atkinson [Link] 1979. Suction is the application of pressure less than atmospheric
pressure either continuously or intermittently. This pressure is usually generated by this machine
with its accessories such as-:
- 2 vacuum bottles with fitting lid
- Non punctured well-fitting connecting rubber tube
- A nozzle or suction tip.
This assembly is used during operations to evacuate blood, and other body fluid from the
operation site into a vacuum bottle securely attached to the machine. The suction machine is a
vital Theatre and ENT equipment for aspirating fluids.
The scientific principle in application is negative pressure (i.e. pressure below atmospheric
pressure)
TYPES
There 2 major types namely:-
1. High Vacuum or Rotary Compressor pump
This type a much high vacuum of between 150-500 mmHg of vacuum could be generated. It is
used during surgical operation.
2. Low Vacuum or Reciprocating pump-This variety generates much lesser vacuum .it is useful
on the ward. It generates the pressure of between 0-140mmHg
CARE OF SUCTION MACHINE
The rubber tubing must be of a proportionally sizeable diameter i.e diameter of the lumen
to prevent blockage and collapse.
The lumen of the tubing should be patent and clean as contents can readily block it or
interfere with the sterilization process where the boiling method is used.
Ensure that the suction bottle is not overfilled as the aspirate can find its way back to the
machine causing damage.
Do not encourage unnecessary generation of very high pressure by kinking the tube or by
occluding the suction nozzle tip as this can produce an excessive strain which damages
the suction unit.
Check the machine before commencement of use/operation for its cleanliness, power and
ability to generates vacuum as you may be disappointed when you need the services of
the machine,
Ensure repairs when faults are detected as well as periodic servicing according to hospital
policy.
Carefully empty the bottle when filled up with a gloved hand at the end of each use after
the anaesthetist has reviewed the level of the aspirate or blood.
Whenever used for infectious case , empty the bottle and clean the machine with a gloved
hand . After which you pour a disinfectant e.g. savlon , purit or diluted jik.
THE DIATHERMY MACHINE
This is an electro-medical equipment which is capable of generating a high frequency electric
current to coagulates or to destroy (cut) body tissue. Although it is used intra-operatively by the
surgeon, the Nurse is not only required to know how it works but how to handle and care for the
equipment.
Electrocoagulation-: This is the use of a high voltage current of electricity to seal off bleeding
vessels during the course of an operation.
Electrocautery-: This is the use of a small loop heated by a steady direct electric current to red
heat. It would coagulate or destroy tissue on contact. Heat is transferred to the tissue with the
heated wire.
The haemostatic effect is as a result of sealing the tissue. There should be a switch control which
should be at least one meter from the anaesthetic machine and face mask. It should not be used in
the mouth, around the head or pleural cavity.
Electrosurgery-: This is the use of alternating current of well over 1000 degree/400 watts via an
electrode to literally slice body tissues (skin exclusive).
The idea of electrosurgical unit was first developed by a physicist named Dr W.T. Bovie in the
early 1920s, it was modified in 1970 to contemporary form of surgical diathermy. This fact
explain the reason why the electrosurgical unit is often called “BOVIE”. The electricity
generated by the machine is conducted by a cord which is heated after fittingly connected to the
diathermy point, pencil or active point.
ESSENTIAL WORKING PARTS OF A DIATHERMY MACHINES
The Foot Switch- This is also called the foot pedal or the foot pad. It can be single or double pad
type. It is usually differentiated by color marking to indicates electrocautery, coagulation or
cutting functions of the pedal.
The Main Switch- This is directly fixed on to the machine to allow electric current to flow from
the source of power supply which is usually a socket on the walls. it should be ensure that
adequate amount of electricity can be obtain and also such sources must never be over loaded .
Also two diathermy machines should not be connected to the same source of electricity.
THE INACTIVE ELECTRODE/PAD/GROUND
The main purpose of having this on the machine is to dispense electricity from the patient’s body
into the machine . This is to avoid any undesirable physiological consequences at the site of
application .The electrode either has an attachment of a lead plate or a flexible metal should be
inspected for wire breakage or fraying and any other condition that can expose patient to danger
should be ruled out before its use.
MAINTENANCE
Always inform the anaesthetist when and if the diathermy is to be used to prevent explosion of
gases or flammable liquids.
Half yearly servicing sheet is maintained by a technician. Daily checking by the operating
room staff is also maintained.
(a) Check that all the parts are available and in safe condition.
(b) Ensure that there are no broken connections or evidence of dysfunction before the operating
list begins.
N.B.
Before application of diathermy the circulating nurse must ensure that the machine and all the
available parts are in good and safe working condition of use.
A record of the date when the machine is installed and proper arrangement are made for
servicing. Yearly servicing sheet is maintained.
However all electro medical equipment must undergo periodic checking for faults and routine
servicing must be adhere to in other to keep the equipment in proper condition of use and to
avoid any disappointment or embarrassment . Plugs should be removed when not in use and the
connection must be made always .Never allow water into the compartment and always prevent
falls.