CHPTR

68

Instruments
o Forceps
o Retractors o Rubber tubes
o Occlusion clamps o Catheters
o Dilators o Sengstaken tube
o Tracheostomy tube o Needles

ARTERY FORCEPS (HAEMOSTAT)

" It is also ALLIS TISSUE HOLDING
called Spencer Well's
aratchet and
two blades with artery forceps. It has FORCEPS (Fig. 68.2)
" It is used to uniform serrations. " It has a
control
but also from veins andbleeding, only from arteries triangularratchet
not and
expansion
points are caught, they capillaries.
are
Once the bleeding at the tip, where
applied. coagulated ligature is serrations
or
sent.
are pre
" The curved
artery is commonlyused (Fig. " It can be used to
hold
" The smaller 68.1B).
version
(Fig. 68.1A). This is
of this is called tough structures such
mosquito forceps as fascia, aponeurosis,
extremely useful
harelip, cleft palate or other plastic surgery in repair of etc.
tions. opera " Even though it can
" It is also
available as straight artery which is used to cause trauma, because
hold the stay sutures (Fig. 68.1C). of its better grip, it
can be used to hold Fig. 68.2: Allis
the duodenumn for forceps
Examinatio
duodenal closure during gastrectomy.
KOCHER'S FORCEPS
(Fig. 68.3 and Key Box 68.1)
This is similar to an artery Voce
is available as curved and forceps with serrations. It
" There is a sharp straight. Viva
tooth at the tip of the
Hence, it has a better grip. instrument. V"
" Kocher's forceps can be
used to hold tough structures
like aponeurosis, fascia, etc.
A During thyroidectomy, it can be used to hold the strap Section
B
muscles for dividing them.
Figs 68.1A to C: (A) Mosquito forceps; (B) Curved artery " Theodor Kocher,a Swiss surgeon, got the
lorceps; (C) Straight artery for his contribution to thyroid Nobel prize
forceps surgery.
1245
 1246 Manipal Manual of Surgery

T Key Box 68.1

Remember
o Kocher's forceps
o Kocher's test
o Kocher's collar incision for
thyroidectomy
oKocher's sign-eyelidphenomenon in hyperthyroidism
staring and frightened look
o Kocher's thyroid dissector
o Kocher's vein
o Kocher's subcostal incision
o Kocher's gland holding forceps

SINUS FORCEPS (Fig. 68.4)

" This is like an artery forceps which has No ratchet. Fig. 68.3: Kocher's forceps Fig. 68.4: Sinus forceps
Serrations are confined to the tip so as to hold the
wallof an abscess cavity, for biopsy.
" In Hilton's method of drainage of an abscess, once
the incision is made, the sinus forceps is thrust into
the abscess cavity and by opening the blades in all
directions, the loculi are broken. To facilitate free
opening of the blades, sinus forceps has no ratchet.
SWAB HOLDING FORCEPS (Fig. 68.5)
" This has a ratchet and two long blades
Operating end is rounded with serrations
It is used to hold the swab (gauze pieces) to prepare
the parts with antiseptic agents at the time of surgery.
" This instrument can also be used as a blunt 'dissector'
with the swab,while dissecting at a depth,e.g. lumbar
sympathectomy, vagotomy. Fig.68.5: Swab holding forceps Fig. 68.6: Babcock's forceps
BABCOCKS FORCEPS (Fig. 68.6)
" An instrument with a ratchet and a triangular
expansion with fenestrations at the operating end. It
does not have any teeth. Thus, it is used to hold
Examination
intestines during anastomosis or resection.
This instrument can also be used to hold many other
structures such as thyroid gland, mesoappendix,
uterine tubes,etc.

Voce LANE'S FORCEPS (Fig. 68.7)

" This is similar to Babcock's forceps but the tip is more
Viva broad, expanded with a bigger opening.
" It isused to hold the appendix
" " However, it does not seem to have any additional
VI advantage when compared to Babcock's forceps.
sc0ssOrS
SectionDISSECTING SCISSORS Fig. 68.7: Lane's forceps Fig. 68.8: Mayo's
surgical
" This is also called Mayo's scissors (Fig. 68.8 and This is used to dissect tissue planesduring
Key Box 68.2). importantstructures.
operations and to cut or divide
" Itdoes not have ratchet and operating end is sharp " It ispopularly called tissue scissorS.
 m Key bo 247
Remenber
o Mavo's heouhaphy

STRAIGHT
lt is used SCISSORS (Fig. 68.9)
to cut he
suture-cutlting [Link] or knots. Hence, called
DISSECTING
. This is a FORCEPS (Fig. 68.I0)
toothed forceps. It is also
toothed forceps.
. available as non
Dissecting forceps
good 'tool' for with dissecting
majority of surgeries. to develop ascissors
a makes
surgeon tissue plane in
. The forceps is very Flg. 68.9: Straignt
useful to 'pick' SCisSOrs Fig. 68.10:. Discrg acoCs
such as individuallayers
serosa, seromuscular layers,
during anastomosis. mucosa, etc.
NEEDLE HOLDER (Fig. 68.11)
. This is a long
operating end. instrument with a ratchet at non
" The
operating end has two small blades with
serrations.
" The
instrument is used to
which are used to suture thehold the curved needles
eps Afirm grip is parts.
essential to apply proper sutures.
SCALPEL WITH BLADE (Fig. 68.12)
" This is
This is popularly
used to
called surgeon's knife.
incise the skin and
tissue. subcutaneous
Due to the sharp nature, it Fig. 68.11: Needle holder
major vascular pedicle once can be used to divide a
Fig. 68.12: Scapei w
Dicce
ligatures are applied.
CHEATLES FORCEPS (Fig. 68.13) Exorifatio
It is a long
"The instrument having a curved shaft
" It is handle has no lock
This kept dipped in antiseptic solutions
" t Voce
Such instrument
is
used to pick up sterilised articles
as
sponges,to the pieces or other instruments
and to transfer gauze Vva
instrument trolley. I"
jcal
DEAVER
"
This is RETRACTOR (Flg. 68.14)
"I popularly called Deaver liver retractor Section
ses. has along
can be blade and operating end is curved
used to retract the liver during vagotonuy,
chol ecystectomy or gastrectomy, etc. Flg. 68.13: Cheatles toiceps Flg. 68.14: Deaver retroctor
 1240
" Since it has ong bldes il can u dto rh the
kidnev upwards, duing mbat snathetomv o
to retrat the rinay hladdeuing sCIV) he
roum,

MORRIS RETRACTOR (HO 68 15)

" This s a long instnument with broad opeating: end
" This is Usi to retract the abdominal wall, one the
peritoneum is opcncd.
" Howcvet, if a sclt-retaining etactor is ut towiden
the lapaotom1 wOund, the ue of Mois retractor
gcts limiti

cZERNY RETRACTOR (F19 68 16)

" This Is adouhle-hooki retractor on one side and a
single bladc on thc other sidc. Fig. 68.15: Moris retractor Fig. 68.16: Crery tac
" This is a superficial retractor, can be used to retract
lavers of the abdominal wall, muscles, etc. Thus,
during ajpendirtomv, hemiorrhaphy or thyroidec
tomr, this instrument is Verv useful.

LANGENBECK RETRACTOR (Fig. 68.17)

" This instrument has onlv one blade
" The uses of this are similar to that of Czerny's
retractor.

MOYNIHAN'S STRAIGHT OCCLUSION CAMP (Fig. 68.18)

" This is a long instrument with a ratchet. The operating
endhas two long blades with serrations in the line of
blades.
This instrument is used to occlude the intestinal
lumen to prevent spillage of intestinal contents
during intestinal resection or intestinal anastomosis.
" This does not interfere with the vascularity of the Flg. 68.17: Langenbeck Fig. 68. 18: Moyniher i
intestine. tetracto Occusion ciamp

Examination
PAYR'S CRUSHING CLAMP (Fig. 68.19)
This is a heavy instrument withdouble lever system,
because of which it has a better grip
" The twoshort blades have uniform serrations
Voce During gastrectomy, when portion of the stomach is
excised, this instrument is applied on the stonach side
Viva so that the stomach with this instrument is excised.

V. DESJARDIN'S CHOLEDOCHOLITHOTOMY FORCEPS

(Fig. 68.20)
Section" This is a long curved instrument with no ratchet
" The operating end is expanded with fenestrations
" The tip is blunt Desjardins
68.20:
. It is used toextract stones from common bile duct. Flg. 68.19: Payr's crushing Flg.
Itcan also be used to extract stones from the ureter. clamp forceps
 Since there is no ratchet, free Instrumnents
the stones do not get
crushed. opening is possible, and During venesection or cut
1249
BAKE'S DILATOR (Fig. be down, the silk suture can
This is a long 68.21) andthreaded
it is tied. within the eye, passed
round the vein
" Itvarious
has a
[Link]
instrument available in TROCAR AND CANNULA (Fig.
handle, long
Once common bile body and the tip is " This has two parts.
The
68.24)
duct
" dilator
is
passage
exploration [Link],
The free passed, to assess for any is
distal
and
this " It is
inner
outer blunt part is
used drain
to
sharp part is the trocar
cannula.
indicate that
of
Bake's obstruction.
there is no distaldilators of different sizes Once hydrocoele hydrocoele fluid.
to be trocar and cannula,sacthe
is
delivered,
confirmed by [Link] (however,
it is
trocar removedpunctured with
KOCHER' S THYROID cholangio gram) drained.
Make sure that trocar and
and the fluid

has a long DISSECTOR (Fig. 68.22) deeper cannula

. This wise injury to the should match, other
and blunt with handle and the HUMBY'S KNIFE
structures (testis)can occur.
Afew an
opening. operating end is small "
(Fig. 68.25)
,This wasloused
ngi tutodidissect
n al This
serrations are present at Wheninstrument
in use, a
has a handle and a
long sheath.
This the upper pole of thyroidthe [Link] disposable blade
instrumernt
. isthmus the thyroid
of can also be used to gland.
dissect the
also instrument is
grafting knife.
can be
called skin used to take skin [Link] to it.
Hence, it is
silk thread can be gland from the " To
facilitate
the fed into the trachea. removed,
the exact
there is a screwthickness
. Withvascular
of the skin to
pedicle or [Link] so as to ligate which, at the be
the prior operating
adjustment should be done.
instrumentavailability of end, with
is not in the
right-angled
routine use nowadays. forceps, "
this MYER' S METAL STRPPER (Fig. 68.26)
This is a long
ANEURYSM NEEDLE (Fig. 68.23) metalic chain or a stripper
varicosea vein surgery.
"It is a long " Ithas used in
end. instrument with an eye at the end which handle which is
T-shaped and the
enters the vein.
It is called operating end comes out of the cut end of is blunt.'advancing'
This Once this
aneurysm needle because was used to " sized head is
ligate the feeding the vein, a
today, this arteryis in an aneurysm. With gentle forceconnected to it. medium
instrument of limited use. However the varicose vein can(traction) exerted on the handle,
be stripped.
Hence, is also called vein
it
stripper

Examina

VOce
Viva

"
VI
. Sectio
68,21: Boke's Fig. 68.22:
Kocher's Fig..68.23:Aneurysm
thyroid dissector Fig. 68.24: Trocar Fig. 68.25: Flg. 68.26: Myer's metal
needle and cannula Humby's knife stripper
 Surgery
Manipal Manual of
1250

SELF-RETAINING RETRACTOR (Fig. 68.27)

withtwo blades.
" It isa strong, heavy instrument,
Hence,
Thisis usedto spread the laparotomy wound.
it is called self-retaining retractor.

Flg. 68.29: Proctoscope

" Proctoscope is used to diagnose haemorrhoids

carcinomarectum or rectal ulcers, etc. Biopsy can be
taken with a biopsy forceps in nonhealing ulcers of
the rectum. Haemorrhoids can be injected and pelvic
abscess can be drained into the rectum with the hole
of a proctoscope.
Fig. 68.27: Self-retaining retractor
LISTER'S METAL DILATOR (LISTER'S BOUGIE)
RIB SPREADER (Fig. 68.28) This is a long instrument curved at the tip. Its dia
" This is also a strong heavy instrument with
two long meter is written near the handle. It is availab]e in
blades. various diameters. The difference between the two
Once an incision isdeepened through the
intercostal numbers is 3. The maximum size of the Lister's dilator
spreader is
spaces and the pleura is opened, the rib the is 9/12 (Fig. 68.30).
used and by rotating the latch handle,
ribs are The tip isolive-pointed and the end of the handle is
round. The minimum and maximum diameter of the
spread apart.
instrument is written on the handle. The other type
of bougie is Glutton's bougie with a plain tip and the
end of the handle is trapezoid. The maximum size of
Gluttons bougie is 24/28 and difference between the
two numbers is 4.

MALE METALLIC CATHETER (Fig. 68.31A)

cases of
These catheters are used to drain urine in
retention of urine when rubber catheter fails.
is curved because the
" Itis a long instrument which
male urethra is long and curved.
Fig. 68.28: Rib spreader end which are situated
" Ithas two eyes at the distal the instrument
Examination
PROCTOSCOPE (Fig. 68.29) laterally and at different levels so that
does not becomne weak at that spot.
" This is an instrument used to visualise the rectumn be lett n
Once the urine is drained, the catheter can rings
and the anal canal. through the two
" It has an outer sheath with the handle (A).
place by passing athreadend and fixing them to
Voce present at the proximal
An inner blunt part is called obturator (B). patient's thigh.
" Before introducing the proctoscope one must make the urethra
Viva passage, injury ttois not used
Due to the fear of false pa
sure that obturator and the outer sheath must match. and introducing infection, this catheter suprapubic
Lubricate the instrument well before introducing. trocar
V" nowadays. It is replaced by
In painful conditions such as fissure in ano, procto cystostomy.
scopy is contraindicated.
Section" Once rectal examination is done, proctoscope is held FEMALE METALLIC CATHETER (Fig. 68.31B)
firmly with the left hand (buttocks separated), the
obturator is supported by the right hand. The " Used to drain urine in females because the
instrument
instrument is slowly introduced inside. The obturator This is a short and straight
is removed and rectum is visualised using light source. urethra is short and straight in females.
 1251

hoicands, be
cers of
nepelhelvicp
Fig. 68.30: Lister's Fig. 68.31A: Male
dilator Fig. 68.31B: Femnale
metallic catheter Fig. 68.32: Towel clip
metallic catheter Fig. 68.33: Right
ts dia
" It has angled forceps
ble in multiple holes at the tip
"
e two Indications for usage of this
dilator because acute retention of urinecatheter are very rare
is rare in females and
even if it occurs, a red rubber
dle is " It is used to empty catheter can be passed.
of the
bladder before vaginal hysterec
tomy and other gynaecologic
type surgeries.
Emptying the bladder is mandatory
ad the gynaecological before any
ize of examination
of a patient.
en the TOWEL CLIP (Fig. 68.32)
This instrument has a ratchet and
is sharp. the operating end Fig. 68.34: Hudson's brace and the burr
" This is
esof
available in different sizes. CRICOID HOOK (Fig. 68.35)
Once the part is cleaned and draped the " This has a broad handle and a
to hold the towels in place.
clips are used thin
shaft with a hook
the at the operating end.
" This is used to
RIGHT-ANGLED FORCEPS: stabilise the trachea by hooking the
ated LAHEY'S FORCEPS cricoid cartilage 'up.
" This is a long " This step is essential in children
nent instrument with right angle at the very superficial and can get injuredwherein veins are
operating end (Fig. 68.33). easily when child Examinati
This instrument is moves the head and neck. By
tin
extremely useful in ligating the
major vascular pedicles, e.g. it is easy to incise the stabilising trachea,
the
superior thyroid vessels. trachea, without injuring the

hra
to

pediLumbarcle-veins:
"Cystic artery: thyroCholecystectomy
idectomy. TRACHEAL DILATOR (Fig. 68.36) Voce
Lumbar sympathectomy .
This is an instrument with no
ratchet at the non Viva
HUDSON'S BRACE AND THE BURR (Fig. 68.34) operating end.
" The operating end is blunt and curved.
This is a
(dril ). heavy
instrument with abrace and the burr " The peculiarity of this
instrument is that when the VI
handle is opened, operating end is closed and when
S2S used to create openings into the cranium so the handle is closed, operating end is Section
"
as to get an
access to the structures within. Tracheal dilator is used in the opened.
h
Thus once a burr' is made, drainage of blood, fluid
Of pus can be
period, when the tube has to be changed due to post-tracheostomy
done. blockage. In such situations, once the tube is
removed,
 1252 Manipal Manual of Sugery

Fig. 68.35: Cricoid hook Hg. 68.36: Trachealdilator Fig. 68.37: ForgUsson's Fig. 68.38: Bone nibbler
amputatlon saw

tracheal dilator is introduced, the opening in trachea DEBAKEY FORCEPS (BAYONET STYLE)
is kept open, and the new tube is introduced. (Fig. 68.41)
However, one the track is formed, tracheal dilator They are
typically large-some examples are
of 12 inches (36 cm) long, and have adistinct upwards
need not be used.
coarsely
FERGUSSON'S AMPUTATION SAW (Fig. 68.37) ribbed grip panel, as opposed to the finer ribbing on
most other tissue forceps, a type of atraumatic tissue
Amputation saw has teeth on its cutting edge to facilitate
cutting through the bone and is of different sizes. They forceps.
are manufactured with one- or two-sided cutting edge Uses: In vascular procedures to avoid tissue damaze
for limb amputations. during manipulation. Less traumatic manipulation of
Uses: In lower limb, amputations commonly-above tissue and used during suturing.
knee (AK) amputation and below knee (BK) amputation.
BONE NIBBLER (Fig. 68.38)
It is also called double action bone nibbler, identified
by long handle and small jaws, top jaw is used for
cutting and lower jaw is used to hold the tissue firmly.
Uses: To make cut end of the bone smooth after
amputation rib cutting and toenlarge burr hole.
Examination
BONE FILE/RASPATORY (Fig. 68.39)
One side of the raspatory is used to hold as a handle,
while its other side has sharp projections with both fine
and coarse teeth on both sides with a flat blade.
Voce Uses:Blunt separation of the periosteum and connective
tissue from the surface of the bone, smoothening of sharp
Viva bony edges after amputation and before fixing fractures.
" VOLKMANN CURETTE (Fig. 68.40)
V The edges of the distal spoon-shaped part of this
Sectioninstrument are sharp which make it possible to remove
the tissues.
Uses: Scoop the granulationtissue, toclean the base of 0ebakey
the infected wound, and to remove the infected bone in 68.41:
Flg. 68.39: Bone Flg..68.40: Volkmann Fig.
the case of osteomyelitis. file Curette
forceps
 Istumont,

-ADSON LAMINECTOMY RETRACTOR

CKMAN.

hinged blades vith 4 x 4

prongs, an adjustable
has
evelams
n la ratehetto hold tissue aart
and.
in roccdures involving deep tissuca
ucs:. Retraction
Jaminctomy for spinalsurReries.
lke
RETRACTOR (Fig. 68 43)
pIBRON MALLEABLE
(manual) may be bent
malleable or riblbonretractor
o various shapes.
case to keep the visceta
Iscs: Itis used atthe end oftheand is also ud to retract
awavduring the fascialclosure
dec wounds.
68.44)
THÆ HARMONIC SCALPEL (Fig. *t
been
a new device that hasIt is a oftca: ig 54 44
The harmonic scalpel isduring last decade. fig 68 43 Mlots
the
introduced tosurgery mechanical energy to
devie that uses high-frequencysame time.
the
cut andcoagulate tissues at to cut tissues while
technology
It uses ultrasound the cut. (More
simultaneously sealing the edges of
details on page 1310).
scalpel employ a rigid
Active tips of the harmonic
which the vibrating energy
active lower blade through
movable upper jaw is used to
is transnmitted. The against the lower blade, thus
compress the vessel vibrationalenergy. Fig 4.45. cCKA [Link]
allowing transfer of the electrosurgery
similar to an
The instrument is open and laparoscopic a mor pr a wrK
instrument andcan be used in itallcan cut through thicker It mmaks poasble to pertorm t l ere
in that sile oi the burreu sfa
Surgenies, but superior ay offer and thewhenhfOnikt ia fqusfed c he Derse
tissue, creates lesstoxic sungical smoke and useful
duringa laparoscopic surgery XLV ( r e n t
greater precisionespecially Uses: Ihyrot surgery when c e getee
Laryngeal nerve) reurosurgery ue pua! ut
BIPOLAR CAUTERY (Fig. 68.45)
electric current is passing betwen the two ALLISONS LUNG RETRACIOR Fg sd 41
When the we call itthe biolardiathermy/
parts of the instrument,
forceps).
cautery (eg. bipolar
othet eat
It d
Uses: fot tetraK t i \ o the lutg n thuNUUNy

ale ot daJge the lung nt the lug c

brtwen the wiues.

GIGLI SAW (Fig od 47)

espatd

Uses: Fe be uttug ut amputstlw SurgrwY RNlat

68.42: BucNIan Aan kawv y lytxk dnpatatis cVutwdy

 Section VI " Viva Voce Examination
Allison's
Iung68.46:
retractor Fig. 1254
"CUFFED " " METAL Uses: andtowel JOLL'
It S
cuffOnce Thi [Link]
s reintroduced.
tracheostomy cleanedand If tothe Once This tube. This
twhaso is
thekeep can a
is is neck, TRACHEOSTOMY has To clip THYROID
self-retaining
th e
TRACHEOSTOMY
inflated the made tracheostomy tube the retract belike
tube eis passed
i tube no adjusted
tube cuff. tubes,
by is
of blocked, is skin forcepsRETRACTOR Fig.
polyvinyl
introduced introduced,
throughin retractor, 68.48:
using place. the flaps using
tubes the on
TUBE inner TUBE Joll's
3-chloride.
5 inner th e
during screw both
thyroid a Fig.
are the (Fig. which (Fig.
ml
within (Fig. long retractor
sides 68.47:
of useful tubeopening tape 68.49) in 68.48)
air. 68.50)
It and is
the isa can is between. to held Gigli
as andpassed the hold
trachea,single permanent be outer surgery. by saw
removed, tied the the Manipal
around
tube. so snort flaps two
the as Manual
Thisis" empyema
MOUSSEAU thoracis. introducerliver MALECOT'
as
bladder
self-retaining and This S " " CORRUGATED " "tracheostomy
" tu68.49:
beMetal
Fig.
operable with feeding period. After
to stops Thus, freely amountsides. ItAlternatively,
outside.
expected. of
cholecystectomy, is
betrachealthe havecases,
tracheal aspiration If The
Surgery
abscess. has is prevent made done this
made laparotomy to cuff
Ryle'scalled
also after a draining. it Whenever
bethe tube
BARBIN'gastrostomy
S leftand widCATHETER
e is of to
cases transvesical of residual used Thisblood of ensure dilator removed. syndrome tube prevents

D
tube catheter. It red RED is
is red
diameter. drain
opening
of MB cavityandin Usually endotracheal blocked,
has
carcinoma like TUBE straightened rubber. for [Link] [Link]
patency and
(Fig. peritonitis, loss a leakage Fig.
tube. prostatectomy tube. IThis abscess The
is major Otherwise, to
thyroidectomy, is
a (Mendelson' it s
(Fig. It 68.52) it used or be 68.50:
attachment. It
68.53)
is can
It is is It takes drain anastomotic surgery
so has
It
DRAIN
intubationof
new kept cleaned is
of
used I used has an
oesophagus
funnel-shaped
a also
be to the
brought with
flower-shaped to the
in
these about is that
corrugations the tubeopen
(Fig. airway. the
emergency.
ai
and
r Cuffed

It drains removed fluid is 68.51) with tube and

is
used can or
dr a in outside. drain postoperative 3-5
gastrectomy, syndrome). tracheostomy
tois help can
leakage done, may
introduced.
the
mucus
is
prevents
are days. after
pal iate used
in tube drai
tourbe
n in ar y
used isa an end It
anoebiofc
used
it
escape some
is
both
on need removed.
hel p plugs In
such acid
 e 1

urethritis
urine
ishe RED "This Before "[Link] This "
FOLEY'
(Figs S drain
rubberred 68.51:
Corugated Fig.
peritonitis.
and also saline. theusing After catheter popular growth,
tube With wall. Once drawn is
which
RUBBER
s controls usage, 68.54A sufficient a dysphagia. brought
used be
introducing is is
if assessed inflating is
SELF-RETAINING
made including the the
it used is a is in
ed, CATHETER is to Inflated it in bulb, and
and and tube in
is it availability the byout It
leftdrain bleeding removed toThus, the of not
considering distance Malecot's
catheter
drain by thecapacitylatex B) stomach, pulling
is is
long urinary preferred. its below through 68.52:
Fig.
bulb the free stitched
it urine (Fig. bulb, with migration,
ved. is n peritoneal
afterself-retaining.
becomes After
catheter, URINARY
and
the
compresses by bladder, flow of the
the 68.55) one of
silicon discomfort is after the
mporarily. prostatectomy. deflating which
laser level other to
urinary of stitched mouth the
mnust doinga
theurine. the of end
cavity not [Link] coagulation growth, Ryle's Barbin's
tube
Mousseau
68.53:Fig.
It the th e bulb make is MB and
bladder.
is in written caused gastrostomy. to of
prostatic as bulb.
can It the the
not It is At tube tube
it
in inflated urethra. sure stomach itRyle's is
self- a causes biliary atthe is
Once is byof cut tube slowlywhich
bed that the tip, not the the Instruments
at
" " NASOGASTRIC " catheterwherebecause
than
retaining catheter
68.54A:
FoleyFig.
ients It It Ryle'Ryle'
intestinal s tube.
s agastric
In Usually toentersthe When
stomach. tube
up aspirating
gastric
gastriumor
auscultating 5-10
stomach,
confirmed
pushing by
ducing
withinthe lead gastricof This
is is volvulus dilatation. 2nd this Foley
also used to shots. is Foley's
tube mark. thlset having
the ml also may of
used in juice. tubetube. catheter.
availability
catheter.
or it tube its
obstruction is of called be
ically tothe used is Life-saving of passed
3 It inairposition Afterthere TUBE/RYLE' At S catheterused.
the mark, marks. is the is
provide
diagnosis passed a the Hence,
stomach, long and intro are end naso Not bulb Fig.
Distended
68.54B:
to up it epi of
il decompress or is cannot Foley's
[Link] pyloric use TUBE routinely
in
of of Fig. cases
GI it be
nutrition stenosis. impossible is Ryle's 68.56: (Fig. catheter.
haemorrhage. passed, of
the 68.56) stricture used
stomach tube Ryle's It
to catheter
rubber
Red Fig.
68.55:
is rednowadays is
comatose to in tube urethra,more
rubber
as pass acute
in
stiff 1255

Section Vi " Viva Voce Examination

 Manipal Manual of Surgery
1256

T-TUBE (KEHR'S)
" This is a flexible tube made
of latex with a long vertical
limb and a short horizontal
limb.
" Whenever the common bile
duct (CBD) is incised, it is
sutured after inserting the
T-tube. The short horizontal
limb is placed vertically
within the common bile
duct after making2-3 holes
within. Some surgeons sl1t triple lurmen
open the entire length of the Fig. 68.57: T-tube (Kehr's) Fig.68.58: Sengstaken-Blakemore double balloon
short limb. tube
exterior from the most
The long limb is brought to the duct and " It should be deflated for a fewW minutes after 24 hours.
dependent part of the common bile Sengstaken tube should be used by an experienced
connected to a sterile container.
due physician. Oesophageal secretions and saliva cannot
Presence of the T-tube may prevent peritonitis be aspirated while using this tube, and if gastric
stones blocking
to biliary leakage in cases of residual balloon is deflated suddenly, it slides up and causes
the lower end of the CBD. choking. The oesophageal balloon should be imme
diately deflated in such situations.
REMOVAL OF THE TUBE Modification of Sengstaken tube is called Minnesota
tube or 4 lumen tube. It has 4 lumens. The 1st to
About7-10days later, a T-tube cholangiography is done
and the T-tube is removed with a gentle pull, provided inflate oesophageal balloon, the 2nd to inflate gastric
balloon, the 3rd to aspirate like a Ryle's tube, and the
following criteria are fulfilled.
4th lumen is used to aspirate oesophageal secretions.
1. The dye flows freely into the duodenum. If there is any difficulty in breathing while using
Minnesota tube, bulb should be
2. No filling defects in the CBD. Sengstaken tube or
deflated or tube should be cut.
3. After clamping the tube for 24 hours, there is no
abdominal pain or fever.
SUTURING NEEDLES (Fig. 68.59)
4. Patient ispassing normal coloured stools.
Once the tube is withdrawn, some amount of biliary Traumatic
leak may persist for 2-3 days and it stops by itself " Round body needle is an eyed needle. These are used
provided there is no distal obstruction. tendons, vessels,
Examination to suture soft tissues, muscles,
intestines, etc.
SENGSTAKEN-BLAKEMORE DOUBLE BALLOON TRIPLE
LUMEN TUBE (Fig, 68.58) Needle chord length

Voce It is used in controlling bleeding oesophageal varices. Needle

It has 3 lumens and 2 balloons, a gastric balloon and Needle Swage
point
radius
Viva an oesophageal balloon.
Needle
Gastric balloon is inflated with about 200-250 ml diameter
Needle
" of air and oesophageal balloon is inflated with about body
Vi 40-60 ml of air. It is pulled upwards so as to snugly
Section fit at the oesophagogastric junction and thus it acts
by internal tamponade.
Sengstaken tube should not be kept in place for more
than 48 hours because itcan cause pressure necrosis Needle length
of oesophagus. Fig. 68.59: Needle and parts
 Cutting nerdles a wd totipsnture lim and sme Noote chord length inear distance between tip and end
hugh stncues. Iheuting is limited tothe point of needle (eye)
sf the necdle whih tjers out to merge
smothly
intoa OundcrOss-se ion. DIheer 1sedinvaular Round hrndy needle Cutting needle
nastonnosis/suery. "tUntormly rrotyne neerlle "No uniform shape
. Reverse Cutting necde is u«el to sutute mucoperio
steum: It is Iriangular in Toag-seien Ita " Tip it taprrerl " Ssharp end has a
ctteta of triangular shape on
the cutting cdge is on he outer surface of the needle Crosseetinn
uraure. Advantage of reverse cuting is atrength " They searate the fisste They cu. penetrate.
nd increases the resistance to bending fhres nd trugh
csendles have an eye. he eve i wider than boy Gfretres
he edle, so issue Irauma is more "Ucd fo suture trssue fihres " ied fo suture fascia
rnusr les intesfines vessrls prnerrais, inea
Afraumatlc Neodlo alha and shin
. 1Ihesledles have n0 eye. Suture is attached to the
nodle ly a process Called swaging Tissue trauma is SUTURE MATERIALS (K BoA 68 31
less, and hence is Uscd insuturing vessels or tor
a small tear in the bowl, ete. This was first fepair ABSORBABLE
by Geoge Merson of England, hence most ofdevices these 1. Plain catgut (7-day catzut)
sutures are called Mersutures. These are disposable
ndles hence sharpness is not affected. " The wofd catgut is derived from kt gut,
which
. Necdles: They are the fneans the viol1n strings I: is the oidest utute
essential
for suturing the defects of skin/tools of a surgeon materal known
anastomosis, vascular anastomosis. fascia/intestinal " Catgut is derived from the submwOs of the sherp
Parts of the needle: Needle has three main parts intestines.
shank, body, point. The body of the nevdle is either " The plain catgut Lzsts tor 7-10 duys herce, ts
are minimal.
s
round, triangular or flattened.
They are made of stainless steel. " It can be used to put iat
fat).
stitches (subeutareos
Traumatic:Needles with eye, suture
into the eye. Needle holes in tissues material
are
loaded
larger that
" It isbiological, absorbable and
mootilament
suture material. Shevp's submucOsa ha a eh content of eiastx
tissue.
Types
2. Chromiccatgut (21-day catgut)
Round bodied, cutting, reverse cutting, taper cut, blunt. " When plain catgut i mied wth chtomc als,
" Round-bodied needles:
Uniformly round, gradually
taper to a point designed
chromic catgut is obtained.
to separate tissue fibres " The strength of the
rather than cut through them soft tissue; chtomic catgu! abou!
and cardiovascular surgery. Cutting needlesintestinal 15-23 days.
for suturing tough or dense tissue, e.g. skin,are used
fascia.
"Chromic catgut is widelv used in inlesnal iatio
" Reverse cutting in which the cutting anastomosis, closure of urinarv bladder,csue o alif
outside of the needle curvature. edge is on the common bile duct, gastrojejunostomy. etc.
Tn Key Box 633
Taper cut needle: It is a combination of round body nevdle Vae
(minimal trace) and penetration like acutting nevdle. Colour
Suture aterial
J Yellow Pla:n catgut
Parts of the needle: o Brown
VIva
Chromic catgu!
Lyeleyeless:Here you thread the suture material. o Violet
Vicvl
Junction of eye and body: Weakest oCreamy yellow Devon
o Creamy
Body: Straight/curved oBlue
POS Section
Prolene
Needle length: Circumferential o Black Sk
Tip: Pointed o White Cotun
 1258 Manipal Manual of SurgcIy

"Catgut is biological, absorbable, monofilanment " Since it is nonabsorbable, prolene can be

used
suture material.
" Chromic catgut is packed along with round body
abdominal closure, repair of
incisional hernia, etc. hernias, repairforof
needle. " It has high memory (recoiling tendency aftor
removal from the pocket) and hence
" The number 2-0 refers to the thickness of the suture.
are required. multiple knots
" Knotting property is good.
" The catgutis preserved in 70% alcohol and is kept 2. Sutupack
soft due to 5% glyerine. " It is a monofilament or multifilament polyamide
3. Vicryl (polyglactin) " Black in colour
" Thisis a copolymer of glycolide and lactide. " It is braided, uncoated and nonabsorbable
" It is a synthetic and absorbable suture. " Uses of sutupack are similar to prolene.
" Unlikecatgut, this is absorbed by hydrolysis. " Knotting property is not very good. Hence, it is
" Since the strength and reliability is more than mandatory to put 4-5 knots.
catgut, vicryl is being used more and more for 3. Mersilk
small intestinal and colonic anastomosis. It has
replaced catgut in suturing bile duct also. " This is nonabsorbable, braided silk, black in colour
" Being synthetic, tissue reaction is less than that of " It has been provided with a round body. This Can
chromic catgut. be used in ligating bleeding points or anastomosis,
" This has also replaced catgut while suturing etc.
Common bile duct.
4. Black silk
"Knotting property is good " This is a nonabsorbable suture material.
" Vicryl can be used in the presence of infection. " It is biological and derived from the cocoon of the
4. Dexon (polyglycolic acid) silkworm larva.
" Synthetic absorbable
" Braided
" It is braided, coated with wax to reduce capillary
action. Tissue reaction is much more with black
" Used like vicryl silk because it is a foreign protein.
5. PDS (polydioxanone suture) " In spite of this, it is widely used because of its easy
" Like vicryl availability and is cheap.
Costly "Knotting property is excellent.
" Creamy in colour 5. Cotton
NONABSORBABLE " White in colour
" Multifilamentinfection rate is high
1. Prolene " Nonabsorbable, cheap
" This is polypropylene and nonabsorbable.
Examination
" It is monofilament, artificial and uncoated. Does Note to students: For more details about the instruments. you
not harbour micro-organism. Hence, the chances may refer to Manipal Manual of Instruments.
of infection are less.

Voce

Viva
.
V
Section