1117
Instruments
Instruments
CHEATLE'S FORCEPS
t is used to pick sterilised articles like instruments and
arapes so that touching of the instruments is avoided
while transferring them. It is kept dipped in antiseptic
solutions. It does not have lock.
Fig. 32.5: Mayo's towel clip
Fig. 32.3: Cheatle's forceps.
(A)
SPONGE HOLDING FORCEPS (RAMPLEY's)
It has got fenestrated, serrated, flat distal end. It is used
to clean the operative field, to swab the cavities, to mop
the oozing area, to hold gallbladder and cervix during
surgeries, tor blunt dissections, as Ovum forceps.
(B)
(C)
Fig. 32.4: Sponge holding forceps. Fig. 32.6: Artery forceps (A) Straight
(B) Curved (C) Mosquito.
MAYO'S TOWEL CLIP (Fig. 32.5)
b. Medium sized artery forceps
fix drapes in operative field.
It is used to C. Large artery forceps.
fix Suction tubes, diathermy wires,
It is used to Based on shape-
cables in operative table.
laparoscopic a. Straight artery forceps.
fix ribs in flail chest.
It is used to b. Curved artery forceps.
ARTERY FORCEPS (HAEMOSTAT)
Features of Artery Forceps
Types: Distal blades have transverse serrations which are well
Based on size
apposed.
a. Small or mosquto artery forceps. Lock in the proximal part.
Anger is a short madness which often creates ife-long tragedy.
adg (Retd)
DR SHAHIDiMAJEED
MBBS, FCPS (Pak)
rofessor of `uyay
Maical CtegiLansksenu
Uses BABCOCK'S FORCEPS
To catch bleeding points Its distal part of distal blades are curved witha
To open the fascial planes in different surgeries fenestra in it which allow soft tissues to triangular
To pass a ligature
bulge
is non-traumatic with transverse serrations on it.
out. Tip
It has
To hold fasca, peritoneum, got a lock in the proximal part.
aponeurosis
To hold sutures
To drain an abscess like a sinus
To hold gauze as
forceps
peanut
RIGHT ANGLE FORCEPS
It is used to dissect pedicles and to pass ligatures.
KOCHER'S FORCEPS
It has got serrations in the distal blades and
tooth in the tip. apposing
It is used to hold
of the muscles.
pedicles, tough structures, cut ends Fig. 32.9: Babcock's forceps.
It is used to hold
gauze for blunt dissection, to hold It is used to hold any part of the bowel,
fallopian tubes,
resected bowel, to hold ribs
during rib resection. appendix, ureter, cord, etc
LANE'S TISSUE HOLDING FORCEPS
It hasgot thick, stout distal blades with oval fenestra in
each blade. It has got
apposing tooth in the tip. It has
got a lock in the proximal part.
Fig. 32.7: Kocher's forceps.
ALLIS' TIsSUE HOLDING FORCEPS
Here distal blades are not
apposing each other.
Tip has got teeth in each blade which are apposin8
It has got a lock on the
It is used to hold skin
proximal part. Fig. 32.10: Lane's tissue holding forceps.
flaps, fasciae, aponeurosis,
bladder wall. It is used to hold bulky and
tough structures, to hold
lymph nodes. It is also used as towel clip,
as
sponge
holding forceps
MORANT-BAKER'S APPENDIX HOLDING FORCEPSs
It is like Lane's
forceps but with apposing serrations
proximal the
to tooth. These serrations give a good grip
in mesoappendix while
holding appendix in appendicec-
tomy. Its use is replaced by Babcock's forceps (Fig. 32.11).
vOLKMANN'S RETRACTOR
Fig. 32.8: Allis' tissue holding forceps. It is used to retract fasciae in soles and palms.
1119
Instruments
MORRIS' RETRACTOR
double blade type.
or
type
blade
It may be single abdominal
wall.
retract
It is used to
retractor
32.15: Morris
Fig.
Fig. 32.11: Morant-Baker's appendix holding forceps.
DEAVER'S RETRACTOR
Fig. 32.12: Volkmann's retractor.
Retractors
Superficial retractors
Deep retractors Fig. 32.16: Deaver's retractor.
Self-retaining retractors I t is a retractor with a broad, gently curved blade.
Itis used to retract liver, spleen and other abdominal
LANGENBECK'S RETRACTOR
It has got a long handle and a small solid blade. It is used viscera.
It is atraumatic and gives adequate exposure of the
in hernia surgery or any superficial surgeries to retract
surgical field.
skin, fascia and aponeurosis, etc.
DOYEN'S RETRACTOR
It is used in pelvic surgeries.
Fig. 32.13: Langenbeck's retracto.
cZERNY'S RETRACTOR (HERNIA RETRACTOR)
This retractor has got thick, small blade on one side and Fig. 32.17: Doyen's retractor.
biflanged hook on the other side in opposite directions.
It is used in surgeries like hernia, laparotomy especially SELF-RETAINING RETRACTOR
during closure. It has
got different adjustable blades so as to retract
abdominal wall and tissues during
surgery (Balfour's
retractor).
Fig. 32.14: Czerny's retractor.
Fig. 32.18: Self-retaining retractor.
Surgery is easy to watch, difficult to do.
SRB's Manual
of Surgery
1120 Atraumatic needle
SINGLE HOOK RETRACTOR
retract skin. needle
It is used to Traumatic cutting type
hook retractor.
Fig. 32.19: Single
with eye
DISSECTING FORCEPS
Reverse cutting needle
NON-TOOTHED
PLAIN
delicate structures like peritoneum,
It is used to hold
tendons (Fig. 32.20).
vessels, bowel, nerves,
TOOTHED-DISSECTING FORCEPSs
Straight needle
structures.
It is used to hold skin and tough
Round-bodied needle
(A)
Fig. 32.21: Needles.
Round body needles are used in soft structures like
(B) peri toneum, muscle, vessel, nerves, tendons, bowel, soft
tissues.
Cutting needles are used to suture skin, aponeurosis
and tough structures.
Reverse cutting needle is used to suture muco-
(C)
periosteum.
Fig. 32.20: Dissecting forceps (A) Non-toothed
(B) and (C) Toothed. NEEDLE HOLDER
Smaller distal blades with criss-cross serrations often
SURGICAL NEEDLES
with a
groove in the middle are the features of a needle
Types holder.
Based the edge
on
a. Round body needle
b. Cutting needle
C. Reverse cutting needle
d. Taper cut needle
e.
Side-to-side flat-Hagedron needle
Based on curvature
a. Straight needle
b. Curved needle. Half circle;
5/8 circle, etc
Based on existence of
the eye
Atraumatic needle is
attached to the needleeyeless. Here suture material is Fig. 32.22: Needle holder.
material and by swaging. Size of the suture
that of needle is same It may be straight or curved. It may be available with
is less. Needle once used is and so tissue trauma
different sizes. While holding a needle in a needle holder
disposed of
(not reusable). one should get a good control and good grip. This is
Traumatic needle:It is
is wider eyed needle. Needle in the eye area
than the body of the achieved by placing the needle at the junction ofproximal
is more. needle and so tissue trauma 2/3 and distal 1/3. Needle holder should be held
These needles are
re-usable. between thumb and ring finger.
1121
Instruments
JOLL'S THYROID RETRACTOR
Itis a
self-retaining retractor specifically used for thyroid
surgeries.
Fig. 32.25: Payr's crushing clamp.
It crushes the bowel once applied. So before applying
it, line of resection of stomach/bowel should be assessed
properly. It is applied to the part which is removed.
Viability of the bowel is lost once it is applied.
It is used in gastrectomy and resection and
anastomosis of the bowel.
DESJARDIN'S CHOLEDOCHOLITHOTOMY FORCEPS
It has got long distal blades with smooth serrations and
fenestra in the tip. It does not have lock and so accidental
Fig. 32.23: Joll's thyroid retractor. damage of CBD mucosa or crushing of the CBD stone are
avoided.
MOYNIHAN'S OCCLUSION CLAMP
I t has got long distal
serrations.
blades with longitudinal
I t may be straight or curved.
I t is non-traumatic,
. I t occludes
non-crushing type.
lumen of
the bowel/stomach
and so
prevents spillage of the content of the bowel. Fig. 32.26: Desjardin's choledocholithotomy forceps
I t also occludes the vessels in the wall
of the bowel It is used for
and so
prevents bleeding during surgery. stones). choledocholithotomy (removal of CBD
.
It is used during anastomosis of the stomacn arnd
other parts of the bowel. BAKE'S DILATOR
It is long malleable metallic instrument with club
terminal end. at the
It is used to assess the
patency or block.
CBD, duodenal papilla for
Fig. 32.27: Bake's dilator.
SINUS FORCEPS (Lister's)
I t has got
straight,
tip. It does not havelonga lock.
blades with serrations in the
Fig. 32.24: Moynihan's occlusion clamp. It is used to drain
pus from abscess cavity
method). It is called as sinus (Hilton's
PAYR'S CRUSHING CLAMP (GASTRIC) forceps because it was
initially originated to pack the sinus cavities. It is
It is stout and heavy instrument with double lever in the traumaticC. less
handle. Sinus forceps has no lock;
blunt.
no
serrations; broad tip;
Surgery is always second best; if you can do
something else, its' better-John Kirklin
1122 SRB's Manual of Surgery
period, patient needs tracheostomy for further
ventilation).
Fig. 32.28: Lister's sinus forceps (A)
SCISSORS
Straight scissors Curved scissor s
VOLKMANN'S SCOOP
B Stitch cutting scissor
Fig. 32.29: Scissors
(B)
To scoop cavities, ulcer
bed, granulation tissues. Fig. 32.31: Tracheostomy tube
On either side different sized (B) Jackson's (A Fuller's
scoops are present. tracheostomy tube.
Indications for tracheostomy
I n head, neck and
. Tetanus
facial injuries
Fig. 32.30: Volkmann's scoop. .Tracheomalacia after thyroidectomy
.Laryngeal oedema/spasm
Major head and neck
surgeries
TRACHEOSTOMY TUBE operation, block dissection, etc. like commando's
Fuller'sbivalved tracheostomy tube:It
and innertube. Outertube hasgotouter tube
is easier. Inner tube is
is biflanged and so insertion DRAINS
longer with an opening on its A drain is
posterior [Link] tube can be removed and
a created channel which
allows
inserted easily whenever re-
collected, to come out after closure of the any fluid
Jackson's tracheostomy required.
tube: It has
main wound.
inner tube and outer got tube, Types
an obturator.
Red-rubber tracheostomy tube.
PVC tracheostomy tube. Corrugated
and
rubber drain: It drains
by capillary action
Modern tracheostomy tubes are made it
gravity. It is cheaper and technically easier. But
of plastic. allows soakage of
are soft, least irritant and They dressings and causes discomfort
cuff which makes it easier disposable. They have inflatable to the patient.
to
Cuff should be deflated at give
assisted ventilation. Tube drains:
regular
tracheal pressure necrosis (For assisted
intervals to prevent Malecot catheter can be used as
ventilation, a tube drain.
endotracheal, tube can be kept for 7 days. Beyond Penrose soft latex rubber tube.
that
Multiple perforated tubes.
1123
Instruments
(A)
(B)
Fig. 32.33: Suction drain used in thyroid surgery.
(C)
Fig. 32.32: Drains (A) Corrugated rubber drains,
(B) Multiple perforated drains, (C) Tube drain.
Advantages of tube drains
Quantity of fluid like bile, pus can be measured
It can be kept for longer time
Skin excoriation will not occur
Patient remains more comfortable
Infection rate is less
Removal is easier
Dye can be injected and cavity or communication
canbe assessed using C-ARM
Fig. 32.34: Romovac suction drain. Here suction is created
Closed suction tube drain by pressing the suction corrugation. There is a sharp metallic
system. introducer to pass the tube into the required area after
Glove drain.
puncturing the skin. It is used for thyroidectomy, mastectomy,
Wick drain is a
gauze drain to drain pus, discharge, radical dissection, wide excisions, flap surgeries, etc.
etc.
Sump drain: This is a type of drain where parallel air Classification of Drain Systems
vent prevents the adjacent soft tissues from being Open (static) drain: For example, corrugated drain,
sucked into the drain when negative pressure is penrose drain. Infection rate is higher.
applied. Closed siphon drain: Here drain is connected to a
sterile bag with or without one-way valve. It reduces
the infection.
Advantages of sump drain
No drain blockade Closed suction drain: Here negative pressure of-100
Resists collapse of the structure when suction is to-500 mmHg is used to create vacuum to drain the
secretions.
applied. Sump suction drain: Here negative suction with a
Uses of siump drain parallel air-vent is used to prevent the adjacent soft
tissues being sucked into the lumen of the drain.
Collection of irritant discharges (entero-
Under water seal drain to drain pleural space.
cutaneous fistula)
Collection of secretions having activated enzymes Indications for drains
(high small bowel, pancreatic fistula) I n drainage of an abscess
Draining proximal stump in TEF with esophageal In bleeding surgical conditions like trauma, per-
atresia to prevent aspiration operative bleed
The postoperative treatment is as essential as the operation and the surgeon is as much responsible
forthe postoperative treatment as for the operation - Roscoe C Giles
SRB's Manual of Surgery
1126
It is made up of India rubber, 45 cm in length. There is
FLATUS TUBE
one opening in the tip and another on the side proximal
to the tip. (Urinary catheter like red rubber catheter has
O
no opening in the tip, only side opening is present). It
is used in sigmoid volvulus to decompress and derotate;
in paralytic ileus; in subacute intestinal obstruction. It is
passed per anal into the recto-sigmoid area. Proximal end
is connected to water container to observe the
quantity
of air bubble which signifies the amount of
gas getting
Fig. 32.43: Flatus tube deflated.