Introduction to Instrumentation

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

2. Grades of Instruments • 3 grades of instruments: • Surgical – highest possible quality instrument. • Stainless steel from Germany or U.S.A. only. • Most made from either 300 or 400 series stainless steel or Electroplated steel (chrome plated) • Few made from Vitallium (inert metal and very $$$$) • Vitallium: Trademark for a cobalt–chromium alloy used for surgical appliances and implants • Titanium Alloy (stronger than stainless, used for micro surgical instruments) • Most important – these instruments go through a process called Passivation: a process in which a chemical dip removes all debris and creates a layer of chromium oxide. This makes the instruments more resistant to corrosion and stains. • Floor Grade – medium/low level quality surgical instruments. • Have shiny finish. • Used to teach. • Not to be used in surgical set. • Disposable – low level quality surgical instruments. • These items are single use only! • Should NEVER be reprocessed. • Stamped “single use” on instrument.

3. Anatomy and ClassifyingInstruments • Jaws • Box lock • Shank • Ratchets • Finger ring

4. Anatomy

5. Five Basic Categories • There are 5 basic categories of surgical instruments: • Hand-held • Largest category of instruements. • Microsurgical • Most are hand-held but require special handling. • Ophthalmic, ENT (Ear, Nose and Throat) and Vascular instruments fall under this category. • Will not have Tungsten Carbide tips (to small) • Powered • Drills, saws, etc. • Endoscopic • Includes Ridged and Flexible Endoscopes, fiber optic light cables, cameras and MIS ( Minimally Invasive Surgery) instrumentation. • Laparoscopic • This category includes Robotic instruments. • Insulated and Non-insulated. • Typically very long, thin and ringed instruments.

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

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

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

9. Cutting Instruments Scissors • There are tissue, suture, wire, and dressing scissors. • Can have Tungsten Carbide tips • Very strong metal that helps tips stay sharper longer. • Black handled scissors are referred to as “Super Sharps”. • One tip can be serrated.

10. Basic Cutting/Dissecting Instruments (continued)

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

12. Basic Grasping/Holding Instruments (continued)

13. Basic Grasping/Holding Instruments (continued)

14. Basic Grasping/Holding Instruments Forceps • Do not have ratchets. • May have teeth, serrations, or smooth. • Vary in length and type. • Common examples: Adson, DeBakey, Russian, Gerald, Cushing Bayonet forceps.

15. Basic Grasping/Holding Instruments

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

17. Grasping and Holding InstrumentsBone Holding Clamps • Use to hold bone in place • Ratcheted and vary in type and size • Example are Lane, Kern, Lowman, and Lewin

18. Clamping/Occluding • Designed to occlude or constrict tissue • Vascular clamps are used in vascular and heart surgery • Hemostats are use to occlude vessels until ligated

19. Basic Clamping/Occluding Instruments

20. Basic Clamping/Occluding Instruments (continued) Kelly

21. Basic Clamping/Occluding Instruments (continued)

22. Retracting • Designed for exposure at the operative site • May be hand held or self retaining • Vary in size, length, and type • May be sharp or dull • May be malleable

23. Basic Retracting/Exposing Instruments Large Richardson or

24. Basic Retracting/Exposing Instruments (continued)

25. Basic Retracting/Exposing Instruments (continued)

26. Basic Retracting/Exposing Instruments (continued)

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

28. Dilating/Probing Instruments

29. Dilating • Used to gradually dilate an orifice to allow a larger instrument to be introduced or measurement of lumen diameter • Used in Endoscopy, GYN, GU (cysto), Vascular surgery

30. Dilating Continued… • Tapered at on end then increase in diameter • Cervical dilators are double ended • Urethral dilators are single ended • Esophageal dilators are the longest and most flexible

31. Suturing • Needle holders are used to hold needles for suturing • Vary in shape and size • Jaws have small serrations to hold needle in place • Similar in part structure to the hemostat • Can have Tungsten Carbide tips. • These can be replaced!

32. Needle Holders

33. Suctioning • Used in removing blood or body fluids from operative site to maintain surgeon visibility to perform surgical procedure • Disposable or non disposable • Type of suction based upon surgical site and procedure • Common suction tips are Yankauer, Poole, and Frasier

34. Basic Visualization Instruments

35. Visualization • Laparoscopic procedures require trocars, ports, cannulas for laparoscopic instrumentation access • Is it a retractor or a speculum? • Also for viewing called a speculum or specula (plural) • Think ear speculum when you visit physician and he/she does an ear exam • Ladies think GYN visit (it’s a Graves speculum they use)

36. Basic Visualization Instruments (continued)

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

38. Diagnostic Operative (channeled) Rigid Visualization: Direct (0°) Angled (30, 70, 120°) Semi-rigid Flexible Visualization: Panoramic Two Types of Flexible: Fiberoptic Visualization through eyepiece Connect to light source Videoscope Visualization on monitor Connect to light source and camera Endoscopes

39. Diagnostic Endoscopes • For observation • No operating channels

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

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

42. Roboticspages 103-105, 132 • Robotic instruments • Similar to laparoscopic instruments • Jaw design and length similar • Differences arise in handling and cleaning procedures • Da Vinci • Endo-Wrist instrumentation. • Multi-use instruments

43. Endo-Wristturn to page 104 • Have 5 main components: • Release levers (A) • Instrument shaft (B) • The wrist (C) • The tip or end reflector (D) • Instrument housing (E)

44. Summary • 3 grades of instruments • Anatomy and Classifying Instruments • 5 basic categories of surgical instruments • Classifications of surgical instruments • Cutting, Grasping and holding, Clamping, Retracting, Probing, Dilating, Suturing, Suctioning, Accessory • Scopes and Robotics

45. Instrument Care and Handling Minor and Major Trays

46. Micro Instrumentation • Small and delicate instruments • Used with a microscope • Made of Titanium instead of stainless steel (Much lighter yet strong) • Held with thumb and forefinger • Beaver blades are used for knife blade • Scissors and needle holders are spring loaded • Usually hand washed after case • Gas sterilized due to the delicate nature of instrumentation (may steam sterilize in separate load) • Tips can be bent very easy • Be very careful when handling and cleaning these instruments

47. Care and Handling • Must be handled with care • Very expensive • Inspection for function before and after surgery in essential • Do not place delicate instruments under heavier instruments • Micro instruments should be hand washed

48. Types of Instrument Trays • Varies from institution to institution • Some procedures require smaller special trays • These would have to be opened in addition to the primary instrument tray • Types of sets include: Laparotomy,OB/GYN,Ophthalmic, ENT, Plastics, Genitourinary, Orthopedics, Cardiac, Thoracic, Peripheral Vascular, and Neuro.

49. Laparotomy Sets • General abdominal procedures • May use major or minor tray • May also need: • Long Instrument tray • Balfour or Bookwalter retractor • Gastrointestinal tray • Gall Bladder tray

50. OB/GYN Instrumentation • Include D&C, Abd. Hysterectomy, Vag. Hysterectomy, Laparoscopic procedures, LAVH, and C-Sections. • Need: • Abd. Hysterectomy tray • Vag. Hysterectomy tray • C-Section tray • LAVH tray • Misc. Lap instruments