SURGICAL INSTRUMENTS

Basic instruments are essential to accomplish most types of general surgery. Each instrument can be placed into one of the four following basic categories: Retracting and Exposing Instruments - Used to hold back or retract organs or tissue to gain exposure to the operative site. Handheld retractors Self-retaining retractors Cutting and Dissecting Instruments - are sharp and are used to cut body tissue or surgical supplies. Scalpels Knives Scissors Bone cutters and Debulking tools Clamping and Occluding Instruments - are used to compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents. a. Hemostatic forceps b. Noncrushing vascular clamps Grasping and Holding Instruments - are used to hold tissue, drapes or sponges. Forceps Needle holders Bone holders SUTURES AND NEEDLES Terminologies: 1. Suture any materials used to sew, stitch or hold tissue together until healing occurs; medical device used to hold skin, internal organs, blood vessels, and all other tissues of the human body after they have been severed by injury or surgery. 2. Ligature commonly known as tie, is a material that is tied around a blood vessel to occlude the lumen. 3. Primary Suture line main layers of the tissue which must be stitched in closing an incision. 4. Stay or Tension Sutures sutures placed in an incision as a secondary measure of reinforcement where coughing or undue pressure or strain may cause the incision to separate. 5. Tensile Strength amount of tension of pull that strand will withstand before in breaks when knotted. 6. Suture Ligature a ligature which is threaded on a needle 7. Suture Tie suture with mosquito forcep 8. Atraumatic suture with needle 9. Nonatraumatic suture without needle Uses of a Suture: 1. To tie off a clamped vessels to prevent bleeding. 2. To approximate tissue until healing is complete. Types of Suture: 1. Absorbable Sterile strands made from collagen from healthy mammals or synthetic polymer Digested by body enzymes and absorbed by living tissues during the wound healing process. The most commonly used absorbable sutures are surgical gut (catgut) collagen and synthetic a. Surgical Gut or CatGut digested by enzymes and absorbed by tissues so that no permanent foreign body remains more absorbed on serous or mucous membranes absorbed slowly in subcutaneous fat collagen derived from the submucosa of sheep intestines or the serosa of beef intestines.

a. b.

a. b. c. d.

a. b. c.

Types of surgical gut

1. Plain gut
Untreated but chromic gut is treated to provide greater resistance to absorption. It is digested relatively quickly, loses tensile strength usually in 5-10 days because the collagen strands are untreated to resist absorption and digested within 70 days. used to ligate small vessels and to suture subcutaneous fat. It is natural yellowish tan in color or dyed blue or black. 2. Chromic treated in a chromium salt solution to resist absorption by the tissues used to ligate larger vessels. loses tensil strength in 14 21 days and is digested within 90 days Color is dark brown or dyed blue or black Chromic 1 all layers of uterus Chromic 4 face b. Collagen Sutures - Used primarily in ophthalmic surgery - Should be used immediately after removal from packet c. Synthetic Absorbable Polymers Polydiaxanone Suture (PDS) - Used in slow healing tissue such as the fascia; maybe used in the presence of infection; absorption is up to 90 days and is completed within 6 months Poliglecaprone 25 (Monocryl) - Most pliable of the monofilament synthetic sutures; indicated for soft tissue approximation and ligation, especially in general, gynecologic, urologic and plastic surgeries but not to be used in cardiovascular, neural and ophthalmic surgeries Polyglyconate (Maxon) - Indicated for the approximation of soft tissue except in cardiovascular, neural and ophthalmic tissues Polyglactin 910 (Vicryl) - For ophthalmic procedures (uncoated: violet); coated polyglactin allows for smooth passage through tissue and precise knot placement Polyglycolic Acid (Dexon) - Loses tensile strength more rapidly and absorbed significantly more slowly than polyglactin 910 - has a minimal absorption in 30 day 2. Nonabsorbable Sutures strands of natural or synthetic materials that resist digestive enzymes or absorption in living tissues; During healing process, suture mass becomes encapsulated and remain for years in tissues w/o any ill effects a. Surgical Silk Color is black or white Loses tensile strength when wet, thus, should not be moistened before use Not truly nonabsorbable: loses tensile strength in 1 year and disappears by 2 years Provides good support to wounds during early ambulation and promotes rapid healing than surgical gut Used in serosa of the gastrointestinal tract and to close uninfected fascia b. Surgical Nylon Produces minimal tissue reaction

 c.

Has a high tensile strength but loses it by 15% to 20% per year due to hydrolysis Used in all tissues that can be sutured by nonabsorbable material

Surgical Cotton One of the weakest the non-absorbable material, but gains tensile strength when wet. Therefore, moisten it before handling to the surgeon. Tensile strength is increased by 10% by moisture. Moisture prevents clinging to the surgeons gloves. May be used in most body tissue for ligating and suturing but it offers no advantages over silk.

The rate of absorption is influenced by: 1. Type of Tissue Surgical gut is absorbed much more rapidly in serous or mucous membrane and absorbed slowly in subcutaneous fat. 2. Condition of the Tissue It can be used in the presence of infection and even the knots are absorbed. However, absorption takes place much more rapidly in the presence of infection. 3. General Health Status of the patient Surgical gut may be absorbed more rapidly in undernourished or diseased tissue, but in old or debilitized or delibitated patients it may remain for a long time. Factors Influencing the Choice of the Types of Suture 1) Desired length of time the sutures are to remain in place. 2) Type of tissue to be sutured. Some tissue absorb suture faster than others. 3) Nutritional status of the patient. The absorbable suture will faster in a malnourished, older, anemic or obese patient. 4) Disease condition rate in increased when infection is present. Layer of Abdomen Skin Subcutaneous Fat Fascia Muscle Peritoneum Suture Vicryl 4 0, 3 -0 Polyn 3 0 Plain 2 0 Chromic 1 Chromic 1 Chromic 2-0 Atraumatic Needle Cutting (wide) Cutting Cutting Round (fine) Round

Methods of Suturing 1. Simple Continuous (Running Stitch): can be used to close multiple layers with one suture; tied only at the end of incision; used to close peritoneum, muscle, fascia, subcutaneous tissue 2. Simple Interrupted: individual stich is placed, tied and cut in succession from one suture (each stitch is taken and tied up separately) 3. Continuous Interlocking (Blanket): single stitch is passed in and out of the tissue layers and looped through the free end before the needle is passed through the tissue for another stitch. 4. Horizontal Mattress: stitches are placed parallel to wound edges 5. Vertical Mattress: used deep superficial bites, with each stitch crossing the wound at right angles for deep wounds 6. Purse String a continuous suture is placed around a lumen and tightened, drawstring fashion to close the lumen. This is used when inverting the stump of the appendix. 7. Subcuticular a continuous suture is placed beneath the epithelial layer of the skin in short lateral stitched. It leaves a minimal scar. 8. Traction may be used to retract a structure to the side of the operative field, out of the way. Suture Sizes Defined by the United States Pharmacopeia (U.S.P.) Sizes range from heavy 1-0 (largest) to very fine 12-0 (smallest) Sizes increase with each number above 1 and decreases with each 0 added. The more 0s added in the number, the smaller the strand Manner of Threading Sutures Certain lengths have been found to be advantageous for various types of stitching. A suture strand that is too long is difficult to handle. Excessive length offers greater opportunity for contamination of this strand as it can be dragged

across the operative field. If the suture strand is too short. It may slip from the eye of the needle or it may be difficult to knot. a. Single one length of suture is threaded on needle, one long end and one short end. The short end is 1/3 of the long one. b. Double both end of the suture is the same in length. Varieties of Ligature 1.Free tie 2.Tie on the carries or carrier tie 3.Tie on the spool, winder, or reels Points to Remember in Suture Technique There should be a suture routine in each operating room; an allowance must be made for changes according to the need soft the surgeon. Prepare ligatures first according to their use. Then prepare the others sutures in the order in which they will be used, in so far as possible. Be conservative and economical. Handle suture materials as little as possible. Know the size of the suture that is handed to the surgeon and keep a close eye on the surgery to anticipate the number and length of the additional suture the surgeon will used. Be ready with suture scissors or a clamp depending on whether the surgeon will cut or hold the suture with a clamp, after the suture is past. Checks each suture for knots before handling to the surgeon. A knot can destroy a line of an important anastomosis by widening the aperture through which the suture has passed. Hand the suture and holder to the surgeon in each functional position. The suture ends should be hanging at the back of the palm, completely free from the handle of the holder. Place strands in suture book with ends extended for enough for rapid extraction. Assessment of Suture Line Check the suture line if: Stitched too tight or too loose Too many or too few stitches Suture holes are not equidistant from the edges so that the bite is not even, or there is uneven spacing between sutures There is inversion or eversion of tissue edges The edges of tissues are overlapping and heaped on each other Removal of Sutures 1. Facial wounds 3 to 5 days 2. Scalp wounds 7 to 10 days 3. Limbs 10 to 14 days 4. Joints 14 days 5. Trunk 7 to 10 days Characteristics of a Good Needle Strong enough so it does not break easily Rigid enough to prevent excessive binding yet flexible enough to prevent breaking after binding. Sharp enough to penetrate tissue with minimal resistance, yet not stronger than the tissue it penetrates. Approximately the same diameter as the suture material it carries to minimize trauma in passage through tissue. Appropriate in shape and size for the type condition and accessibility of the tissue to be sutured. Free from corrosion and burns to prevent and tissue trauma. Classification of Needles 1. According to the Eye a. Regular eyed threaded like ordinary sewing needle b. Eyeless or swayed atraumatic, also known as dulex, atroloo c. French or Spring Eye there is slit from the end of the needle to the eye, through which is the suture is drawn to thread it. 2. According to Shape, of shaft, cutting or non-cutting a. Non-cutting These are rounded bodied and are use on tissue that offers a small amount of resistance to the needle as it passes thru.

 used to suture the viscera, peritoneum, muscle

b. Cutting These make a slight tear in tissue, and the suture tends to cut it a little more. Used for tough tissues that a round needle cannot well go through such as tendon, peritoneum, fascia, subcutaneous and skin. 3. According to Shaft or Body a. Straight used primarily for skin closure b. Curved used inside for quickly recovery of the point of needle. Needle Care during the Operation In order to keep or prevent losses of needle, one should always keep the suture book always closed. After handling a suture with needle to the surgeon, thread another one of the same kind immediately. Account for each used by the surgeon. Be certain of receiving the empty needle back before handling another to the surgeon. Needle Care After the Operation All needles (used, unused, broken) must be accounted for after each operation. After all the needles have been accounted for: Make sure that all needles have been removed from the suture hook before discarding into the soiled linen hamper. Points to Remember in Using Surgical Needles Thread needle from inside curve towards outside. Straight needles are not used on needle holders Select a needle strong enough and large enough for tissue in which it is to be used If the needle breaks, locate both pieces. To prevent needle, breakage, the needle holder should be placed approximately 1/3 of the distance from the eye. The needle should be near the end of the needle holder. Select a needle holder with appropriate size jaws for the size needle to be used. An extremely small needle requires a needle holder with very fine tipped jaw. Select an appropriate length needle holder for the area of the tissue to be sutured. When the surgeon works deep inside the abdomen, chest or pelvic cavity, a longer needle holder will be needed then on superficial areas