Introduction to Instrumentation

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

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Anatomy and ClassifyingInstruments

• Jaws
• Box lock
• Shank
• Ratchets
• Finger ring

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Anatomy
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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.

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Classifications

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

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Cutting

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

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Cutting InstrumentsScalpels

• Handles commonly come in s 3,4,7,and 9.

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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.

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Basic Cutting/Dissecting Instruments (continued)
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Grasping and Holding

• Designed to manipulate tissues.
• Use to dissect, suturing assistance, reduce, or
  stabilize.

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Basic Grasping/Holding Instruments (continued)
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Basic Grasping/Holding Instruments (continued)
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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.

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Basic Grasping/Holding Instruments
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Ratcheted Grasping and Holding Instruments

• Allis
• Babcock
• Kocher
• Lahey thyroid tenaculum

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Grasping and Holding Instruments Bone Holding
Clamps

• Use to hold bone in place
• Ratcheted and vary in type and size
• Example are Lane, Kern, Lowman, and Lewin

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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

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Basic Clamping/Occluding Instruments
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Basic Clamping/Occluding Instruments (continued)
Kelly
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Basic Clamping/Occluding Instruments (continued)
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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

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Basic Retracting/Exposing Instruments
Large Richardson or
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Basic Retracting/Exposing Instruments (continued)
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Basic Retracting/Exposing Instruments (continued)
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Basic Retracting/Exposing Instruments (continued)
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Probing

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

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Dilating/Probing Instruments
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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

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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

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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!

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Needle Holders
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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

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Basic Visualization Instruments
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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 (its a Graves speculum
  they use)

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Basic Visualization Instruments (continued)
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Accessory Instruments

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

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Endoscopes

• 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

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Diagnostic Endoscopes

• For observation
• No operating channels

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Operative Endoscopes

• Channeled irrigation, suction, insertion of
  biopsy forcep or needle, connection of accessory
  instruments such as cautery or laser

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Tools Required to Perform Minimally-Invasive
Surgery With an Endoscope
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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

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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)

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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

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Instrument Care and Handling Minor and Major
Trays
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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

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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

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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,Ophthalmi
  c, ENT, Plastics, Genitourinary, Orthopedics,
  Cardiac, Thoracic, Peripheral Vascular, and
  Neuro.

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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

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OB/GYN Instrumentation

• Include DC, 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

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Ophthalmic Instrumentation

• Eye procedures
• Need
• Conjunctival tray
• Muscle tray
• Cataract tray
• Cornea tray
• Globe and Orbit tray
• Ophthalmoscope
• Retinal Instruments

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ENT Instruments

• Use in Ears, Nose, and Throat surgery
• Trays for
• Myringotomy
• Tympanoplasty
• Nasal procedures
• Tracheotomy
• All other head and neck type procedures

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Plastic Instrumentation

• Covers cosmetic and reconstruction procedures
• Need delicate as well as larger instrumentation
• May include Reattachments
• Some small bone instruments may be needed
• Liposuction

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Genitourinary Instrumentation

• Includes kidney and prostate procedures
• Need
• Major tray.
• Kidney or flank tray.
• Vascular and a thorocotomy tray.
• Long Instrument tray.
• Prostatectomy
• Major tray.
• Prostatectomy tray.
• Long instrument tray
• Special trays for
• Pyeloplasty, ureteroplasty, tuboplasty, and
  vasectomy.

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Orthopedic Instrumentation

• Used for all bone and total joint procedures
• Universal bone
• Basic total joint tray
• Total tray
• Fracture systems
• Misc. bone holding instruments

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Cardiac Instrumentation

• Cardiac procedures
• Need instruments for
• Heart
• Great vessels
• Cardiopulmonary bypass
• Saphenous vein harvest or internal mammary artery
  dissection
• Coronary anastamosis
• Sternal saw and Sternal retractors
• Internal mammary artery retractor
• Valve sizers
• Valve instruments

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Thoracic Instrumentation

• Chest/Thoracic procedures.
• Need
• Major tray or cardiovascular tray
• Chest instrument tray
• Sternal saw available
• Self retaining chest retractors (Burford,
  Finochietto, or Tuffier)
• Thoracoscopy set if thoracoscopy
• Still need open instruments in case converts just
  like with laparoscopic cases

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Peripheral Vascular Instrumentation

• Vascular repairs and shunts
• AAA trays
• Major tray or Cardiovascular tray
• Self Retaining Retractor (Bookwalter or
  Omni-tract)
• Carotid tray
• AV fistula tray
• Specialty surgeon trays

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Neurosurgical Instrumentation

• Brain and Spine
• Need
• Brain
• Craniotomy tray
• Rhoton Instruments
• Micro scissors
• Farley or greenburg retractor
• Spine
• Spine trays
• Self retaining retractors
• Spine fixation trays

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Instrument Check List

• An inventory sheet with all instruments in that
  tray
• Used for counting
• Locate missing instruments or incomplete trays
• Tracking instruments out for repair