A Brief History of Surgical Instruments

The history of surgical instruments has an important place within the history of medicine, as well as

in the history of technology. Archaeologists have discovered primitive knives from as early as 10,000

B.C., and there is evidence of attempts to suture from as far back as 2500 B.C. Orthopedic surgery was a

very early concern. As far back as 5000 years ago, the Egyptians used palm bark and linen bandages,

wood and clay to stabilize fractures.

It was in Ancient Greece, however, that the precursor to modern instrumentation was born and

orthopedic surgery came to prominence. The father of modern medicine, Hippocrates (460-ca. 377 B.C.),

founded classical surgery. It is from Hippocrates that we have reports of instruments formed of hardened

iron. In addition to iron and copper, bronze and brass were used to make instruments, which were either

cast, forged or cold-worked. Some reports indicate the existence of as many as 200 instrument types.

After the decline of the Greek civilization, this development continued in the Roman Empire. Roman

generals followed the motto For the best legions, the best surgeons, and at those surgeons disposal

was a multitude of instruments including knives, saws, catheters, needles, forceps and specula. The

Romans also knew how to make steel instruments. When the ancient city of Pompeii was discovered,

archaeologists uncovered a large package of surgical instruments in a building called the House of the

Surgeon (or Physician) in the Strada del Consulare in Pompeii which may have housed a very early

surgical instrument business.

Tibetan surgeons could conduct surgical operations as complicated as craniotomy in the eighth

century, 1,000 years earlier than Western medicine, according to a renowned Tibetan medicine

dictionary. The book, called Four Volumes of Medicine Dictionary, was codified in the eighth century, and

recorded 360 bones, the meridian of human body and operational methods of surgical instruments at that

time. Tibetan surgeons' deep understanding of human body derives from a popular funeral custom

prevailing in the region: the celestial burial. According to descriptions recorded in the Four Volumes of

Medicine Dictionary, the Dalai Lama's Surgeon Damo Losang Aoizhag had about 100 surgical

instruments, which are kept in the museum of Tibetan history. Tibetan medicine remained unnoticed until

the seventeenth century in the fifth Dalai Lama's reign.

Large leaps in technology continued in the centuries to follow. Surgery came into its own as a

discipline in the 1700s, and in the 1800s Paris became its center. To judge from archaeological finds,

Germany by that time was also a center for instrument craftsmen. It was only with the discovery of

anesthesia and surgical asepsis that new surgical instruments were invented. The invention of stainless

steel in the twentieth century brought perhaps the greatest change to the manufacturing process, until the

most recent event of minimally invasive instrumentation. A veritable explosion of new tools occurred with

the hundreds of new surgical procedures which were developed in the 19th century and first decades of

the 20th century. New materials, such as stainless steel, chrome, titanium and vanadium were available

for the manufacturing of these instruments. Precision instruments for microsurgery in neurosurgery,

ophthalmology and otology were possible and, in the second half of the 20th century, energy-based

instruments were first developed, such as electrocauteries, ultrasound and electric scalpels, surgical tools

for endoscopic surgery, and finally, surgical robotics.

As surgery has developed, the trade of the instrument makers has developed alongside it. There is

evidence that in ancient times there were metal craftsmen who specialized in the manufacture of medical

instruments. Two of the very striking features of the ancient instruments were their good quality and their

elaborate ornamentation. The purpose of the decorations was partly functional: they provided a more

secure grip for the surgeon. In later periods, instruments were crafted by blacksmiths, cutlers and

armourers. With the onset of the Industrial Revolution, and the general increase in the rationalization of

production methods, instrument-making advanced another step. It has continued to develop, to reach the

high level of precision crafting we know today.

Modern Surgical Instruments

A surgical instrument is a specially designed tool or device for performing specific actions of

carrying out desired effects during an operation, such as modifying biological tissue, or to provide access

or viewing it. Along time, many different kinds of surgical instruments and tools have been invented,

some of them of a more general character, others designed for a specific type of surgery. Accordingly,

the nomenclature of surgical instruments follows certain patterns, such as a description of the action it

performs (for example, scalpel, hemostat), the name of its inventor(s) (for example, the Kocher forceps),

or a compound scientific name related to the kind of surgery (for example, tracheotome).

Surgical instruments exist in vast numbers and varieties. The following are examples of the basic

instruments that should learned by every student of medicine.

Scissors

Scalpels

Forceps

Needle Holders

Retractors

Towel Clamps

C D E F G

SCISSORSClassification by type of points: All types of scissors can have blunt or sharp blades. All types can have

either straight or curved blades.

A) Mayo scissors are used for cutting heavy fascia and sutures.

B) Metzenbaum scissors are more delicate than Mayo scissors and are used to cut delicate tissues.

Metzenbaum scissors have a longer handle to blade ratio.

Other kinds of scissors are C) bandage, D) stitch, E) operating, F) abdominal, G) iris as well as specialized types used for special procedures in the Surgical sub-Specialties.

A B

SCALPELS / BLADES/ KNIVESThe scalpel is the instrument that perhaps best defines a Surgeon the Cutting Edge of Medicine.

Blades are used to incise, cut away and shape tissues. All surgical blades are used with the

blade/scalpel handle.

Blades #10, #15, and #20 are used for skin and other tissue incisions as well as general cutting and

shaping of tissues depending on location, size of working area or specimen to be dissected or excised.

Blade #11 is also known as the stab knife and may be used for Incision and Drainage of abscesses,

making small incisions in hollow organs such as the bile duct, intestines (for stoma creation) and vessels.

Blade #12 is in the form of a hook to facilitate precise placement of small incisions or stabs.

Blades #10-15 fit in Handle #3 while Blade #20 is used with Handle #4. Handle #7 is for delicate

surgery and may be used with Blades#10-15.

FORCEPS: are clamping and occluding instruments which are used to hold or grasp tissues, compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents. They can also be used

to hold drapes or sponges.

These can have a hinged locking device or consist of two tines held together at one end with a

spring device that holds the tines open.

These non-locking can be either tissue or dressing forceps.

Dressing forceps have smooth or smoothly serrated tips. Short smooth dressing forceps arte also

called thumb forceps.

Tissue forceps have teeth to grip tissue. Many forceps bear the name of the originator of the

design, such as the Adson tissue forceps. Interdigitating teeth hold tissue without slipping.

Russian tissue forceps are used to grasp a bigger amount of tissue.

Adson Tissue Forceps have small serrated teeth on edge of tips. The delicate serrated tips are

designed for light, careful handling of tissue.

DeBakey forceps are used to grasp delicate tissue, particularly in cardiovascular surgery.

Hinged (locking) forceps are used for grasping and holding tissue.

Allis: An Intestinal Tissue Forceps

Interdigitating short teeth to grasp and hold bowel or tissue. Slightly traumatic, use to hold intestine,

fascia and skin. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis"

holds breast tissue.

Babcock: An Intestinal Tissue Forceps

More delicate that Allis, less directly traumatic. Broad, flared ends with smooth tips. Used to

atraumatically hold viscera (bowel and bladder). A Babcock is used to grasp delicate tissue (intestine,

fallopian tube, ovary). Available in short and long sizes.

Kocher forceps is used to grasp heavy tissue. It may also be used as a clamp. The jaws may be

straight or curved. It is also called an Ochsner.

Sponge Forceps

Sponge forceps can be straight or curved. Sponge forceps can have smooth or serrated jaws.

They may at times be used to atraumatically hold viscera (bowel and bladder). However, the main use is

to grasp sterile sponges or to transfer sterile instruments and materials to and from the operative field.

Hemostatic forceps: Many hemostatic forceps bear the name of the designer (Kelly, Halsted, Crile).

They are used to clamp and hold blood vessels. Classification may be by size, shape and size of tips

Hemostatic forceps and hemostats may be curved or straight.

Kelly forceps and Mosquito forceps are Hemostatic Forceps.

Both are transversely serrated.

Mosquito hemostats (A) are more delicate than Kelly (B) hemostatic forceps.

A

Mosquito hemostats (A) have a smaller, finer tip.

Carmalt are heavier than Kelly. These are preferred for clamping of ovarian pedicles during surgery

because the serrations run longitudinally.

A

B

Doyen Intestinal Forceps

These are non-crushing intestinal occluding forceps with longitudinal serrations and are used to

temporarily occlude the lumen of the bowel.

Payr Pylorus Clamps

This is a crushing intestinal forceps and is used to occlude the end of bowel to be resected.

Needle holder: used to hold the needle while suturing tissue.

Mayo-Hegar

Heavy, with mildly tapered jaws. No cutting blades.

Ryder-French has fine delicately tapered jaws suitable for holding very fine needles (appropriate for

Plastic, Intestinal or Vascular surgery). Another type has an angled jaw (Finochietto).

Towel clamps secure drapes to a patient's skin. They may also be used to hold tissue.

Backhaus Towel Clamp

Locking forceps with curved, pointed tips.

RETRACTORSRetracting and exposing instruments are used to hold back or retract organs or tissue to gain

exposure to the operative site. They are either "self-retaining" (stay open on their own) or "manual" (held

by hand). When identifying retractors, look at the blade, not the handle.

A Deaver retractor (manual) is used to retract deep abdominal or chest incisions. Available in

various widths.

A Richardson retractor (A) is used to retract deep abdominal or chest incisions and is similar to a

Kelly retractor (B).

AB

An Army-Navy retractor (manual) is used to retract shallow or superficial incisions.

A goulet (manual) is used to retract shallow or superficial incisions.

Malleable or ribbon retractor (manual) is used to retract deep wounds. May be bent to various

shapes.

A Weitlaner retractor (self-retaining) is used to retract shallow incisions.

A Gelpi retractor (self-retaining) is used to retract shallow incisions.

A Balfour with bladder blade (self-retaining) is used to retract wound edges during deep abdominal

procedures.

A great variety of retractors may be encountered in the OR attesting to the variability of usage,

preference and situations Surgeons may encounter. Other examples are:

DoyenSenn

Ragnell

CrileLahey

Vein retractor

CushingVolkman

CORRECT USAGE AND HANDLING OF SURGICAL INSTRUMENTS

The decision about which instrument to use sometimes has to be made on the basis of what is

available. When you have a choice between instruments:

Choose the shortest instrument that will comfortably reach the operative site,

If cutting suture or other non-tissue material, avoid using fine scissors that are designed to cut

tissue or dissect tissue planes; use larger and blunter scissors for non-tissue materials

Choose instruments in good repair; forceps that cross at the tip, scissors that do not cut easily

and needle drivers that do not grip the needle securely can be frustrating and dangerous.

When holding instruments:

Use three-point control: have three points of contact between your hand and the instrument to

stabilize the instruments and increase the precision of use

When using instruments that open and close, extend your index finger along the instrument to

provide extra control and stability

Place only the tips of your fingers and thumb through the handles on instruments that open and

close. In this way, rotation of the instrument can come from your wrist and forearm and provide a

greater arc of control. It is also quicker and less cumbersome to pick up and put down the

instrument.

1. Scalpels

The way in which the scalpel is held depends on its size and the procedure being performed. Most

procedures are performed with a #3 handle and either a #10, 11 or 15 blade. Use a #10 blade for large

incisions, #11 for stab incision and #15 for fine precision work. If a larger #4 handle is used, use a #20 or

#22 blade.

The scalpel is held with thumb, middle and ring finger while the index finger is placed on the upper

edge to help guide the scalpel.

Long gentle cutting strokes are less traumatic to tissue than short chopping motions.

The scalpel should never be used in a "stabbing" motion.

When incising the skin or abdominal wall, use the larger scalpel and blade. Hold the knife parallel to

the surface with your third to fifth finger, thumb and index finger; this provides the three-point control. Your

index finger will guide the blade and determine the degree of pressure applied.

When using the scalpel for dissection, use a smaller knife and hold the instrument like a pen with

your thumb, third finger and index finger holding the knife and your index finger controlling the dissection.

2. Forceps

Forceps are either toothed or non-toothed. Toothed forceps are also referred to as atraumatic as

they are less likely to crush tissue. Hold these forceps like the small scalpel or a pen. Thumb Forceps

are not called tweezers. Thumb Forceps are not held like a knife.

Artery (hemostatic) forceps come in many sizes and shapes. Place your thumb and fingers through

the handles just enough to sufficiently control the instrument. Place your index finger on the shaft of the

instrument to provide three-point control.

Hold curved dissection scissors in the same way.

CARE OF SURGICAL INSTRUMENTS

Instruments that function improperly or are used improperly impede a Surgeons work and are a

hazard to the patient and to the operative team. When taken care of properly, surgical instruments can

last for many years rendering excellent service. When misused or abused, instruments are a source of

frustration on the part of the Surgeon, financial loss to the hospital and even a cause of litigation as a

result of mishaps and unfortunate occurrences.

During Surgery, there is no place for rough and improper handling of instruments. These should

not be thrown or dropped to the floor in fits of rage and temper. Idiosyncracies of personality and

temperament should be left in the Dressing room. Certainly errors may occur (wrong instruments

prepared or passed to the Surgeon, missing or inappropriate sizes, etc.) The safety and well-being of the

patient are of paramount importance. Proper discipline and self-control must always be exercised to

achieve harmony and mutual respect among the operative team in particular and the operating room

workplace in general.