1 SURGICAL INSTRUMENTS A surgical instrument is a specially designed tool or device for performing specific actions of carrying out desired effects during a surgery or operation, such as modifying biological tissue, or to provide access for viewing it. Categories of Surgical Instruments: A. Clamps B. Retractors and Dilators C. Forceps D. Sharps A. Clamps It is an instrument with serrated jaws and locking handles, used for gripping, holding, joining, supporting, or compressing an organ, vessel, or tissue. In surgery, clamps generally are used for hemostasis and clamping tissue. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.) A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes. Other names: Rochester Pean.
1. Straight Kelly
2. Curved Kelly
An Allis is used to grasp tissue. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue. Also called Allis clamp .(Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.)
Discussion by Professor Sheryl Renomeron-Morales
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Foerster Clamp
Towel Clamp
B. Retractors and Dilators It is 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 Richardson retractor (manual) is used to retract deep abdominal or chest incisions
An Army-Navy retractor (manual) is used to retract shallow or superficial incisions. Used to lift up or pull back lighter tissues. Other names: USA, US Army.
Discussion by Professor Sheryl Renomeron-Morales
3 A Deaver retractor (manual) is used to retract deep abdominal or chest incisions. Available in various widths.
A malleable or ribbon retractor (manual) is used to retract deep wounds. May be bent to various shapes.
A Balfour or bladder retractor is used in abdominopelvic surgery such as cesarean section (CS). It is also used to hold back the urinary bladder, thus protecting it.
Discussion by Professor Sheryl Renomeron-Morales
4 C. Forceps It is a pair of any of a large variety and number of surgical instruments, all of which have two handles or sides, each attached to a dull blade. The handles may be joined at one end, such as a pair of tweezers, or the two sides may be separate to be drawn together in use, such as obstetric forceps. Forceps are used to grasp, handle, compress, pull, or join tissue, equipment, or supplies. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.) Types: o alligator forceps a grasping forceps with a scissorlike handle and blades opening in a vertical plane similar to the jaws of an alligator. o bayonet forceps a forceps whose blades are offset from the axis of the handle. o capsule forceps a forceps for removing the lens capsule in cataract. o Chamberlen forceps the original form of obstetric forceps, invented in the sixteenth century. o clamp forceps a forceps-like clamp with an automatic lock, for compressing arteries or other structures. o dressing forceps forceps with scissor-like handles for grasping lint, drainage tubes, etc., in dressing wounds. o Magill forceps forceps used to introduce an endotracheal tube into the trachea during nasotracheal intubation. o obstetric forceps forceps for extracting the fetal head from the maternal passages.
o rongeur forceps a forceps designed for use in cutting bone. o thumb forceps a forceps with serrated blades and with or without teeth. o tissue forceps a forceps without teeth or with one or more small teeth at the end of each blade, designed for handling tissues with minimal trauma during surgery. (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.)
Discussion by Professor Sheryl Renomeron-Morales
5 D. Sharps These are used for cutting and dissecting. A sharp instrument used to cut body tissue or surgical supplies. 7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue. 3 handle with 10 blade (inside knife) – Used to cut superficial tissue. 4 handle with 20 blade (skin knife) - Used to cut skin.
#7, #3, #4 (left to right)
Straight Mayo scissors is used to cut suture and supplies. Also known as: Suture scissors EX: Straight Mayo scissors being used to cut suture.
Curved Mayo scissors is used to cut heavy tissue (fascia, muscle, uterus, breast). Available in regular and long sizes. Discussion by Professor Sheryl Renomeron-Morales
6 Metzenbaum scissors - Used to cut delicate tissue. Available in regular and long sizes.
E. Other Instruments A Babcock is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes.
A Kocher is used to grasp heavy tissue. May also be used as a clamp. The jaws may be straight or curved. Other names: Ochsner.
Discussion by Professor Sheryl Renomeron-Morales
7 INTRODUCTION TO SURGICAL PROCEDURES Generally surgery involves cutting into the body (incision) to explore or remove tissue while the patient is under anesthesia. Surgical techniques used for surgery include cryosurgery, electrocausterization surgery, laser surgery, gamma knife, and enbloc resection. TYPES OF SURGERY: Microscopic examination of biopsy samples is the ideal way that a positive diagnosis of cancer can be made. This procedure involves physically removing all or part (tissue, cells, or fluids) or a suspected tumor and examining this material under a microscope. The purpose of a biopsy is to identify the histologic type of cancer and possible stage of disease. Any organ in the body can be biopsized utilizing a variety of techniques. Some may require major surgery, while others may not even require local anesthesia. There are hundreds of different types of surgery and many ways to categorise them. Some common categories (which can overlap) include: A. B. C. D. E.
The The The The The
aim of surgery urgency of surgery seriousness of surgery field of surgery surgical approach.
A. The aim of surgery. Surgeries can be grouped according to their purpose. For example: •
•
•
•
Diagnosis – surgery can establish whether a person has a particular illness, disease or condition. Diagnostic surgery may be recommended when the person has signs that something may be wrong – for example, they may report unusual symptoms or have a positive test result. An example of diagnostic surgery is a breast lump biopsy. Prevention – the removal of tissue to stop a disease from happening. An example of this type of surgery is an operation to remove bowel polyps that may turn cancerous if left untreated. This type of surgery is also called prophylactic surgery. Ablation – means the surgical removal of tissue. Typically, ablative surgery involves cutting out diseased or severely damaged body parts. In most cases, the name of the surgery ends in -ectomy. Examples include mastectomy (removal of a cancerous breast) or cholecystectomy (removal of a diseased gall bladder). Reconstruction – the aim is to restore use (such as knee reconstructive surgery) or improve appearance (such as breast reconstruction following mastectomy). Sometimes, reconstructive surgery achieves both. For Discussion by Professor Sheryl Renomeron-Morales
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•
•
example, a cleft palate repair enhances the person’s appearance and also improves their ability to eat, swallow and talk. Transplantation – this is surgery to replace a body part that no longer works properly: for example, a hip replacement or a lung transplant. The part may be artificial (made from silicone, stainless steel or titanium) or natural (donated from a deceased person). Palliative care – the aim is to reduce pain, control symptoms and improve quality of life when there is no chance of cure. An example of this type of surgery is nerve resection to stop a person from feeling constant pain.
B. The urgency of surgery. Surgeries may be classified by degree of urgency. For example: •
•
Emergency surgery – must be done as soon as possible to save the person’s life or preserve function of a body part. An example is surgery to repair damage to internal organs following a motor vehicle accident. ‘Elective’ surgery – is not urgent but must be done at some point for the sake of the person’s ongoing health or quality of life (for example, surgery to repair severe scoliosis or deformity of the spine) or because the person chooses to have an operation which may be helpful but is not necessarily essential (for example, cosmetic surgery to change the appearance of a person’s nose, or rhinoplasty). In Australia, the public hospital system operates on three main categories of elective surgery – urgent, semiurgent and non-urgent. All non-emergency surgeries are planned in advance.
C. The seriousness of surgery. All surgery carries risk to the person. The factors that determine the degree of risk include the body part that is affected, the seriousness of the medical condition, the extent of surgery, the complexity of surgery and the expected recovery time. Categories include: •
•
Major surgery – such as surgery to the organs of the head, chest and abdomen. Examples of major surgery include organ transplant, removal of a brain tumor, removal of a damaged kidney or open-heart surgery. The person will need to stay in hospital for some time. The risk of complications may be high and the person will take a longer time to recover. Minor surgery – presents a low risk of complications and fast recovery time. The person can usually go home the same day. Examples of minor surgery include tonsillectomy, sewing up a cut or biopsy of a breast lump.
D. The field of surgery. Surgeries can be categorized by field, which includes body systems, diseases or conditions. For example: •
Orthopaedic surgery – musculoskeletal system Discussion by Professor Sheryl Renomeron-Morales
9 • • • • •
Ocular surgery – the eyes Neurosurgery – brain and spinal cord Cardiac surgery – heart and surrounding blood vessels Surgical oncology – treats cancer Bariatric surgery – treats obesity.
E. The surgical approach. Surgeries can be categorized by broad technique. For example: •
•
•
Open surgery – the traditional approach. The surgeon makes a large single incision to access the internal organs. An example is open-heart surgery, where the person’s chest is cut down the middle and opened up like a book. Open surgery of the abdominal cavity is known as laparotomy. Keyhole surgery – the surgeon makes several small cuts (incisions) instead of one large one. Slender surgical instruments are passed through these incisions, including a laparoscope. This is a special viewing tube fitted with a light so the surgeon can see the internal organs. For this reason, keyhole surgery is also known as laparoscopic surgery. Microsurgery – is used for delicate work on very small body structures. The surgeon relies on special equipment and microscopes to magnify the area to be operated on and uses tiny surgical instruments. An example of an operation that uses microsurgery techniques is a vasectomy reversal or re-attaching a severed finger. (Retrieved date, December 31, 2012 http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Surgery)
SURGICAL TECHNIQUES 1. Scalpel The scalpel is the traditional cancer surgery tool; scissors are involved in cancer diagnostic surgeries. However these traditional cancer surgery tools are being replaced by new and more effective cancer surgical tools such as laser and radiation.
Scalpel. From Dorland's, 2000.
2. Cryosurgery It is the use of subfreezing temperature to destroy tissue. Cryosurgery is performed in the destruction of the ganglion of nerve cells in the thalamus in the treatment of Parkinson's disease, in the destruction of the pituitary gland
Discussion by Professor Sheryl Renomeron-Morales
10 to halt the progress of some kinds of metastatic cancer, and in the treatment of various cancers and lesions of the skin. The process is also used in ophthalmology to cause the edges of a detached retina to heal and to remove cataracts. The coolant is circulated through a metal probe, chilling it to as low as 160° C (-256° F), depending on the chemical used. The moist tissues adhere to the cold metal of the probe and freeze. Cells are dehydrated as their membranes burst; eventually they are discarded or absorbed by the body. No specific postoperative nursing care is required. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.)
3. Electrocauterization Electrocoagulation, electrosurgery, fulguration Surgery Cauterization by passage of high frequency current through electrically heated tissue; excision of abnormal or diseased tissue or control of bleeding in small blood vessels of the skin and in a surgical field with controlled electric current running through it, to cauterize (burn or destroy) the tissue. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.)
3. Laser Surgery Definition Laser (light amplification by stimulated emission of radiation) surgery uses an intensely hot, precisely focused beam of light to remove or vaporize tissue and control bleeding in a wide variety of non-invasive and minimally invasive procedures. Purpose Laser surgery is used to: • •
Cut or destroy tissue that is abnormal or diseased without harming healthy, normal tissue Shrink or destroy tumors and lesions
Discussion by Professor Sheryl Renomeron-Morales
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Cauterize (seal) blood vessels to prevent excessive bleeding.
Precautions Anyone who is thinking about having laser surgery should ask his doctor to: •
•
Explain why laser surgery is likely to be more beneficial than traditional surgery Describe his experience in performing the laser procedure the patient is considering.
Because some lasers can temporarily or permanently discolor the skin of Blacks, Asians, and Hispanics, a dark-skinned patient should make sure that his surgeon has successfully performed laser procedures on people of color. Some types of laser surgery should not be performed on pregnant women or on patients with severe cardiopulmonary disease or other serious health problems. Description The first working laser was introduced in 1960. The device was initially used to treat diseases and disorders of the eye, whose transparent tissues gave ophthalmic surgeons a clear view of how the narrow, concentrated beam was being directed. Dermatologic surgeons also helped pioneer laser surgery, and developed and improved upon many early techniques and more refined surgical procedures. Types of lasers The three types of lasers most often used in medical treatment are the: •
•
Carbon dioxide (CO2) laser. Primarily a surgical tool, this device converts light energy to heat strong enough to minimize bleeding while it cuts through or vaporizes tissue. Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Capable of penetrating tissue more deeply than other lasers, the Nd:YAG makes blood clot quickly and can enable surgeons to see and work on parts of
Discussion by Professor Sheryl Renomeron-Morales
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•
the body that could otherwise be reached only through open (invasive) surgery. Argon laser. This laser provides the limited penetration needed for eye surgery and superficial skin disorders. In a special procedure known as photodynamic therapy (PDT), this laser uses light-sensitive dyes to shrink or dissolve tumors. (Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.)
5. Gamma Knife A trademark for a radiologic nonsurgical device used in stereotactic radiosurgery. (The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.)
It is an apparatus for precisely aimed intersecting beams of gamma rays that delivers radiation therapies as treatment for intracranial lesions, either tumors or vascular anomalies. It is used in stereotactic radiosurgery. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.)
6. Photodynamic Therapy (PDT) PDT is an intravenous administration of hematoporphyrin derivative, which concentrates selectively in metabolically active tumor tissue, followed by exposure of the tumor tissue to red laser light to produce cytotoxic free radicals that destroy hematoporphyrin-containing tissue. (Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.)
PDT is a revolutionary medical technology that uses lasers to activate light-sensitive pharmaceuticals to treat cancer (and other diseases) in a minimallyinvasive manner.
Discussion by Professor Sheryl Renomeron-Morales
