Surgical Instrument Finishes, Classifications, and Handheld Instrument Essentials

Finishes and Grades of Surgical Instruments

Floor grade instruments
- Made from stainless steel but with less chromium
- May bend or break more easily
- Not made for repeated use in sterilization; not intended to be reused
Disposable grade instruments
- Often found in the emergency room or on the patient floor (e.g., suture removal kits)
Finishes added during manufacturing
- Common finishes include polished and satin
- Polished finish
- Highly polished bright finish increases resistance to corrosion
- Can be distracting due to glare and reflection during surgery
- Satin (dull) finish
- Less reflective and reduces glare but more prone to staining
Anecdote: glare and finishes in clinical practice
- A colorectal surgeon preferred a brand-new instrument with a high polished finish for hemorrhoidectomies
- Bright lights caused glare; turning down lights helped, but some surgeons are very particular about finish
Specialized finishes for specific needs
- Evanized (black chromium) finish
- Non-reflective and virtually eliminates glare
- Recommended for procedures involving lasers to prevent laser beam deflection
- Tungsten carbide
- Keeps scissors’ cutting edge sharper for a longer period
- Prevents suture needles from slipping in the jaws of needle holders
- Diamond dust finish
- Hardens the working surface of the jaws for improved durability and wear resistance
Why some scissors have gold handles
- Gold handles help indicate tungsten carbide blades or inserts that maintain sharpness
- The presence of tungsten carbide in blades is a key reason for this distinction
Instrument finishes in context
- Finishes affect glare, durability, and laser compatibility
- Choice of finish can reflect surgeon preference and procedure requirements

Instrument Classifications and Design

Instruments are categorized by design: handheld, powered, endoscopic, and robotic
Handheld instruments
- Most commonly used in surgery
- CSTs (certified surgical technologists) should learn the common parts of a handheld instrument: handles, ratchets, shanks, box lock, jaws or blades, and tips
Common parts of handheld instruments
- Handles: the part the surgeon grips
- Can be finger rings (most common), pistol grip, or spring-loaded
- Ratchets: interlocking parts near the handles that lock the instrument closed
- Shanks: the long section between the handles and the jaws/tips
- Box lock: the joint that allows articulation between handle and jaw
- Jaws or blades and tips: contact tissue; can be smooth or serrated
- Typical terminology used by clinicians and learners
Handheld instrument variants and terminology
- Jaws vs blades vs tips: jaws are the gripping surfaces; blades/tips refer to the cutting edge or gripping surface at the end
- Emphasis on recognizing these parts for proper use and handling

Cutting and Dissecting Instruments

Cutting and dissecting instruments
- Instruments with one or more sharp edges used for incision, sharp dissection, or excision of tissue
- Primary categories include knives or scalpels
Knife vs scalpel terminology
- Scalpel: typically has detachable disposable blades mounted on a nondisposable handle
- Knife: generally has a nondisposable handle with the blade as a single unit (e.g., amputation knife)
Scalpel handles and blade loading
- Scalpels may have locking mechanisms on some handles instead of grooves for blade loading
- Blades must be loaded onto and removed from the handle with an instrument (typically a needle driver); never with bare fingers
- Blades are not universal to all handles; blades fit specific handles
Common handle sizes and long options
- Standard handle sizes: $3, 4, 7, 9$
- Lengths: $3\text{ and }4$ handle are $5\text{ inches}$ long
- The $7$ handle is slightly longer than 5 inches
- The $3\text{L}$ and $4\text{L}$ denote long versions (e.g., $3\text{L}, 4\text{L}$ )
Blade and handle compatibility
- Blades numbers $10, 11, 12, 15$ fit onto handles $3, 7, 9$
- The phrase “beaver” refers to certain blade/handle types; common beaver blade is the $ext{ hebeaverblade}$ , with the most frequently used beaver blade being the ext{ ext{ ext{ ext{ ext{ ext{ ext{ ext{ ext{ ext{#69}}}}}}}}}
- Blade loading specifics
- ext{ ext{ ext{#10}}} blade is typically loaded onto the $3$ handle
- ext{ ext{#11, #12, #15}} blades are usually loaded on the $7$ handle
- The #15 blade is the $3\text{L}$ (long) variant for deep wounds
Special blade notes
- The #12 blade is used for tonsillectomies and is distinctive in curvature/orientation
- The #12 blade can be used for delicate procedures like bone work in some contexts
Other cutting instruments and cautions
- Wire scissors (usually #7) and bandage scissors exist for cutting non-tissue materials; do not use tissue scissors for non-tissue tasks
- Metzenbaum scissors are tissue scissors used for dissection; not for cutting suture or drapes
- Straight Mayo scissors are versatile for cutting various materials, including tissue or suture in some contexts
- Tissue scissors can be heavy, medium, or light construction; tips can be pointed or blunt; blades can be curved or straight
- Tungsten carbide blades provide extra durability and edge retention; often paired with bold ring handles to indicate special properties
- Curved Mayo scissors are preferred for heavy tissue; curved Metzenbaum for medium to fine tissue
- Delicate tissue is often dissected with Iris, Jameson, Westcott, tenotomy, and Potts-Smith scissors
- Straight nail scissors are used for cutting suture only
Additional scissors across specialties
- Jorgensen scissors for final hysterectomy cuts; Cushing scissors for dural incisions
Important practice notes
- Do not cut non-tissue items with tissue scissors to avoid dulling blades
- Always match blade size to the needle holder and other instruments used

Needle Holders and Suturing Instruments

Needle holders (needle drivers)
- Hold curved suture needles for suturing
- Length varies; must match needle size and suture used
- Jaws are designed to immobilize the needle during suturing
- Tungsten carbide inserts with crosshatch serrations improve needle immobilization
- Gold ring handles are common on many needle holders
Specialty needle holders
- Castro and Viejo needle holders are used for microsurgical, ophthalmic, and vascular procedures; often have spring action with a single ratchet to protect small delicate sutures

Forceps and Grasping Instruments

Thumb forceps
- Used by the nondominant hand to grasp and manipulate tissue during suturing or dissection
- May have teeth, serrations, or be smooth
- Vary in length and height
Common forcep types
- Rat tooth forceps
- Adson’s (with or without teeth)
- Ferris Smiths
- DeBakeys
- Browns
- Russians
- Gerald’s
Forceps purposes and attributes
- Atraumatic (nontraumatic) forceps have smooth surfaces to minimize tissue injury
- Choice depends on tissue type and surgical context

Clamping, Occluding, and Retracting Instruments

Hemostats and occlusion
- Designed to occlude (clamp) bleeding vessels until ligated
- Often used to retract wound edges or hold sutures on the drape
- Important practice: avoid cutting the suture; keep length of suture outside the wound
Retractors and exposure devices
- Retractors expose the operative site and may be handheld or self-retaining
- Self-retaining retractors include Wheat Lantern (Wheat-Lantern), Gelby, Bookwalter, O’Connor-O’Sullivan, and Balfour
- These retractors have interchangeable blades/depth options for various tissues and procedures
- Malleable retractors (flat, bendable) such as ribbon retractors can be bent into desired positions; brain spoons are examples of malleable retractors
- In sterile processing, some malleable retractors may be returned to their original shape to ease reuse
Viewing and accessing the operative field
- Viewing instruments can include specula used to retract vaginal walls and visualize the cervix in gynecologic procedures
- Viewing instruments also include endoscopes, cameras, fiber optic lights, and devices that transmit images to a computer system

Probing, Dilating, and Urethral Instruments

Probes
- Malleable, wire-like instruments used to explore a structure (e.g., fistula, duct, vessel)
- Probes are typically used with guides called through directors
Dilators
- Used to gradually dilate an orifice or duct to permit larger instrumentation or to open a stricture
- Found in numbered sets; through-dilators gradually taper from proximal to distal ends
- Cervical dilation in uterus procedures: cervical dilation to facilitate access
- Double-ended dilators (Haney and Hegar cervical dilators)
- Opposite ends provide one size up or down to speed the process
- Urethral dilators
- Female urethral dilators (single-ended) are shorter than single-ended Van Buren urethral dilators used in men

Suction, Aspiration, and Fluid Management

Aspiration and suction basics
- Suction tips are connected by plastic tubing to a suction canister or a vacuum device (e.g., Neptune)
- Tips may be nondisposable or disposable; vary by procedure and fluid volume
Common suction tips
- Yankauer (angled) tip for general suction and visualization
- Poole’s tip for abdominal suction and draining larger fluid volumes
- Angled Yankauer tips are preferred for certain deep or angled spaces
The Neptune suction system
- A larger, reusable suction unit used in the OR; suction canister must be emptied and maintained
Practical notes
- Suction and irrigation are critical for maintaining visibility and a clear operative field
- Proper selection of suction tip design depends on tissue type, location, and fluid quantity

Practical and Ethical Considerations

Safety and best practices
- Never handle blades with bare fingers; use needle drivers or other appropriate tools for blade loading/removal
- Ensure instrument compatibility (blade size with handle, etc.) to prevent damage or improper function
Surgeon preferences and clinical relevance
- Finishes, blade types, and instrument categories may be chosen based on surgeon preference and procedure requirements
- Some procedures benefit from specific finishes (e.g., non-reflective evanized finishes for laser work)
Real-world relevance
- Understanding instrument families, parts, and usage improves efficiency, safety, and outcomes during surgery
- Knowledge of instrument maintenance (e.g., returning malleable retractors to their original shape) supports instrument longevity and sterility
Ethical considerations in instrument use
- Proper handling and care of instruments to minimize tissue trauma and ensure patient safety
- Respect for evolving standards and surgeon-specific preferences while adhering to universal safety protocols

Quick Reference: Common Sizes and Identifiers (Recap)

Handle sizes: $3, 4, 7, 9$
Standard vs long handles: $3\text{L}, 4\text{L}$ , etc.
Blade family: $ext{blades } 10, 11, 12, 15$
Common beaver blade: #69
Double-ended cervical dilators: Haney and Hegar (opposite ends represent next size up/down)
Needing precise matching: ensure needle holders and needles are compatible (e.g., tungsten carbide inserts; crosshatch serrations; gold ring handles for easy identification)
Examples of specialized instruments: Bookwalter, Gelby, O’Connor–O’Sullivan, Balfour, Wheat Lantern, Yankauer, Poole’s, Neptune