SURGICAL INSTRUMENTS

Dr. Aravind. D
Resident
Department of General Surgery
SGMC

SUTURE MATERIALS
Types of suture materials Depending on the behavior of the suture material in the tissues,
the sutures may be :
A. Absorbable sutures: These sutures get absorbed in the tissues either by enzymatic
digestion or by phagocytosis. Depending on the source, these sutures may be:
1. Natural absorbable sutures:
− Plain and chromic catgut.
2. Synthetic absorbable sutures:
− Polyglycolic acid (dexon)
− Polyglactin 910 (vicryl)

− Polyglactin 910 rapide (vicryl rapide)

− Polydioxanone suture (PDS)
− Polyglecaprone 25 (monocryl).

B. Nonabsorbable sutures: These sutures remain in the tissues for indefinite period.
Depending on the source, these sutures may be:
1. Natural nonabsorbable sutures:
− Linen thread
− Silk.
2. Synthetic nonabsorbable sutures:
− ​Polypropylene (prolene)

− Monofilament polyamide (ethilon)

− Polyester (ethibond)
− ​Nylon​.

Depending on the number of strands in the suture materials, sutures may be:
Monofilament sutures:
•Sutures consisting of a single strand of fiber are called monofilament sutures.
•These sutures are smooth and strong.
•Chance of bacterial contamination is less.
•The disadvantage is that knot tied may become loose. •Polypropylene, Polyamide, Catgut,
Monocryl, Polydioxanone, Polyglactin finer sizes 6/0-9/0.

Polyfilament sutures:
•Sutures consisting of multiple strands braided together are called polyfilament sutures.
•They are easier to handle and the knot tied does not slip.
•The disadvantage is that the bacteria may lodge in the crevices of the sutures so these
sutures are not suitable in presence of infection, e.g. silk, linen, polyglycolic acid, polyglactin
910, braided polyamide and braided polyester.
What are the criteria of an ideal suture material? Should have adequate tensile strength
Should incite minimal tissue reaction
Should have easy handling property
Should have good knotting quality
Should be nonallergenic and noncarcinogenic
Should be easily available and cheap.

Uses

a. Plain catgut:
•Plain catgut is used to tie small sub- cutaneous vessels
•Used to approximate subcutaneous tissues during closure of an incision
•Used during circumcision to suture the cut margins of the prepuce
•Used in repair of wounds of lip or oral cavity.

Chromic catgut:
•Used to suture muscles, bowel anastomosis, closure of peritoneum,gut resection
anastomosis.

B. SYNTHETIC ABSORBABLE SUTURES

Common Features
These may be monofilament (monocryl, polydioxanone and finer sizes vicryl) or polyfilament
(vicryl and vicryl rapide)
They can be of natural color or can be colored green (dexon) or violet (vicryl)
They are twice as strong as compared to natural absorbable suture
They are absorbed by a simple process of hydrolysis and evoke minimal tissue reaction
They maintain tensile strength in tissues for a longer time and are absorbed in tissues after a
variable time.

Polyglactin Sutures (Vicryl)

These sutures maintains tensile strength in the tissues for about 28–30 days and get
absorbed in 80–90 days

NATURAL NONABSORBABLE SUTURES:

SILK
The silk is derived from the cocoon of silk worm larvae The suture is braided round a core
and coated with wax to reduce the capillary action
Handling property is best and it knots securely
Silk maintains tensile strength for a longer time and the tensile strength is lost in 2 years
time.

SYNTHETIC NONABSORBABLE SUTURES

1. Polypropylene Suture
This is a synthetic, monofilament, nonabsorbable suture.
Used for closure of midline abdominal incision
Used for repair of incisional hernia

Nylon Sutures
RAMPLEY’S SWAB HOLDING FORCEPS

Used for cleansing the skin with swab dipped in antiseptic solution during all operations.
Used to hold the fundus and Hartmann's pouch of the gall bladder during cholecystectomy.

TOWEL CLIPS
Doyens’ Cross Action Type Towel Clip
Backhaus’ Towel (Corner) Clip

Used for fixing the draping sheets.

May be used as a tongue holding forceps.
May be used as cord holding forceps.
May be used for holding the ribs while elevating a flail segment of chest.

BARD PARKER’S HANDLES

It is used to make skin incisions for any operation.

It is used for incision and drainage of an abscess.
It is used to incise the skin for inserting drains.

HEMOSTATIC FORCEPS
A. Spencer Well’s hemostatic forceps - straight​, curved

The full length of the blades are provided with transverse serrations. The tips are conical and
non toothed. When the rachet is closed the blades are apposed
B. Kelly’s hemostatic forceps

Longer,The blades are long and the transverse serrations are not present along the whole
length of the blades
C. Adson’s hemostatic forceps.

The blades are smaller in comparison to the shaft. The transverse serration are present in
the terminal part of the blades
How will you differentiate it from a needle holder?
The hemostatic forceps is a lighter instrument.
The blades are longer and there are transverse serrations in the blades.
The needle holder is a relatively heavier instrument. The blades are smaller and there are
criss cross serrations in the blade and there may be a groove in the center of each blade.
Use
1.Used to hold bleeding vessels
2.Appendicectomy through McBurney’s Gridiron incision the hemostatic forceps may be
used to split the internal oblique and transversus abdominis muscle.
3.May be used to crush the base of appendix during appendicectomy.
4.Open an abscess by Hilton’s method.
5.May be used to hold the end of a ligature while suturing.
6.May be used to tie a knot after suturing.
7.May be used as a dressing forceps.
What is primary hemorrhage?
Bleeding during operation or at the time of injury.
What is reactionary hemorrhage?
Reactionary hemorrhage occurs within 24 hours following operation or injury after the
primary hemorrhage is controlled.
This may be due to slippage of a ligature or dislodgment of a clot.
Resuscitation from shock may increase the blood pressure and may cause reactionary
hemorrhage.

​ hat is secondary hemorrhage?

W
Secondary hemorrhage usually occurs 7–14 days following the operation or injury.
This is usually due to infection and sloughing of vessels.

KOCHER’S HEMOSTATIC FORCEPS

Kocher’s hemostatic forceps are more or less similar to a Spencer Wells’ hemostatic forceps
except
The blades are slightly longer than in a Spencer Well's type of hemostatic forceps.
At the tip of the blades there is a tooth in one blade and a groove in the other blade where
the tooth fits when the rachet is closed.
Used during appendicectomy operation to crush the base of appendix.
Used in obstetrics for artificial rupture of membrane.
Used to hold the meniscus during menisectomy.

LISTER’S SINUS FORCEPS

This is a long slender instrument with a pair of small blades with transverse serrations.
There is no ratchet in the handle.
Uses
For incision and drainage of abscess by Hilton’s method.
May be used to hold a gauge swab to clean the abscess cavity.
What is Hilton’s method for drainage of abscess?
There are total 10 Steps of Hilton’s Method of Incision and Drainage. These are as follows.
1. Topical anaesthesia: Topical anaesthesia is achieved with the help of ethyl chloride spray.
2. Stab incision: made over a point of maximum fluctuation in the most dependent area
along the skin creases, through skin and subcutaneous tissue.
3. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps
(to avoid damage to vital structures).
4. Closed forceps are pushed through the tough deep fascia and advanced towards the pus
collection.
5. Abscess cavity is entered and forceps opened in a direction parallel to vital structures.
6. Pus flows along sides of the beaks.
7. Explore the entire cavity for additional loculi.
8. Placement of drain: A soft yeat’s or corrugated rubber drain is inserted into the depth of
the abscess cavity; and external part is secured to the wound margin with the help of suture
9. Drain left for at least 24 hours.
10. Dressing: dressing is applied over the site of incision taken extraorally without pressure.

ALLIS’ TISSUE FORCEPS

The tip of the blades are provided with sharp teeth with grooves in between. When the
ratchet is closed the teeth of the one blade fits in the groove of the other blade and vice
versa
Uses
1. During laparotomy through midline incision, skin margins may be retracted by applying
Allis tissue forceps to the skin margin while linea alba is incised. The linea alba may be lifted
up by applying Allis tissue forceps while incising the peritoneum.
2. While closing the midline incision the linea alba may be held up by Allis tissue forceps
during suturing.
3. Used to hold the skin margins during incisional hernia operations to raise the skin flaps.
May be used to hold the margins of the fascial gap while dissecting the hernial sac.
4. Used during thyroid operations, neck dissection to hold the margins of the skin.

BABCOCK’S TISSUE FORCEPS

The terminal part of the blades are curved and fenestrated. The tip is provided with a ridge in
one blade and groove in the other. When the rachet is closed the ridge of one blade fits into
the groove of the other blade. As there are no teeth this is a non-traumatic forceps. The
fenestration in the blade allows some soft tissue to be accommodated in the hollow while
holding it
Uses
1. Used during appendicectomy. Usually three pairs of Babcock’s forceps are required
during appendicectomy. One pair holds the appendix near its tip, one pair holds the body of
the appendix and the third pair holds the base of the appendix.
2. Used during gastrectomy, gastrojejunostomy to hold the margins of the stomach while
applying an occlusion clamp.
3. Used during small and large intestine resection anastomosis to hold the margins of the
gut before applying an intestinal occlusion clamp. In open method of resection anastomosis,
intestinal occlusion clamps are not applied. The cut margins of the gut are held up with
Babcock‘s tissue forceps and sutured.
4. Used during gastrostomy or jejunostomy to hold the gut while applying purse string
suture.
5. Used during choledochoduodenostomy to hold the duodenum before making an incision
in the first part of the duodenum.
6. Used to hold the cut margins of the bladder during transvesical prostatectomy or
suprapubic cystolithotomy.

LANES’ TISSUE FORCEPS

The terminal part of the blades are curved and fenestrated. At the tip there is a heavy tooth
in one blade with groove in the other blade and with the ratchet in closed position, the tooth
and the groove in the blade fits in. Because of stout teeth at the tip this holds tissues firmly
but it is traumatizing
Uses
1.Used during submandibular or parotid gland excision to hold the gland during dissection
from the adjacent structures.
2.During mastectomy it may be used to hold the breast while dissecting it off from the
pectoral fascia.
3.May be used to fix the draping sheets and also to fix the suction tube and the diathermy
cable to the draping sheets as an alternative to towel clip.

KELLY’S RECTAL SPECULUM (PROCTOSCOPE)

Parts:(A) Speculum proper. (B) Obturator
The instrument is about 3 inches long. There is a hollow outer sheath where a handle is
attached.
The terminal end of the sheath is either round or obliquely cut. The inner rod is called the
obturator and its terminal part is smooth and rounded and fits well with the outer sheath.
Diagnostic use:
•Diagnosis of piles: The pile mass protrudes into the lumen of the proctoscope
•An anal or a rectal polyp may be seen protruding into the lumen of the proctoscope
•Carcinoma of anal canal or rectum may appear as a proliferative mass or an ulcerating
lesion
•Diagnosis of ulcerative colitis: Associated proctitis may appear as red, congested mucosa
which bleeds to touch and in some cases pseudopolyps may be seen
•The internal opening of a perianal fistula may be seen •The apex of an intussusception may
be seen in the anal canal through the proctoscope.
Therapeutic uses:
•Used during injection sclerotherapy of piles. The injection is made at the base of the pile
mass visualized through the proctoscope
•Used during polypectomy
•Used while taking a biopsy from a rectal or an anal growth.
What are the different types of anal fistula?
The different types of anal fistula include
1. Subcutaneous fistula: External opening at the perianal skin and the internal opening at
the skin lined part of the anal canal.
2. Submucous fistula: This is more like a sinus than a fistula. The internal opening is at
the anal canal and the tract traverses upto the submucous coat.
3. Low anal fistula: The external opening is at the perianal skin and the internal opening
lies at the anal canal below the anorectal sling.
4. High anal fistula: When the internal opening of the fistula lies at or above the anorectal
sling.
5. Pelvirectal fistula: In this case the fistulous tract traverses through the levator ani muscle
and the internal opening of the fistula is at the rectum.
What is Park’s classification for perianal fistula?
1. Intersphincteric: The fistulous tract runs between the internal and the external sphincter.
Depending on the internal opening it may be high or low intersphincteric fistula
2. Trans sphincteric fistula: From the external opening at the perianal skin the fistulous tract
traverses through both the external and the internal anal sphincter. Depending on the
position of the internal opening at the anal canal this may also be low or high trans
sphincteric fistula.
3. Supralevator fistula: The fistulous tract traverses through the levator ani muscle and the
internal opening is into the rectum.

What is Goodsall’s rule?

When the external opening of the fistula lies in the anterior half of the anal opening, then the
fistulous tract tends to be straight. When the external opening of the fistula lies in the
posterior half of the anal opening, then the fistulous tract is usually curved and the internal
orifice usually lies in the posterior midline. There may be multiple external openings but the
internal opening is usually single
What investigations may help to map out course of perianal fistula?
TRUS (Transrectal ultrasonography) or MRI may be helpful in delineation of a complex
fistula.
What are the important causes of multiple perianal fistula?
Multiple perianal fistula is often associated with tuberculosis, Crohn’s disease or
lymphogranuloma inguinale. Hidradenitis suppurativa may be associated with multiple
perianal sinuses.

FOLEY’S BALLOON CATHETER

This is a variety of self retaining catheter:

A. In two ways Foley’s balloon catheter, the side channel is used to inflate the balloon so
that it is kept indwelling. There is a valve in the side channel. The main channel is for
drainage of urine. The catheter number (no. 16 Fr.) and the balloon capacity (30–50 mL) is
mentioned on the main or side channel.
B. In three ways Foley’s balloon catheter, there is an additional third channel for either
irrigation or drainage.
Uses
For relief of retention of urine by urethral catheterization.
May be used for suprapubic cystostomy
May be used for tube nephrostomy
May be used for urethral catheterization following urethroplasty.

KEHR’S T-TUBE

Kehr’s T-tube (Number 12, 16 and 18 are also available). Silastic and latex T tube are also
available. There is a short horizontal limb which is inserted into the bile duct and a long
vertical limb which is brought outside.
Uses
1.Following choledochotomy, the bile duct is closed over a T-tube, as primary closure of bile
duct is associated with higher incidence of leakage.
2.Used to drain the bile duct following repair of bile duct injury. The T-tube acts as a stent
and is usually kept for about 4–6 weeks.
3.May also be used to stent a choledochojejunostomy or choledochoduodenostomy
anastomosis.
4.May be used as a stent following repair of ureteric injury.

RYLE'S TUBE
It is one meter long and is made of red rubber or plastic. It has got three lead shots in the tip
which makes it radio-paque. It also facilitates easy passage of the tube through the
oesophagus. It has got markings at different levels:
At 40 cm distance, at the level of gastro-oesophageal junction.
At 50 cm distance, at the level of body of the stomach. At 60 cm distance, at the level of the
pylorus.
At 65 cm distance, at the level of the duodenum.
Diagnostic :​ For gastric function tests-to assess free acid and total acid
Hollander's test for completion of vagotomy
To diagnose trachea-oesophageal fistula
Baid test for pseudocyst of the pancreas
Therapeutic :​ In acute abdominal conditions like peritonitis/obstruction
In abdominal trauma
After abdominal surgeries In pyloric stenosis

ENDOTRACHEAL TUBE

Use
Mechanical ventilation
During resuscitation
Angioneurotic edema.

LANE’S PAIRED GASTROJEJUNOSTOMY CLAMPS

Uses
This instrument is used during gastrojejunostomy. One pair of clamp is applied to the
stomach and one pair is applied to the jejunum. As the two instruments are kept side by side
and the screw is tightened the stomach and the jejunum is kept steadied and anastomosis is
done easily.
Advantages​ : Non traumatic bowel handling
Prevent spillage of bowel contents
Self retaining, so Anastomosis is easy.
Both clamps can be used separately.

DESJARDIN’S CHOLEDOCHOLITHOTOMY
FORCEPS

This is a long and slender instrument. There are finger bows but no catch. The shafts are
curved, There are no serrations in the blade.
Uses
1.his is used during choledocholithotomy.The Desjardin’s forceps is then introduced into the
bile duct and the stones are removed by holding the stones in the fenestrated blade.
2.This is used during laparoscopic cholecystectomy. While extracting the gallbladder through
the epigastric or umbilical port, as the gallbladder is partially delivered through the port
wound, it usually gets stuck if there are large stones in the gallbladder or there are
multiple small stones in the gallbladder. The gallbladder is partially delivered through the
wound. The gallbladder is opened and the stone removed from the gallbladder by the
Desjardin’s choledocholithotomy forceps.
3.It may also be used during removal of kidney, ureteric or bladder stone.

CORD HOLDING FORCEPS

Uses
Used during hernia operation to hold the spermatic cord so that the cord can be retracted
during repair of the posterior wall of the inguinal canal.

JOLL’S THYROID RETRACTOR

This is also a self retaining retractor used during thyroid operations to retract the skin
flaps. After the skin incision is made, the platysma is incised in the same line. The upper and
lower skin flaps are dissected and raised. The upper skin flap is raised up to the upper
border of the thyroid cartilage and the lower skin flap is raised up to the suprasternal notch.
Once the skin flaps are raised the upper and the lower skin flaps are held by the towel clip
like forceps attached to the retractor and the retractor is opened by the screw mechanism
attached to the retractor.

DEAVER’S RETRACTOR
Uses
Used during cholecystectomy for retraction of right lobe of liver.
Used during truncal vagotomy for retraction of left lobe of liver.
Used during gastrectomy for retraction of liver.
Used during pancreaticojejunostomy for retraction of stomach.

LANGENBECK'S RETRACTOR

It has got a long handle and a small solid blade. It is used in hernia surgery or any superficial
surgeries to retract skin, fasciae and aponeurosis, etc.

TOOTHED DISSECTING FORCEPS

Uses
Used during almost all operations to hold tough structures like skin, fascia and aponeurosis.
1. Used to hold the cut skin margins during suturing.
2. Used to hold the linea alba or the rectus sheath during closure of abdominal incision.
3. Used to hold the scalp during closure of scalp incision.
4. Fine tipped toothed dissecting forceps is used to hold the cut margins of the prepuce for
suturing during circumcision.

HUMBY SKIN GRAFT KNIFE

NEEDLE HOLDERS
The blades of the needle holder are smaller in comparison to the shaft of the instrument.
There are criss cross serrations in the blade and there is a longitudinal groove in the center
of the criss cross serration which allows firm gripping of the needle. However, the groove
may not be there in all needle holders. The blades of the needle holders may be fine or
heavy. The needle holders with fine blades are used to hold finer needles (2/0, 3/0, 4/0
atraumatic catgut, vicryl, mersilk). The small sized needle holders are used for suturing on
the surface. The long needle holders are used for suturing at the depth inside the abdomen,
pelvis or chest. The curved needle holders are used for suturing in a cavity or at a depth for
better visualization.

RIGHT ANGLED FORCEPS (LAHEY’S FORCEPS)

Like a hemostatic forceps this instrument has finger bows, a catch, a pair of shaft and a pair
of blades. The terminal part of blades are bent at right angles to the shaft of the instrument
and there are transverse serrations in the blade.
Uses
1.This is usually used to dissect pedicles of important organs and a ligature may be passed
around the dissected vessels.
2.This may also be used as a hemostatic forceps to hold a bleeding vessel at a depth.
This is used during cholecystectomy to dissect the cystic duct and the artery and to pass a
ligature around these structures.
3.Used during gastrectomies to dissect and pass ligatures around the left gastric artery, right
gastric artery, gastroepiploic vessels before their divisions. 4.Used during vagotomy to
dissect the anterior and posterior vagus nerves and pass ligatures around these structures
before their division.

Mollison self retaining hemostatic mastoid retractor

1.To Harvest temporalis fascia graft

2. To expose the mastoid cortex and hold the soft tissue apart
3. In difficult neck surgical procedures where two hands need to be free
4. In surgeries involving the skull