Instruments at a Glance

(About Accessory Instruments)

Instrument usage: Accessory instruments are instruments that do not fall within the other general instrument categories due to their function. Many accessory instruments are used to enhance the use of basic instruments or to facilitate the procedure.¹ They can be considered miscellaneous items and can include measuring instruments, picks, cautery devices, implantable items such as arc bars, mirrors, and manufacturer’s specialty items.² The accessory instruments are used in all specialties of surgery and are just as important during a surgical procedure as the more commonly known instrumentation.

Key differences:

Measuring instruments can include calipers, depth gauges, and rulers that are vital to accurately measure during a surgical procedure.

Picks come in an array of sizes and angles that are specific to the surgical specialty. The tips can be difficult to visualize, but the scrubbed personnel must be able to distinguish the correct pick for the surgeon.

Cautery devices can include loops or needle tip cautery tips that are used to control bleeding and for diathermy.

Implantable items, such as arc bars, screws, plates, and wires are used and remain in patients after the procedure.

Mirrors can be used to visualize hard to see areas in the body.

Manufacturer’s specialty items found on specific manufacture’s trays, especially in orthopedics and neurosurgery, can contain items that are used with a specific system.

Safety on the sterile field:

Picks should be handled as a sharp item and the tips should be protected to prevent damage, as well as injury to the scrubbed personnel.

Cautery devices must be handled carefully and according to manufacturer’s instructions for use on the surgical field to prevent a burn or a fire.

Implantable items must be recorded in the operative record, in order that the scrubbed personnel can keep track of the size and quantity of items implanted.

Mirrors should be examined prior to use for visibility and cracks, and an anti-fog solution can be used to prevent fogging when inserting into the body.

Manufacturer’s specialty items should be maintained within the sterile tray that they were processed in and be used only with items from the same manufacturer and according to the use that it was intended by the manufacturer.

Instrument names:

Accessory instruments are commonly called by their name “ruler” and the intended use, such as “bone tamp” or “dental mirror”. The surgeon may also call it by the manufacture’s trade name, if it is a specialty item.

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Nemitz, Renee. Surgical Instrumentation-eBook: An Interactive Approach. Elsevier Health Sciences, 2017.

(About Arthroscopic Instruments)

Instrument usage: Arthroscopic instruments are used to cut and trim tissue in a joint, such as a hand, hip, knee, shoulder, or any other small joint.¹ The instrumentation used in arthroscopic surgery can range in size depending on the joint that it is being introduced into, such as a hip or knee joint would accommodate instruments that are 2.7mm and 3.4mm, while a smaller joint, such as the temporomandibular joint, would accommodate a scope that is 1.8mm to 2.6mm.

Instruments include biters, graspers, retrievers, punches, picks, knives, curettes, hooks/probes, elevators, scissors, and rigid scopes. Cannulas/trocars, reusable and disposable, are used to instill fluid and introduce the scope. Powered shavers are also used to trim bone and cartilage or on more complex cases to excise bone and tissue.

Key differences:

Biters, graspers, retrievers, punches, elevators, and scissors have ringed hand pieces, ratchet or un-ratcheted, and a 4 inch to 8 inch shaft.¹ The jaws will be unique to their use and are commonly about 2mm.¹ They may be angled and/or turned to the right, left, upward, downward, or straight.

Picks, knives, and curettes have a solid handle and come in different tip sizes and angles.

The arthroscopic probe or hook is a popular instrument that is commonly used at the beginning of the surgical procedure to examine the joint. The probe is blunt and usually 9.5 inches long and 3 mm to 5mm in diameter. It has calibrations on it so that the surgeon can measure while examining the joint.

The rigid arthroscope is commonly 4mm for knee joints but can be 2.7 mm for smaller joints such as wrist or ankle.

The cannulas/trocars have an obturator that can be sharp or blunt. The choice of the sharp or blunt obturator is dependent upon the surgeon’s preference.

Powered shaves have many different disposable tips that are used for multiple purposes and come in different diameters and angles depending upon the joint and its use.

Safety on the sterile field:

It is important to organize the arthroscopic instruments according to their use and unique jaws.

When passing arthroscopic instruments they should be clean of debris and any bone or tissue that is retrieved must be saved for pathology according to the facilities policy.

The arthroscope should be handled with care throughout the surgical procedure and should be examined before use to be certain that the image is clear and the scope is in working order.

Powered instruments must be assembled correctly since they are complex with gears, rotating shafts, and seals.²

The operator of the powered instrument should also be in control of the foot pedal, which will prevent premature activation of the device, and the foot pedal should be moved away when not in use so that it is not inadvertently activated.²

Air-powered instruments should be used at the correct pressure (measured in pounds per square inch or PSI) set by the manufacturer.²

When passing a powered instrument, it is important to have the safety latch engaged so that the instrument does not start spinning if activated accidentally.

Powered equipment tips and knives should be disposed of with other sharp items on the sterile field and disposed of in a sharps container.

Scrub personnel must use proper precautions during the handling or disposing of sharp items, such as the obturator, knife, or pick to prevent injury and/or damage to the instrument.

Instrument names:

Arthroscopic instruments are commonly called by their name such as “biter” or “grasper” and the angle of the instrument, such as “right angle biter” or “upward grasper.”

References:

1. Millennium Surgical (2022) Arthroscopic instruments from Millennium Surgical. Retrieved from https://www.surgicalinstruments.com/arthroscopy-instruments-from-millennium-surgical

2. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

(About Bone Instruments)

Instrument usage: Bone instruments are sharp instruments used for cutting into or through bone and cartilage.¹ Bone instruments include osteotomes, files, elevators, rongeurs, manual saws, mallets, bone holders, and screwdrivers. These cutting instruments can be blunt for bluntly dissecting or sharp for cutting.² Bone instruments are most commonly used in orthopedic surgery, but can also be used in thoracic, cardiac, and plastic surgery.

Key differences:

Osteotomes are sharp and are used to decrease the bulk of firm tissue/bone and not usually used to cut along defined tissue planes.¹ Osteotomes come guarded or unguarded and can be straight or curved.

Files are also sharp and used to decrease the bulk of firm tissue/bone, so are used by filing down the unwanted tissue.¹

Elevators, such as periosteal elevators, are used to bluntly separate tissue planes such as the periosteum from bone or dura from the inner aspect of the skull.¹ Elevators come in many sizes with different tips that can be straight or curved.

Rongeurs can be single action or double action with a scooped tip used to extract heavy tissue or bone.

Manual saws are used to cut into or through bone and cartilage.¹ The blade of the saw should not be touched by scrub personnel because it is sharp.

Mallets are hammers that are used to drive a cutting instrument into bone.¹ Mallets can have a soft silicon end or stainless steel end, and they come in different sizes.

Bone holders, such as pliers and bone clamps, are used to stabilize bone.¹ Some styles of bone holders have ring handles and locking ratchets, while others have compression grips and do not lock.¹

Screwdrivers are used to affix screws into bone.¹ It is vital to use the correct screwdriver for the screw that is being used. This will assure that the screw is placed securely and that the integrity of the screw is maintained.

Safety on the sterile field:

Bone instruments that come in multiple sizes should be arranged on the sterile field from smallest to largest.

Osteotomes may be packaged in a sterilization rack so that the blades and tips are suspended.¹ These instruments should remain in the rack on the sterile field until they are needed during the surgical procedure.¹

When passing an osteotome, the scrub personnel should pass a mallet. These instruments are used together.

When passing a rongeur, the scrub personnel should have a wet radiopaque sponge or lap pad to clean out the jaws of the rongeur from bone. The bone should be saved on the sterile field for specimen.

When passing a manual saw, it should be passed by the handle, since the blade is sharp.

The scrub personnel must use proper precautions during the handling or disposing of bone instruments to prevent injury and/or damage to the instrument.¹

When passing a sharp bone instrument, a neutral zone or hands-free technique can be used so that the scrub personnel uses a no-touch technique.³

Instrument names:

These instruments are most often called by their use, such as osteotome, file, elevator, rongeur, saw, mallet, bone holder, or screwdriver. If there are multiple sizes or angles, then the size and the angle would be specified, such as “small curved rongeur.”

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

3. Guidelines for Perioperative Practice. Sharps Safety. AORN, Inc, Denver, CO; 2021

(About Clamps)

Instrument usage: Clamps are used for holding tissue or other surgical material.¹ All clamps have finger rings or ring handle where the user’s can hold the instrument.¹ The shank of the clamp can have varying lengths. The ratchet allows the tip to be locked in three positions.¹ The joint of the clamp can be a box lock, screw joint, or semibox joint, which joins the two halves of the instrument allowing the instrument to open and close.¹ The jaw of the clamp can be traumatic, which cruses tissue, or atraumatic which is non-crushing so that the tissue remains undamaged.² The length the of shank of the clamp depends upon the intended function and the depth of the body cavity. Clamps can be straight or curved and are used in all surgical specialties.

Key differences:

The jaws of the clamp are key in determining how the clamp will be used.

Hemostat clamps are traumatic clamps that have deep transverse cuts in the jaw that will sever vessels and tissue.¹ This will prevent bleeding and slipping of the tissue.¹ Some examples of a hemostat clamp are Halsted clamps and Kelly clamps.

Non-crushing clamps have vertical serrations or finely meshed, multiple rowed teeth that cause minimal trauma to the tissue.¹ These clamps prevent leakage when clamping the bowel, vessels, or ducts that need to maintain their integrity and be reanastomosed.¹ Some examples of these clamps are Debakey clamps and bowel clamps.

Grasper/holding clamps have transverse serrations and large teeth at the tip used for tissue retraction.¹ Some examples of these clamps are Kocher clamps and Allis clamps.

Safety on the sterile field:

It is important to use the clamps for their intended use and not use them to clamp tubing. This can cause malalignment of the clamp, cracking, or breaking.¹

Scrub personnel should inspect each clamp prior to placing on the Mayo stand to be certain that it functions properly, is aligned, and the tip meets properly.¹ Also, observe for worn spots, chips, dents, cracks, or sharp edges.¹ Any damaged clamp should be set aside and sent for repair or replacement.¹

Clamps should be cleaned between use and debris should be removed using water and next saline.¹

Clamps should be closed on the first ratchet when passing to surgeon.² This will make it easier to open and apply during the surgical procedure.

Instrument names:

It is important to know the names of the clamps and the specific usage for the clamp. There are also slang names for many of these clamps that vary with surgeon and facility. Some common names for a Halsted clamp are “Point” or “Crile.” A mosquito clamp can also be called “snap.” Kocher clamps can also be called “Ochsner.”

Sometimes the surgeon will use a hand signal of holding hand out to indicate the need for a clamp. This most often means a basic Halsted clamp.

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

3. Criscitelli, Theresa. Fast Facts for the Operating Room Nurse: An Orientation and Care Guide. Springer Publishing Company, 2021.

(About Curettes)

Instrument usage: Curettes are used to remove soft tissue or bone by scraping with the loop, ring, or scoop at the end of the instrument.¹ Curettes come in many different shapes and sizes depending upon their use and the needed size for the patient. They can be sharp or blunt,² and reusable or disposable. They can also be straight or angled in order to get into small spaces. Curettes are used in many surgical services, including gynecology, orthopedics, general surgery, neuro surgery, and nasal surgery.

Key differences:

The tip of the instrument should be examined to determine what type of curette it is. Also, the instrument can be numbered with incremental sizes of curettes. It is important to look at the shaft of the curette to confirm the imprinted number.

Tissue curettes commonly have a scoop shape so that they can be used to scrape tissue or bone. They look like a spoon that comes in different tip sizes and lengths.

Uterine curettes commonly have a ring or a loop that can be sharp or dull to scrape the lining of the uterus.

Disposable curettes, such as a suction curette, come in different sizes and shapes and are disposed of after the procedure.

Safety on the sterile field:

Curettes should be organized in size order on the sterile field.

The curette should be wiped with sterile water and any debris should be saved as a specimen for pathology.

When passing a curette during the procedure, it should be clean and free of any debris in the tip of the curette. It cannot be effective to remove tissue or bone if the tip has any debris in it.

If the tip of the curette is sharp, it should handled carefully on the sterile field and team members should avoid touching the tip of the instrument.

Instrument names:

Curettes are commonly called by their name and intended use, such as “bone curette” or “uterine curette.” The surgeon may designate it by the number (ie, the size of the curette), such as “number 4 curette.”

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

(About Dilators and Probes)

Instrument usage: Dilators and probes are considered accessory and ancillary instruments. They are used to enhance the use of basic instruments or to facilitate the procedure.¹ Dilators are made of malleable copper and brass, while probes can be plated with chromium or silver.² Dilators, with their blunt tapered tips, are used to gradually enlarge an orifice through progressive dilatation.³ Probes are used to explore a structure, opening, or tract, such as a wound or a fistula, or to locate an obstruction.^2,3 Probes are most often blunt, malleable, and wire-like.³ Both types of instruments can be used to tunnel and create passages under the skin.² Dilators and probes come in an array of sizes and shapes that can be used in many surgical specialties.

Key differences:

Dilators and probes should be organized on the sterile field in incremental size order from smallest to largest.³ It is important to look at the shaft of the dilator or handle of the probe to see the imprinted number or size. The sizes are usually in the French scale (F).³

Water-based lubricant is commonly used with dilators, so it should be available on the sterile field.

Uterine/cervical dilators and lacrimal probes are double-ended, meaning they have two working ends, such as 9-10F or 13-14F uterine dilator or a 000-00 lacrimal probe.

Some dilators, such as urethral dilators, come in male and female due to the differences in anatomy, so it would be vital to know the sex of the patient prior to opening the dilators onto the sterile field.

The probe and grooved director are commonly used together so that the grooved director can guide the probe.³

Balloon dilators, such as a dilating balloon, are disposable and have a balloon tip that inflates to dilate.

Safety on the sterile field:

Dilators and probes should be organized in size order on the sterile field.

Dilators and probes should be wiped with sterile water and any debris should be removed before using again.

When passing a dilator or probe during the procedure, it is important to verbally indicate the size to the surgeon.

Instrument names:

Dilators and probes are commonly called by their name and intended use, such as “cervical dilator” or “lacrimal probe.” The surgeon may call it by the number representing the size of the dilator, such as “number 9-10 cervical dilator” or a “double zero.”

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

3. Nemitz, Renee. Surgical Instrumentation-eBook: An Interactive Approach. Elsevier Health Sciences, 2017.

(About Endoscopic Instruments)

Instrument usage: Endoscopic instruments are inserted into a body orifice.¹ Endoscopes used for viewing are hollow instruments with a rigid hollow sheath made of brass, stainless steel, or plastic, such as bronchoscopes, esophagoscopes, or sigmoidoscopes. Endoscopes can also have a fiberoptic cable inside to provide light or can be used for manual insufflation of air for visibility.¹ Endoscopes can also be lensed and be either rigid or flexible with eyepiece lens to view in several directions, and can have the ability to connect to a light source for illumination and a working channel to pass instrumentation.¹ Endoscopic instruments include instrumentation, which may be disposable or reusable, including forceps, graspers, and scissors.²

Key differences:

Rigid endoscopes, such as sinuscopes, with cords come in multiple sizes that can attach to a camera in to take photos and videos and allow the surgical team to view the procedure.¹

There are a variety of forceps, graspers, and scissors with different types of tips and sizes and some that can remove tissue, cauterize, and control bleeding.² The tips can vary, but they all have a ringed handle that can be locking or nonlocking.¹ The surface of the jaws can be smooth, serrated, or toothed, and the jaws can rotate or be fixed.¹

Flexible endoscopes, such as colonoscopes, have a cord that is attached for light and is attached to a camera in order to take photos and videos and allow the surgical team to view the procedure. The working channel can accommodate flexible forceps, graspers, and cautery.

Safety on the sterile field:

Scopes should be examined before use to be certain that the visibility is appropriate and that the light cord fits correctly.

It is important to wipe the tips of the forceps, graspers, and scissors between uses with a wet sponge to remove any debris. Most often, the debris that is removed should be saved for pathology, depending upon the facility’s policy.

A cold scope entering a cavity can cause fogging.¹ A scope warmer and anti-fog solution should be used on the sterile field.

Scrub personnel must look at the sheath of the forceps, graspers, and scissors to be certain that the instrument is in working order.

Flexible endoscopes must be precleaned at the point of use before processing at the end of the procedure.³

Instrument names:

Instruments are called by their use, such as “scope” or “grasper.” If there are multiple sizes or angles, the surgeon will preface the size or type of tip before the name, such as “45 degree scope” or “upward grasper.”

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

3. Guidelines for Perioperative Practice. Flexible endoscopes. AORN, Inc, Denver, CO; 2021.

(About Energy Devices)

Instrument usage: Energy devices are used to control bleeding during surgical procedures and seal off vessels.¹ There are many different types of energy devices that can be used, such as high frequency electrical current, ultrasound, bipolar electrosurgery, radiofrequency, cryoablation, and microwave ablation.¹ The type of device will be chosen based on the type of surgery, surgeon preference, and patient condition. Energy devices are used in all types of procedures that are open, laparoscopic, or robotic.

Key differences:

High frequency electrical current can coagulate, cut, or do a blend of coagulating and cutting.² The active electrode is the hand piece and the return electrode is the grounding pad that is placed on the patient.²

Ultrasound devices are used to remove or reduce tumors in highly vascular, delicate tissue, such as the brain, liver, kidney, and spleen.² The ultrasound hand piece converts electrical energy into mechanical motion by vibrating at an ultrahigh frequency.² The working end of the hand piece can be a scissor or a blade.²

Bipolar electrosurgery uses electrical current that goes through instrument prongs and back to the machine, not using a grounding pad.¹ Advanced bipolar devices can seal vessels up to 7mm.¹

Radiofrequency devices use low-frequency radio waves through electrodes that cause friction and increase the temperature of the tissue.¹ There is a plate that is placed under the patient for the radio waves to return to the generator.¹

Cryoablation devices use extreme cold to destroy tissue.¹

Microwave ablation devices use a microwave antenna that is placed directly on a tumor so that the high temperature will destroy tissue.¹

Safety on the sterile field:

When using high frequency electrical current, a suction evacuator should be used to prevent the patient and staff members from inhaling the plume or smoke that is generated by the device.²

When using high frequency electrical current, place the return electrode as close to the surgical site as possible, on a well-vascularized muscle. Avoid getting it wet and do not cut the grounding pad.¹

When using high frequency electrical current, the hand piece should remain in the holder unless it is being used by the surgeon.²

Ultrasound devices should be kept clean at the tip by using a moist sponge. The scrubbed personnel should avoid letting the hot tip touch the patient because it can cause an unintentional burn.²

Bipolar cautery should be used on patients that have implantable electronic devices, such as pacemakers.¹

All energy devices should be examined before use for cracks in the handpiece or cord, and checked to assure that they are in good, working order.

Placement of all energy devices should be carefully considered to avoid electromagnetic interference.¹

Instrument names:

Energy devices are called by the type of device they are and the manufacture’s name, such as “vessel sealer” or “bipolar cautery” or “harmonic scalpel.” The high frequency electrical current devices are commonly called “ESU” for electrosurgery unit or “cautery” or “Bovie,” which is an older manufacturer of this device.

References:

1. Criscitelli, Theresa. Fast Facts for the Operating Room Nurse: An Orientation and Care Guide. Springer Publishing Company, 2021.

2. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

(About Forceps)

Instrument usage: Forceps are used to grasp tissue atraumatically and hold tissue in place during the surgical procedure while dissecting or suturing.¹ There are many different types of forceps with different tips depending upon the type of tissue that is being grasped or held. It is vital that the surrounding tissue is not damaged and not perforated.¹ All surgical specialties use forceps.

Key differences:

Forceps can be toothed or smooth depending if it is being used on skin or heavy tissue or deeper on more delicate tissue. A common toothed forcep used on skin is an Adson forcep. A common forcep used in general surgery in the abdomen is a plain forcep.

The forcep can also be straight or angled, also known as bayonet style.^1,2 Bayonet style forceps help prevent the surgeon’s hand from occluding the line of vision by offsetting the handle with an angle.¹ This is commonly used in small spaces such as nasal or neuro surgery.

Forceps can be short for superficial grasping and holding or long for when in a deep body cavity. A commonly used long forcep that is used in the abdomen is a long plain forcep.

Forceps can have a fine tip for delicate tissue, such as a debakey forcep used in vascular surgery.¹

Safety on the sterile field:

It is important when passing a forcep on the sterile field to look at the tip of the forcep and be certain to pass the correct type of forcep so that the tissue is not traumatized by using the incorrect forcep. Also, when working in the body cavity, it is important to determine when a longer forcep is needed to reach the tissue that is being grasped or held.

When passing a suture on a needle holder, a forcep is always passed alongside the suture on the needle holder because both are used together. The forcep will be used to approximate the tissue and assist in pulling the suture needle through the tissue.

It is good practice to pair forceps on the back table and nest them within each other. Always bring the pair of forceps up on the mayo stand. There should never be just one forcep brought up to the mayo stand.

Instrument names:

All forceps can also be called “pick-ups.”1 Smooth forceps can also be called “thumb forceps.” Usually, smooth forceps are used on layers beneath the skin or on delicate tissue. Toothed forceps also called “mouse-tooth forceps” or “rat-tooth forceps” and are used on skin and heavy tissue such as fascia.² All other forceps are called by their name, such as “Adson”, “DeBakey”, “Gerald,” or simply “forcep”, if the same one is used repeatedly. Sometimes the surgeon will use a hand signal of the thumb taping the pointer finger to indicate the need for a forcep.

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

(About Laparoscopic Instruments)

Instrument usage: Laparoscopic instruments are inserted through a small, minimally invasive incision.¹ Laparoscopes are rigid and allow for viewing a body cavity and come in many sizes and angles. Laparoscopic instruments include instrumentation, which may be disposable or reusable, and needles and trocars, forceps, graspers and scissors, clip appliers and stapling devices, needle holders, aspiration-irrigation systems.²

Key differences:

Verres needles and trocars, both sharp and blunt, are used to provide access and insufflation to create a working space.² They come in different sizes and connect to CO2 tubing that allows the gas to flow at 1L to 2L per minute to create an intraperitoneal pressure of approximately 15 mmHg for the average adult.¹ For other body cavities, such as a joint or the bladder, fluid can use fluid to create working space.

Laparoscopes with cords come in multiple sizes that can attach to a camera to take photos and videos, and allow the surgical team view the procedure.¹ The angle of the laparoscope used, which can be 0 degree, 30 degree, 45 degree or 70 degree, is determined by the field of view that is required for the surgical procedure.

There are a variety of forceps, graspers, and scissors with different types of tips and sizes and some that can cauterize and control bleeding. 2 The tips can be duckbill (flat and straight), dolphin (pointed and straight), Babcock (tubular), or Maryland (curved), but they all have a ringed handle that can be locking or nonlocking.¹ The surface of the jaws can be smooth, serrated, or toothed and the jaws can rotate or be fixed.¹

Clip appliers, stapling devices, and needle holders are most often disposable and the cutting instruments usually require a larger port of entry such as a 12mm trocar.¹ Suturing instruments use a fixed instrument and a mobile jaw, that moves the needle back and forth through the tissue, with a knot pusher that slides the knot into place. 1 This is called extracorporeal knot tying.

Aspiration-irrigation systems are tubular instruments that irrigate and aspirate fluid. They can have a blunt tip or needlepoint tip.

Safety on the sterile field:

Needles and trocars on the sterile field should be handled as sharp instrumentation.

Scopes should be examined prior to use to be certain that the visibility is appropriate and that the light cord fits correctly.

It is important to wipe the tips of the forceps, graspers, and scissors between uses with a wet sponge to remove any debris.

CO2 should be warm. If it is cold, it can cause fogging. A cold scope entering the body cavity can also cause fogging.¹ A scope warmer and anti-fog solution should be used on the sterile field.

Scrub personnel must look at the sheath of the forceps, graspers, and scissors to be certain that there is no break in continuity. A pinpoint hole can cause a patient burn.

Direct coupling can occur if a metal instrument accidentally contacts the abdominal wall; therefore, the surgeon should avoid activating the instrument when not in touch with tissue.¹

Instrument names:

Instruments are called by their use, such as “trocar” or “scope” or “grasper.” If there are multiple sizes or tips, the surgeon will preface the size or type of tip before the name, such as “10 mm trocar,” “5mm scope,” or “Maryland grasper.”

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

(About Needle Holders)

Instrument usage: Needle holders are used to grasp and hold suture needles.¹ They can look similar to a clamp, with a ring handle and locking ratchet.¹ Because this type of instrument grasps a metal suture needle and not tissue, it is damaged often and requires repairs and replacement.² It is vital that the needle holder is used only for its intended purpose and that it is in working order, able to firmly grab the suture needle.²

Key differences:

The length of needle holders vary depending on whether they are needed superficially or deep in the body cavity. The jaws of the needle holder also vary and are designed for specific needs.² Standard needle holder jaws have a longitudinal groove that releases tension and prevents the needle holder from moving or denting the needle.² Diamond jaw needle holders have tungsten carbide in the jaw so that the needle does not rotate or move.² The jaws can be straight, curved, or angled.¹

Some needle holders, such as the Westcott, do not have a ratchet and instead have a spring action that can lock or be non-locking.

Safety on the sterile field:

The size of the needle holder should match the size of the needle—a large needle requires a large needle holder and a small fine needle requires a small fine tip needle holder, such as a vascular needle holder.¹

When loading a suture needle onto a needle holder, the “no-touch technique” should be used whereby the needle is not handled with gloved hands.²

When pulling the suture out of the packet, the scrub personnel should grab the needle with the needle holder and gently pull from the packet.²

The needle holder should be positioned approximately two thirds from the tip of the needle unless the surgeon requests a different position.

When passing a needle holder, a neutral zone or hands-free technique should be used.3

When passing a needle holder with a suture on it, a forceps should also be passed because it will be used simultaneously with the needle holder. Then a suture scissor should be ready to be passed to cut the suture.

Instrument names:

Needle holders are commonly called for by their length, such as “long needle holder,” “medium needle holder,” or “short needle holder.” Sometimes the first name of the needle holder can be used, such as “Webster” for a Webster needle holder.

Sometimes the surgeon will use a hand signal, motioning with an upward movement like suturing, to indicate the need for a needle holder.

References:

1. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

3. Guidelines for Perioperative Practice. Sharps Safety. AORN, Inc, Denver, CO; 2021

(About Powered Devices)

Instrument usage: Powered instruments are used to drill, cut, shape, and bevel bone, or for skin grafting and abrading skin.¹ The use of a powered instrument prevents using a manual instrument that can fatigue the user and may not be as powerful.¹ These instruments include microsurgical air-powered drills, saws, reamers, and abraders that are operated by a foot pedal or have fingertip control.¹ These instruments come in various sizes and shapes. Powered instruments can be powered by compressed air or nitrogen or they can connect to electrical power, such as a battery or plug.¹

Key differences:

The action of the powered instrument can be rotary, reciprocating, or oscillating.¹ Some instruments can have a combination of actions that can be changed by adjusting the controls.¹

Rotary movement is used when a hole needs to be drilled or to insert a screw, wire, or pin.¹

Reciprocating is a front to back movement and oscillating is a side to side movement that are both used to cut or remove bone or skin.¹

Drills, burrs, blades, reamers, and abraders come in many different sizes and can be disposable.

Battery powered instruments are cordless and have rechargeable batteries that must be attached to a battery charger between uses and then sterilized.

Safety on the sterile field:

Powered instruments must be assembled correctly because they are complex, with gears, rotating shafts, and seals.¹

The operator of the powered instrument should also be in control of the foot pedal, which will prevent premature activation of the device. The foot pedal should be moved away when not in use so that it is not inadvertently activated.¹

Before passing a powered instrument, the scrub personnel should check that it is working and if the battery is fully charged and working.

Electrically powered equipment should only be plugged into a power source that is in the off position and should be connected to the outlet before anesthetic gases are administered, but not disconnected until anesthetic gases are stopped.¹

When passing a powered instrument, it is important to have the safety latch engaged so that the instrument does not start operating if activated accidentally.

Scrub personnel should be certain that drills, burrs, blades, reamers, or abraders are cleaned with sterile water and that no bone chips are left in the ridges.

Drills, burrs, blades, reamers, or abraders that are disposable should be kept with other sharp items on the sterile field and disposed of in a sharps container.

Heat is generated when powered instruments are used and the heat can damage bone cells, so sterile saline is commonly dripped using a bulb syringe onto the operative area to keep the heat to a minimum.

Surgical team members must wear eye protection and a face shield to prevent splatter of blood and bone.¹

Surgical team should keep their hands away from powered instruments when activated.¹

Air-powered instruments should be used at the correct pressure (measured in pounds per square inch, PSI) set by the manufactuer.¹

Instrument names:

Powered instruments are commonly called by their name such as “reamer” or “saw” and by the size of the instrument, such as “25mm reamer” or “10mm saw blade.”

References:

1. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

(About Retractors)

Instrument usage: Retractors are used to hold back wound edges, anatomical structures, or tissue in effort to provide exposure of the operative site.¹ Retractors come in many different shapes and sizes depending upon their use and the needed size during the specific procedure.

Key differences:

Retractors can be manually held (ridged or malleable) or be self-retaining, and even attach to the OR bed.^1,2

Manual retractors that are ridged have a handle and a blade that comes in various widths and lengths to accommodate the size and depth of an incision.²

Some manual retractors can have prongs and be sharp or dull, such a Volkman rake retractor.²

A very commonly used retractor, the Army Navy retractor, has blades at both ends with the handle in the middle.

Malleable retractors are flat and can be bent into position to fit any angle and depth.²

Self-retaining retractors, such as the Weitlander retractor and Balfour retractor, do not need to be held by an assistant during the surgical procedure.²

Self-retaining retractors that attach to the OR bed are stabilized by being clamped to the bed and often contain different size blades and attachments.²

Safety on the sterile field:

Retractors are heavy instruments and should be placed at the bottom of the instrument tray, so that they do not damage delicate instruments.²

It is important not to place the retractor on tissue when not retracting, since it can damage tissue due to the weight of the retractor.²

Retractors are commonly used in pairs, so two of the same retractors should be placed on the mayo stand.²

When passing a retract that is sharp, a neutral zone or hands-free technique should be used so that the scrub personnel uses a no-touch technique.³

Some retractors, such as a Balfour retractor come with multiple pieces that must all be counted.

Instrument names:

Retractors are usually called by their instrument name, such as an Army Navy retractor would be called “Army Navy” or a Balfour retractor would be called “Balfour.” Sometimes, they will be called by their type of retractor, such as “self-retainer.”

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

3. Guidelines for Perioperative Practice. Sharps Safety. AORN, Inc, Denver, CO; 2021

(About Robotic Instruments)

Instrument usage: Robotic instruments are inserted through small, minimally invasive incisions. A programmable manipulator manipulates specialized instruments to complete a surgical procedure.¹ These instruments work under partially programmed control by the surgeon, can be modified by the surgeon, and can be controlled by a telemanipulator that mimics the surgeon’s exact or scaled hand movements.¹ The needles, trocars, laparoscopes, and instrumentation that are used during robotic surgery are similar to those used for laparoscopic surgery. Robotics are commonly used general surgery, gynecologic surgery, urologic surgery, and cardiac surgery.

Key differences:

Verres needles and trocars, both sharp and blunt, are used to provide access and insufflation to create a working space.¹ They come in different sizes and connect to CO2 tubing that allows the gas to flow at 1L to 2L per minute to create an intraperitoneal pressure of approximately 15 mmHg for the average adult.² Fluid can be used in other body cavities to create working space, such as in the bladder or joints.

Robotic laparoscopes with cords have a 3-D binocular eyepiece that comes in multiple sizes and angles that attaches to a 3-D high-definition-capable camera to take photos and videos and allow the surgical team view the procedure.¹ The console, either single or double, allows for communication between surgeons that are working together and control over video, audio, and ergonomic settings.²

Robotic instruments have an articulating wrist that rotates 360 degrees located near the tip of the instrument guided by electronics in the instrument base.¹

There are a variety of instruments tips that are similar to laparoscopic instruments used during robotic surgery. They have electronics that can communicate and log each use of the instrument, the status of the instrument, and when it needs to be changed or repaired.² Most of these instruments have 10 uses and can be manually marked to document the number of uses.

Clip appliers, stapling devices, and needle holders are manipulated through the robotic console.

Aspiration-irrigation systems are tubular instruments that irrigate and aspirate fluid. They can have a blunt tip or needlepoint tip.

Safety on the sterile field:

Needles and trocars on the sterile field should be handled as sharp instrumentation.

Scopes should be examined before use to be certain that the visibility is appropriate and that the light cord fits correctly.

It is important to wipe the tips of robotic instruments with a wet sponge between uses to remove any debris.

Instruments are moved by a pulley system within the robotic arms and it is important that the scrub personnel press the pulley to confirm that they are able to move freely.¹

If a robotic procedure converts to an open procedure, the scrub personnel must release the robotic arms from the trocars and undock the robot to move it out of the surgical field.¹

A sterile wrench to disengage the articulating arms should be included in the instrument set in order to convert to an open procedure in the case of an emergency.²

The robot has a rechargeable battery that can run for 20 minutes if there is a power failure and it is important to know where the override switch is to continue surgery.²

Instrument names:

Instruments are called by their use, such as “monopolar scissors” or “spatula,” or by the manufacturer’s name.

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's operating room technique. Elsevier Health Sciences, 2016.

(About Scalpels)

Instrument usage: Scalpels are used to cut, incise, separate, or excise tissue.¹ Scalpels are used in almost all surgical procedures. It is most common to use a scalpel to cut through the skin, but can also be used at other times during the surgical procedure. All surgical specialties use scalpels.

Key differences:

Most scalpels have reusable handles made of brass and disposable blades made of carbon steel.^1,2 The handles have various widths, lengths, and angles.¹ A longer handle would be used deeper in a body cavity, while a shorter handle would be used superficially. The scalpel blades have various sizes and shapes.¹ The scalpel blade may have one or two cutting edges and is designed for very specific purposes.¹

There are specific blades for different types of surgery, such as a 10 blade or a 20 blade, which is larger, for a skin incision, while a 15 blade is commonly used for more delicate cutting or plastic surgery.

There are many different sizes and shapes of beaver blades for arthroscopy surgery and other surgical specialties. Beaver blades may be inserted into a universal handle that is nondisposable or may come on a disposable handle.

Specialty blades, such as a lancet knife, are most often completely disposable or have a disposable blade tip.

Safety on the sterile field:

The scalpel blades can be changed during the procedure when necessary.² When changing the scalpel blade during the procedure, a heavy clamp, such as a Kelly clamp, should be used to detach and attach a new blade.¹ Fingers should never be used and needle holders are not recommended or designed to load a scalpel blade.¹

It is important that when a scalpel blade is used on the skin, it is not also used deeper in the body cavity. Because skin cannot be considered sterile, this blade is considered dirty. The blade should be taken out of use after the skin incision.

It is important to keep scalpels separate from other instruments and protect the sharp edges when cleaning, sterilizing, and storing them.¹ It is also important to keep blades safely separated on the sterile field and all knife blades, used and unused, with other sharps.

The scrub personnel must use proper precautions during the handling or disposing of scalpels to prevent injury and/or damage to the instrument.¹

When passing a scalpel, a neutral zone or hands-free technique should be used so that the scrub personnel uses a no-touch technique.³

Instrument names:

The scalpel that is initially used for the skin incision is called the “skin knife” or “dirty knife.” It may also be called by the name of the blade, such as a “10-blade” or “20-blade.” When a longer knife handle is needed in a body cavity, it may be called a “long knife.” Usually, a longer handle would use a finer blade, such as a 15 blade. Specialty scalpels are most often called by the type of blade it is associated with.

References:

1. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

3. Guidelines for Perioperative Practice. Sharps Safety. AORN, Inc, Denver, CO; 2021.

(About Scissors)

Instrument usage: Scalpels are used to cut, incise, separate, or excise tissue.¹ Scalpels are used in almost all surgical procedures. It is most common to use a scalpel to cut through the skin, but can also be used at other times during the surgical procedure. All surgical specialties use scalpels.

Key differences:

Most scalpels have reusable handles made of brass and disposable blades made of carbon steel.¹,2 The handles have various widths, lengths, and angles.¹ A longer handle would be used deeper in a body cavity, while a shorter handle would be used superficially. The scalpel blades have various sizes and shapes.¹ The scalpel blade may have one or two cutting edges and is designed for very specific purposes.¹

There are specific blades for different types of surgery, such as a 10 blade or a 20 blade, which is larger, for a skin incision, while a 15 blade is commonly used for more delicate cutting or plastic surgery.

There are many different sizes and shapes of beaver blades for arthroscopy surgery and other surgical specialties. Beaver blades may be inserted into a universal handle that is nondisposable or may come on a disposable handle.

Specialty blades, such as a lancet knife, are most often completely disposable or have a disposable blade tip.

Safety on the sterile field:

The scalpel blades can be changed during the procedure when necessary.² When changing the scalpel blade during the procedure, a heavy clamp, such as a Kelly clamp, should be used to detach and attach a new blade.¹ Fingers should never be used and needle holders are not recommended or designed to load a scalpel blade.¹

It is important that when a scalpel blade is used on the skin, it is not also used deeper in the body cavity. Because skin cannot be considered sterile, this blade is considered dirty. The blade should be taken out of use after the skin incision.

It is important to keep scalpels separate from other instruments and protect the sharp edges when cleaning, sterilizing, and storing them.¹ It is also important to keep blades safely separated on the sterile field and all knife blades, used and unused, with other sharps.

The scrub personnel must use proper precautions during the handling or disposing of scalpels to prevent injury and/or damage to the instrument.¹

When passing a scalpel, a neutral zone or hands-free technique should be used so that the scrub personnel uses a no-touch technique.³ Sometimes the surgeon will use a hand signal with the first and middle fingers, as illustrated here, to indicate the need for scissors.

Instrument names:

The scalpel that is initially used for the skin incision is called the “skin knife” or “dirty knife.” It may also be called by the name of the blade, such as a “10-blade” or “20-blade.” When a longer knife handle is needed in a body cavity, it may be called a “long knife.” Usually, a longer handle would use a finer blade, such as a 15 blade. Specialty scalpels are most often called by the type of blade it is associated with.

References:

1. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

2. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

3. Guidelines for Perioperative Practice. Sharps Safety. AORN, Inc, Denver, CO; 2021.

(About Specula)

Instrument usage: Speculums are viewing instruments that are used to examine the interior of body cavities, hollow organs, or structures.¹ Speculums are commonly made of stainless steel and are reusable, but some, especially gynecological speculum, can be disposable and made of plastic.

Key differences:

Speculums can be hinged, with blunt blades used to enlarge and hold open a canal, such as a vaginal speculum or nasal speculum.¹

Some speculums act like a retractor, such as a weighted vaginal speculum or an eye speculum.²

Rectal speculums can be self-retaining with rounded blades that are held in place to provide exposure during rectal surgery.²

Other speculums are like a funnel, such as an ear speculum.¹

Safety on the sterile field:

Speculums can come in various sizes and should be organized on the sterile field from smallest to largest.

If the speculum has multiple parts and screws, all parts must be part of the surgical count.

When inserting a speculum into the rectum, the scrub personnel should have sterile saline, betadine, or water soluble lubricant available on the sterile field to place on the end of the speculum.

If the laser is being used with the speculum, an ebonized, glare-free, non-reflective speculum should be used to prevent injury of the patient or staff.

Instrument names:

Speculums are commonly called by their instrument name, such as “vaginal speculum” or just “speculum.” If multiple sizes are used, they would be referred to by the size that is needed, such as “number 4 ear speculum.”

References:

1. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

2. Nemitz, Renee. Surgical Instrumentation-eBook: An Interactive Approach. Elsevier Health Sciences, 2017.

(About Staplers and Clips)

Instrument usage: Surgical staplers are used to resect part of an organ, transect tissue, and anastomose structures.¹ Surgical staplers can be reusable, partially reusable, or disposable. The staples are commonly made of titanium, stainless steel, or absorbable material.² The staples are nonreactive and permanently remain in the body.¹ The stapler can place one or multiple rows of staples in a straight or circular pattern, and can cut and anastomose.¹ The use of staplers significantly decreases operating time and can shorten length of stay for the patient.¹ Surgical staplers are used in gastrointestinal, gynecologic, and thoracic procedures, and many other surgical specialties.¹

Clips are used to occlude blood vessels, nerves, and other small structures, or to mark tissue.¹,2 Clips are single staples that can be placed using a preloaded multiple clip applier or a single clip applier.² Clips are small V-shaped staples made of stainless steel, titanium, or synthetic absorbable suture material.¹

Key differences:

Staplers can be circular, curved, endo-GIA, end-to-end anastomosis, linear, open, or laparoscopic stapler.¹

Terminal end staplers are L-shaped and are made to be positioned across the end of a hollow organ, such as bowel or stomach. Some can have ends that articulate to get into a specific area.¹

Internal anastomosis staplers are straight, with two parts that are made to connect segments of a hollow organ to make a pouch or reservoir.¹ The two tube-shaped organs are aligned next to each other and one side of the stapler is positioned in each opening. When the instrument is fired, the tubes are stapled along the adjoining lengths and an internal knife blade cuts between the two sets of double staple lines, which creates a longitudinal opening on the inside of the anastomosed organ segments.¹

End-to-end circular staplers are long and are designed to staple two hollow, tubular organs to each other to create a continuous circuit.¹ The ends of the tubular organs are positioned over the distal and proximal tips of the stapler and are secured with a suture, then the end of the stapler is closed, with the tissue of the tied ends completely in the stapler, a double row of staples is fired in a circle, and a circular knife trims the excess rim of tissue from the ends of the tubular organs.¹

Clips can be manual or powered and are available in multiple sizes.²

Safety on the sterile field:

Reusable staplers have many moving parts that must be assembled prior to use on the sterile field.² It is important for the scrub personnel to know how to proficiently assemble the reusable stapler so that it works properly.

Disposable staplers come completely assembled² and only need to have the staple cartridge replaced for multiple uses.

The cartridge for both reusable and disposable staplers are disposable. It is important to keep track of how many times the disposable stapler is fired, since the device has a limit set by the manufacturer. The cartridges should be a counted item when doing surgical counts.

After a stapler or clip applier is used, the surgeon will most likely ask for a scissor or a cautery, if the stapler or clip does not have a cutting component within the device.

When using an end-to-end circular stapler, it is important to retrieve the tissue that is left in the stapler for pathology.¹

It is important to pass the correct stapler with the correct staples or clip depending on the tissue that is being stapled or clipped.

Instrument names:

The stapler or clip is most often simply called “stapler” or “clip.” They may also be called by their style or by the manufacturer’s name.

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

(About Suction Devices)

Instrument usage: Suction instruments are considered accessory and ancillary instruments that are used to enhance the use of basic instruments or to facilitate a procedure.¹ Suction or aspiration is when negative pressure is applied to evacuate blood, body fluid, tissue, or irrigating solution from the surgical site.² Suctioning during a surgical procedure helps to provide better visibility. Suction can also be used to remove plume generated from electrosurgery or laser devices from the surgical field and should be attached to a smoke evacuator. Suction can be mechanical or manual with disposable or reusable tips.² Suction tips come in an array of sizes and shapes that can be used in many surgical specialties.

Key differences:

The style of the suction tip is determined by where it will be used and the preference of the surgeon.²

For large amounts of blood or fluid, such as in abdominal surgery and trauma surgery, a Poole suction tip or Yankauer suction tip should be used so that the blood or fluid can be evacuated quickly.²

For less blood and more delicate surgery, such as in otolaryngology procedures, neurosurgery, and plastic surgery, a Fraiser suction tip may be used.²

Suction can be used to evacuate a cavity, such as a suction curette, and be attached to a suction machine that controls the amount of vaccum.²

Suction and irrigation during laparoscopic procedures is commonly doneusing a reusable or disposable suction irrigator.

Suction can also be attached to the port of a trocar, scope, or instrument.²

Small lumen suctions may have a stylet that can be used to maintain patency.

Safety on the sterile field:

The appropriate suction tip should be attached to the suction tubing that is passed off of the sterile field and connected to the suction generator for mechanical suction.

The suction tip should be attached to an empty syringe for manual suction.

Because the inner lumen of the suction tip is difficult to clean and sterilize, disposable suction tips are commonly preferred when their use is possible.²

Reusable suction tips should be irrigated with sterile water before to assure patency prior to use. If it is not patent, another suction tip should be used.

During the procedure, the scrub personnel should monitor the suction tip and clear it with sterile water when necessary. When using sterile water to clear suction, the scrub personnel must account for how much water is suctioned so that it is not part of the blood/fluid loss of the patient.

Some reusable suction tips have screws that must be accounted for during the surgical procedure and should be part of the initial and end instrument count.²

When suctioning delicate tissue, a lap pad, radiopaque sponge, or neurosurgical pattie may be used as a filter between the suction tip and tissue.¹

At the end of the procedure, it is important to flush all reusable suction tips with sterile water to prevent organic debris from drying.² This will assist in the central sterile processing of this instrument.

Instrument names:

Suction tips are commonly called by their name, such as “Yankauer” or “Frazier,” or may just simply be called “suction.” If different sizes of suction are needed, the scrub personnel should indicate the size of the suction when passing it to the surgeon or assistant.

References:

1. Rothrock, Jane C. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health Sciences, 2018.

2. Phillips, Nancymarie. Berry & Kohn's Operating Room Technique. Elsevier Health Sciences, 2016.

Instrument name: 0.035" Wire

Alternate name: EUS wire

Instrument category: Accessory

Used for: Placing through an EUS needle that then can help create a tract

Specialty commonly used in: Endoscopy procedures