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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 6
Classical (Open) Surgery
6.1 “CLASSICAL” SURGICAL INSTRUMENTS FOR CONVENTIONAL SURGERY
Surgical instruments have a very long history but those currently in use
were mostly developed in the relatively short era of scientific surgery.
They often bear the name of the respective surgeon who introduced
them into clinical practice. A systematic overview including names and
images is given in
Although many of them do not represent “modern” biomedical engineering, a sound knowledge is necessary, since the understanding of the
mode of action is fundamental to the design of innovative tools.
6.1.1 Surgical Knives/Scalpels
A scalpel is a bladed surgical instrument used to make cuts into the body.
This is a very sharp instr ument and comes in various sizes for different
types of cuts and surgeries. Most blades are made of either carbon or
stainless (medical grade) steel (
The shape of the blade is designed according to the intended use.
Scalpels are often used as a symbol of surgery, but actually they do not
play a major role any longer in surgery. It is more or less confined to skin
incision (
effective and safer. Reusable scalpels have to be sharpened regularly.
Reprocessing often leads to injuries due to careless handling. All these
problems including resterilization can be avoided by the use of rather
cheap disposable knives.
Fig. 6.2).
Today, scalpels are most commonly disposable since they are more cost
[1].
Fig. 6.1).
6.1.2 Forceps/Tweezers
Forceps are hinged surgical instruments used to grasp, hold, and to move
tissue or other objects during an operation. The instrument comes in a
variety of types and sizes, and is one of the most important elements of
the surgical armamentarium. Forceps are also used to grasp blood vessels,
tissues, and other objects (
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
Fig. 6.3).
All rights reserved.
221
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Biomedical Engineering in Gastrointestinal Surgery
Figure 6.1 (A) Standard disposable surgical scalpel; (B) four different blades
(top down): incision scalpel, scalpel to remove skin sutures, small scalpel for small,
delicate incision, standard blade for incision of the abdominal wall; (C) historical
reusable scalpel; (D) amputation knife. From MITI.
Figure 6.2 Inguinal skin incision. Note the characteristic grip with three fingers.
From MITI.
Classical (Open) Surgery
Figure 6.3 (A) Anatomical forceps have a blunt tip with groove for gently grasping
the tissue like small bowel (top left). Surgical forceps have three or more teeth to
fixate firmly a more robust anatomical structure, e.g., the skin (bottom left). (B) The two
edges of a skin incision are gripped firmly by two “surgical” forceps. (C) An intestinal
loop is grasped with two anatomical forceps. All from MITI.
223
Forceps are not only necessary to grasp structures when fingers are too
large to grasp them, but also necessary to avoid direct contact between
the surgeon and the anatomical site. This “mediating” tool can easily be
sterilized, whereas the hand of a surgeon—even though being washed
and wearing gloves—may lead to contamination.
6.1.2.1 Basic Forceps Designs
There is a large range of forceps available today. Those in use in general
surgery differ from those used in neuro- or vascular surgery. The challenge is always to find a good compromise between secure fixation and
minimal trauma.
In abdominal surgery, blunt-nosed (anatomical) forceps of different
lengths are most commonly used. Since forceps are often used to coagulate small vessels, it is helpful if part of the shaft is insulated (
Fig. 6.4).
A high quality of the forceps is required to hold tissue in place when
a suture has to be applied, even within a deep cavity (
Fig. 6.5).
6.1.3 Scissors
Surgeons use surgical scissors during an operation in order to cut tissues
at the surface or inside the human body. The blades can be either curved
or straight.
The effect of tissue dissection is achieved when the sharpened edges
slide against each other when the bows opposite to the joint are closed.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 6.4 Standard forceps for visceral open surgery. They are provided in different
lengths with broad or slim tips according to the purpose. They are almost completely
covered by an insulating plastic cover. From MITI.
Figure 6.5 (A) Long forceps used to fixate the tissue (stomach); (B) coagulation of
a small vessel by means of the forceps. The instrument closes the circuit between
the thermocauter and the patient. All from MITI.
For a better wound healing, scissors should cut exactly at the point where
the blades meet. Shearing effects due to bluntness or floppy joints have to
be avoided. Scissors are usually designed for right-handed persons. Highquality surgical scissors with good tension can also be used by left-handed
individuals.
Classical (Open) Surgery
225
Scissors are the most important and valuable items of the surgical
instrument set
[2]. They are produced of high grade medical stainless
steel, frequently hardened (tungsten carbide). Some approaches have
already been made to offer disposable scissors to the market. Up to now,
the success is limited
able. About 2000 different types of surgical scissors are in use (
[3]. Still today high-quality surgical scissors are reus-
Fig. 6.6).
In visceral surgery, however, the need for highly specialized scissors
is low. The most frequently used one is the Metzenbaum type (
Fig. 6.7).
For the handling of abdominal tissue and organs which are mostly
delicate and fragile, the Metzenbaum scissors are ideally suited. The blades
are usually blunt and curved. Since the shanks are comparatively long
as compared to the blade, the haptic feedback is excellent. The surgeon
Figure 6.6 (A) Standard Metzenbaum scissors as largely used in visceral surgery.
Note the relatively long shank-to-blade ratio. The blades are curved. (B) Robust
variant of the Metzenbaum scissors as used in gynecology and orthopedics. (C)
Typical issue of a vascular scissors. (D) Microscissors for neurosurgery. (E) Rib scissors.
(F) Bandage scissors. From MITI.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 6.7 Medium size Metzenbaum scissors. From MITI.
Figure 6.8 In addition to severing tissue (A), Metzenbaum scissors are also used for
blunt dissection (B). All from MITI.
feels well whether the structure dissected is soft or hard which helps him
to discriminate the border between critical areas (
Fig. 6.8A). Even more
important is this “sensitivity” of the scissors in case of blunt dissection,
since the scissors can also be used to spread the tissue (
Fig. 6.8B).
High-quality Metzenbaum shears are expensive and should not be
used for too rough tasks, e.g., cutting of material like sutures, meshes, or
sponges. For these purposes Mayo scissor s are very adequate (
Fig. 6.9).
Mayo scissors have semiblunt tips. The blades and handlings are stronger than in Metzenbaum scissors. Often they are called suture scissors or
material scissors. Meshes (
Fig. 6.10A), plastics, and rubber (Fig. 6.10B)
require higher cutting forces than most tissues. The sharp branch of the
Mayo scissors facilitates a precise elaboration of the object.
An interesting, relatively new development is so-called “electrical”
shears: to prevent smaller bleeding out of capillaries and tiny arteries,
Classical (Open) Surgery
Figure 6.9 Mayo scissors. The joint is positioned to the middle of the instrument.
One branch of it is sharp, one is blunt. From MITI.
227
Figure 6.10 (A) Mayo scissors used to shape a mesh for inguinal hernia repair;
(B) cutting out a segment of the circumference of a T-tube. All from MITI.
specially insulated scissors are available (Fig. 6.11A). Prior to the definitive
cut, coagulation of the tissue between the blades is induced by an
electrical impulse.
This is usually initiated by the surgeon via a foot pedal. Necessarily,
this type of scissors needs two cables which is found irritating by many
surgeons (
Fig. 6.11B).
Electrical scissors avoid bleeding and speed up the surgical manipulation.
How e ver, lateral heat spread has to be considered, which ma y lead to injuries
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Biomedical Engineering in Gastrointestinal Surgery
Figure 6.11 (A) Electrical scissors are available in various lengths. They resemble
Metzenbaum scissors in shape. The body is insulated with exception of the tips.
(B) Half-opened scissors with cables. All from MITI.
of adjacent tissue (e.g., nerves). The risk may even be higher than with ultrasound activated dissectors (see
Section 6.3: Ultrasound Dissection) [4].
6.1.4 Fixation Instruments/Locking Forceps
Surgical clamps (Fig. 6.12) are locked forceps designed to grasp, hold, or
occlude anatomical structures and objects. The tips are shaped according
to the purpose. The forces exerted vary considerably. A strong Mikulicz
clamp is suitable to grip the fascia but far too strong to hold vessels.
6.1.4.1 Hemostats
Surgical clamps that are used to avoid bleeding by temporarily occluding
the vessel either completely or partially are called hemostats. If a vessel
has to be severed, it is firstly mobilized. Then a pair of (usually curved)
hemostats is positioned. The vein/artery is cut and the stumps finally
Classical (Open) Surgery
Figure 6.12 A selection of typical surgical clamps: (A) Backhaus: Very sharp tips to fixate robust objects firmly; (B) Mikulicz: Enable the surgeon to hold tough tissue reliably,
e.g., the fascia of the abdominal wall; (C) Babcock: Smooth grip, e.g., for ligaments or
tubular shaped objects; (D) Collin or Foerster: Characteristic circular eyelet. Used to
hold the gallbladder or the stomach; (E) Allis: Popular instrument with distinct coarsely
ribbed grip panel to hold and manipulate intestinal organs; (F) Duval or Pennington
clamp with characteristic triangular eyelet, e.g., for colorectal surgery. All from MITI.
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Figure 6.13 (A) Severing a small blood vessel using Kelly clamps. The tip may be
either straight or curved. (B) If both sides are secured with the clamps, the vessel can
be cut through in-between. All from MITI.
occluded by means of a ligature. As soon as the stump is secured, the
hemostat can be taken off (
Fig. 6.13).
As compared to the relatively small Kelly clamps, Overholt forceps are
longer and stronger (
Fig. 6.14).
Overholt clamps are widely used in visceral surgery since they do not
only serve as hemostats but are, in addition, ideally suited for blunt
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Biomedical Engineering in Gastrointestinal Surgery
Figure 6.14 Overholt clamp. This type of forceps is available in various lengths with
different angles of bending. If the ends are positioned in a 90 degrees angle to the
main axis, it is also denominated “rectangle.” (A) Typical Overholt clamp. Note the
clamp mechanism. (B) Different angles of the tips. All from MITI.
Figure 6.15 (A) A finger-shaped tissue specimen has to be resected. To avoid bleeding out of the remnant, a clamp is positioned. (B) After resection a thread is slung
around it. (C) After 34 knots, the clamp can be released. The wound is held open
by a self-retaining retractor. All from MITI.
dissection. A typical application of the Overholt clamp is demonstrated in
Fig. 6.15.
6.1.4.2 Vascular Clamps
Successful vascular surgery is only possible if the surgical site is dry, i.e., the
bleeding has to be stopped first before the lesion can be repaired or a bypass
be sutured. Accordingly, a special type of clamp is required which compresses the arterial wall as firmly and reliably as an ordinary hemostat but