Instruments II: Retractors, Suction and Specialty Sets

This is Unit Thirteen of Tech in Surgery Prep. Unit Twelve ended with look-alikes kept apart on the Mayo stand. This unit finishes the basic tray, with retractors and suction, then opens the specialty sets. Carry one idea through this lecture. Multi-part instruments come apart, and that is why every blade, screw and part is counted on its own. A worked example near the end shows a count that found a missing part only because it was listed separately. By the end you will be able to choose handheld and self-retaining retractors. To match suction tips to the job. To describe instrument sets and the specialty, laparoscopic and powered instruments. And to inspect instruments and account for every part of a multi-part instrument.

Eight entries on retractors, held by hand or holding themselves, matched to the depth of the wound.

Holding tissue aside.

TSC 301 Why Retraction Matters

Retractors hold tissue and organs aside so the surgeon can see and reach the site. Handheld retractors are held by the surgeon or an assistant; self-retaining retractors hold themselves open with a frame or ratchet. Retraction is placed with care, because too much pressure can injure the tissue it protects.

Chosen by depth.

TSC 302 Handheld Retractors

Handheld retractors suit different depths and tissues. For skin and shallow tissue in small incisions there are Army-Navy retractors, often in pairs, and toothed rake retractors. For shallow to medium wounds, the Richardson has a right-angled blade. For deep abdominal and pelvic work, the Deaver's long, smooth curve holds back organs such as the liver. To protect organs and bowel deep in a wound, the ribbon or malleable retractor is a flat, bendable blade. Rakes are passed like sharps, teeth away from hands, and never placed where they could catch bowel or a vessel.

Two small retractors.

TSC 303 Army-Navy and Senn

Army-Navy and Senn retractors are small, for skin and shallow tissue. The Army-Navy has a blade at each end and is often used in pairs; the Senn has a small rake at one end and a right-angled blade at the other. Ask which end the surgeon wants, and pass that end toward the wound.

An angle and a curve.

TSC 304 Richardson and Deaver

Richardson and Deaver retractors are larger, for abdominal surgery. The Richardson's right-angled blade suits shallow to medium wounds; the Deaver's one long curve holds back deep organs and the abdominal wall. A sharp right angle means Richardson; a smooth, sweeping curve means Deaver.

A blade bent to fit.

TSC 305 Ribbon and Malleable

Ribbon or malleable retractors are flat blades bent to fit the space. They hold back and protect organs and bowel, and are often used to protect the intestines during abdominal closure. Once bent, the blade keeps its shape, so reshape it as the surgeon directs.

Retractors that hold themselves.

TSC 306 Self-Retaining Retractors

Self-retaining retractors hold a wound open by themselves, with a ratchet or a frame of adjustable blades. Small ones, such as the Weitlaner, use toothed arms locked by a ratchet. Large abdominal ones, such as the Balfour, retract in several directions. Table-mounted systems, such as the Bookwalter, attach to the table and carry many blades. Every blade, screw and part of a multi-part retractor is counted separately, because parts can separate during the case. Know how many went into the wound, and confirm they all came out.

A small self-retainer.

TSC 307 Weitlaner

The Weitlaner holds open a small or shallow wound by itself. Its toothed arms spread the edges and a ratchet locks them, freeing the assistant's hands. Its teeth are sharp, so it is handled like other sharp retractors.

A large abdominal self-retainer.

TSC 308 Balfour

The Balfour is a large self-retaining retractor for big abdominal incisions, holding the edges apart in more than one direction with adjustable blades. Its blades and parts are removable, so each is counted separately and checked when it comes out of the wound.

Three entries on suction tips and on using suction to clear smoke.

Three tips, three jobs.

TSC 309 Suction Tips

Suction tips remove blood, fluid and debris so the surgeon can see. The Yankauer is a rigid tip for general surface suction, less likely to pull in tissue, and anesthesia uses one for the mouth and throat. The Poole is a long tube with a perforated sleeve for large volumes in a cavity; without the sleeve, the inner tube gives finer suction. The Frazier is a fine, angled tip for deep, narrow spaces, as in ear, nose and throat work and neurosurgery. A Frazier in a pool of blood will clog, and a Poole will not fit a narrow cavity.

Matching the tip.

TSC 310 Yankauer, Poole, Frazier

The Yankauer handles general surface work, the Poole removes large amounts of fluid from cavities, and the Frazier reaches deep, narrow spaces. Have the next likely tip ready, especially when bleeding increases.

Suction for smoke.

TSC 311 Suction and Smoke

Suction at the field can also clear surgical smoke from the site. Room suction used for smoke should have an in-line filter, with the nozzle kept close to where the smoke forms. A dedicated smoke evacuator is used when there is a lot of smoke.

Seven entries on how instrument sets are organized, and on the instruments of each specialty.

Sets, trays and their lists.

TSC 312 Instrument Sets and Trays

Instruments are grouped into standardized sets, so the same instruments arrive for the same kind of procedure. A basic set holds common instruments for open procedures. Specialty sets serve particular procedures, and implant systems may arrive on several vendor trays. Each set has the same type and number of instruments and a tray list used for counting. Rarely used instruments may be peel-packed or kept on backup trays, and trays are reviewed to remove what is seldom used. If a set does not match its list when opened, the circulating nurse is told before the case begins.

Gentle on vessels.

TSC 313 Vascular Instruments

Vascular instruments handle vessels gently and stop flow without injuring the wall. Examples are atraumatic clamps that fully occlude vessels during repair, fine angled scissors for opening them, and small spring clamps. They are delicate, and their jaws are protected so they keep closing evenly.

Instruments for bone.

TSC 314 Orthopedic Instruments

Orthopedic instruments work on bone and are often heavier: rongeurs to remove bone, elevators, osteotomes, curettes and rasps, powered saws and drills, and implants such as pins, plates, screws and joint replacements. Many arrive as multi-tray implant systems, which need careful counting and tracking.

Gynecologic instruments.

TSC 315 Gynecologic Instruments

Gynecologic instruments include specula designed for the vagina, cervix and uterus. A weighted speculum holds back the posterior vaginal wall without a hand; others hold the walls apart to show the cervix. A weighted speculum is heavy, so it is placed gently and never left where it could fall.

Long, fine instruments.

TSC 316 ENT and Neuro Instruments

Ear, nose and throat surgery and neurosurgery use long, fine instruments for deep, narrow spaces: nasal specula, angled suction tips, bayonet forceps that keep the hand out of the line of sight, and fine bone-cutting instruments for the spine. Fine tips bend or break easily, so they are inspected before and after use.

Instruments through ports.

TSC 317 Laparoscopic Instruments

Laparoscopic instruments are long, thin versions of open instruments, working through small ports. The insufflator fills the abdomen with carbon dioxide for working space, and a Veress needle is one way to start. Trocars are the ports through the abdominal wall. The camera, lens and light source show the inside on a monitor, and lenses may need defogging. Long graspers, scissors, dissectors and needle holders do the work. The light cable can burn drapes or skin, so keep it connected to the scope while on, and never lay a lit cable on the field.

Saws and drills.

TSC 318 Powered Instruments

Powered instruments, such as bone saws and drills, use electric or battery power to cut, drill and shape bone. Saws are used freehand or with a cutting guide, and drills and reamers prepare bone for implants. They are inspected before use and run only as their manufacturers direct.

Two entries on inspecting and protecting instruments, then two worked examples. The opening idea is paid off at the last.

Checking every instrument.

TSC 319 Inspecting Instruments

Instruments are inspected for damage and completeness before use and at the counts. Check that tips meet, jaws close evenly, ratchets hold, scissors cut cleanly, and multi-part instruments have every part. A damaged instrument is set aside, labelled and reported for repair, never used.

Protecting fine instruments.

TSC 320 Care of Delicate Instruments

Delicate instruments, such as fine scissors and microsurgical instruments, need protection to stay precise. Tip caps protect fine ends during sterilization and transport, and heavy instruments are placed so they cannot crush delicate ones. A fine instrument used for a heavy task can be ruined in one use.

A set, family by family.

TSC 321 Building a Laparotomy Set

A worked example, constructed for this course, follows Drew checking a major laparotomy set against its tray list. Cutting: two knife handles, curved and straight Mayos, and Metzenbaums. Grasping: DeBakeys, toothed forceps and long forceps. Clamps: hemostats in two sizes, right angles, Kochers and Babcocks. Retractors: Army-Navys, Richardsons, a Deaver, malleables and a Balfour with its blades. Suction: a Yankauer and a Poole. Needle holders in two lengths, towel clamps and sponge forceps. Drew notes the Balfour's two side blades and centre blade, each counted. A malleable on the tray card is missing, and Drew tells the circulator before the count, so the record starts accurate and a replacement is opened.

One blade short.

TSC 322 A Missing Retractor Blade

A worked example, constructed for this course, pays off the opening idea. At the first layer of closure, Morgan and the circulating nurse count instruments and find the Balfour on the back table without one of its blades. Morgan says so, the surgeon pauses, and a recount confirms it. The supervisor is told. The surgeon searches the wound edges, Morgan the stand, table and drapes, the circulator the floor and linen. The surgeon finds the blade, detached under the edge of the incision. The count is now correct and documented, and the retractor goes for repair of its loose screw. Counted as one whole retractor, the blade could have stayed behind while everyone believed it was returned.

Look at what you can now do. You can choose handheld retractors by depth, from Army-Navy to Deaver and malleable, and explain self-retaining retractors such as the Weitlaner and Balfour. You can match the Yankauer, Poole and Frazier to the space and the volume of fluid, and use filtered suction for smoke. You can describe how sets and tray lists are organized, and the vascular, orthopedic, gynecologic, fine, laparoscopic and powered instruments. And you can inspect and protect instruments, build a set against its list, and count every part of a multi-part instrument. Unit Fourteen sets up the back table and Mayo stand.