Surgical Instruments Guide
Surgical Instruments Guide
Surgical Instruments Guide
Chapter I
About Sklar
For 123 years, Sklar has set the standard for surgical instrumentation. In 1892, German born
instrument maker John Sklar, founded the company to fill a need for American made surgical
instruments and the rest is history. Sklar rose to prominence during World Wars I and II and was
awarded the principal contract as the surgical instrument provider for the United States military.
This contract established Sklar as the industry leader and placed it on the forefront of the surgical
marketplace, where it went on to receive Certificates of Merit and Achievement from the U.S.
Navy and six Army Navy “E” Production Awards.
During the 1930s, Sklar’s research department helped to develop a stainless steel alloy especially
suited to the manufacture of surgical instruments. The company’s investment in research was
justified long-term; most surgical instruments are still made of long-lasting, rust resistant,
stainless steel.
Today, Sklar is headquartered in West Chester, Pennsylvania where it remains the authority on
the manufacture of high quality surgical instruments to medical professionals in 75 countries
worldwide. Throughout its history, Sklar has collaborated with leading surgeons and medical
facilities to develop thousands of unique surgical instrument patterns. In recent years, Sklar has
expanded its product line to include more than 19,000 precision crafted, stainless steel
instruments: the largest offering of surgical instruments in the world. Specialty practices include:
OB/GYN, Orthopedic, ENT, Cardiovascular, Endoscopic, Dermatology, Podiatry, Veterinary,
Dental, etc.
The prevention and reduction of healthcare associated infection (HAI) is a top priority in medical
facilities today. The Centers for Disease Control Prevention (CDC) has cited “a critical gap in
patient safety,” calling for increased vigilance toward recommended instrument reprocessing
procedures. Many medical practices are converting from reusable to disposable instruments, and
Sklar is leading the trend with a full line of high quality, sterile and non-sterile, single-use
instruments to complement its trusted and longstanding stainless steel patterns.
Products
The CDC mandates that instrument end-users “comply with all steps as directed by the device
manufacturer”. The International Association of Healthcare Central Service Materiel
Management (IAHCSMM) recommends that processes such as care and cleaning; and the
management of instrument assets; involve the “original equipment manufacturer”. The U.S. Food
and Drug Administration (FDA) points to “a need for manufacturers of reusable medical devices
to validate instructions for usage, labeling and reprocessing for the device user community, in the
name of patient safety.”
As an instrument manufacturer with a reputation for the highest degree of quality, consistency
and staying power, Sklar is uniquely qualified to present Surgical Instruments: An Introductory
Guide. The education of healthcare professionals is one of Sklar’s primary goals. Education
improves quality control, determines instrument care and usage, and ultimately impacts patient
satisfaction.
With five different grades of instruments, a full line of disposab les, convenience kits, stainless
steel-ware, and care and cleaning solutions to support every stage of the healthcare process, Sklar
defines proper usage, handling, safe practices and generally accepted requirements for members
of the medical community who work with surgical instruments.
OR Grade – The highest quality surgical instruments made from U.S and German grade
stainless steel and designed to meet the exacting standards required in a surgical setting.
Mid-Grade – High quality, Mid-Grade OR instruments made of Pakistani stainless steel,
deliver significant value and performance in the clinics, physician’s offices and other
surgical settings.
Physician’s Grade – Forged from surgical grade Pakistani stainless steel and designed
for routine surgical or diagnostic use in the office setting.
For anyone who works in the surgical arena, central service supply, instrument manufacturing or
the healthcare field in general, improved patient outcome is the ultimate goal. It is the
responsibility of the instrument manufacturer to stay abreast of current trends, innovations a nd
regulations in healthcare, and to develop instrumentation that responds to the real-time needs and
concerns of medical professionals.
The FDA recently issued its final guidance on reprocessing reusable medical devices
(“Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling
Final Guidance – March 24, 2015”). The document emphasizes the importance of instrument
design – calling on the instrument industry to create devices that are less challenging to reprocess
than some of those on the market presently. It also singles out the “human factors” affecting
instrument reprocessing, saying reprocessing instructions should be “technically feasible” in the
intended, everyday work environment.
The movement toward the use of disposable instruments as a means of reducing the time cost
and liability associated with the care and cleaning of reusable instruments has begun. Disposable
instruments are often a viable alternative to their multi- use counterparts, and because of this you
will see examples of them within this book.
Single-use instruments:
Surgical Instruments: The Introductory Guide and Surgical Instruments Basic Course #1
for CE Cre dit, are designed to provide a basic overview of the most widely used surgical
instruments and a primer to the instrument industry. This guide gives up to date information
about:
Prehistory
Many uses of surgical instruments reflect basic, instinctual acts of self-preservation on which our
earliest ancestors relied. The first surgical instruments were teeth and hands, used in conjunction
with available natural materials like twigs and thorns.
Paleolithic humans are thought to have first developed stone tools 2.5 million years ago, forever
wedding human history and health to the implements we invent. It is likely that people in the Old
Stone Age used the sharp edges of early tools for rudimentary medical applications.
Archaeologists have found clear evidence that stone tools were used for surgery during the
Neolithic period (10,000 – 2,000 BC). Skulls found show the unmistakable signs of Trepanning
(the practice of drilling a hole into the skull to treat neurological problems like seizures ). Flint
blades, borers and scrapers were used to accomplish this earliest elective surgery.
Metallurgy, smelting of copper and the casting of bronze began in 5,000 – 4,000 BC. This
revolution in human engineering did not immediately result in a wave of novel surgical
instruments; however, it did bring new blacksmithing and crafting tools whose basic forms
would become surgical staples through to the present day. These include metal tweezers, tubes,
forceps and saws.
The advent of writing systems ushered in the historical period circa 3,500 BC. The discovery of
iron and steel followed, moving surgical instruments into the forefront of modernity.
The Ancient Egyptian civilization had a robust medical system that included surgery. In 2011,
archaeologists discovered early bronze surgical tools in the tomb of Qar, an Egyptian physician
who lived over 4,000 years ago during Egypt’s Sixth Dynasty.
No figure in ancient medical history looms as large as Hippocrates, the famous physician of
Classical Greece and the father of modern medicine. Hippocrates established medicine as a
working discipline, distinct from philosophy and religion. He and his followers also produced a
significant body of writings and instruction that included surgical directives, using instruments of
bronze and iron.
The rise of Rome brought about a renewed emphasis on the importance of surgery. The Empire
required competent surgeons to keep the conquering legions on their feet and in fighting
condition. The Roman Empire’s greatest surgeon was Ga len, whose writings would guide
medical practice for centuries.
Surviving artifacts and period writings demonstrate the sophistication of Greco-Roman surgical
instruments. Many of the fundamental instruments still used today, such as scalpels, forceps,
scissors, specula, probes and catheters, were well known to the ancients. Roman surgeons
worked with both steel and bronze instruments.
Arabic
During the Dark Ages, classical Western knowledge was maintained in the Islamic world. Much
Greco-Roman philosophy and science survived in Arabic translations that eventually resurfaced
in the West. Abu al-Qasim Al-Zahrawi, a surgeon in Islamic Spain, made the greatest
advancements in surgical instruments during this period. Known as Albucasis in Europe, he
produced a renowned 30-volume medical encyclopedia. The most famous volume contained
illustrations of surgical instruments and his book was widely translated into European languages
and disseminated among medieval surgeons.
After the Roman Empire fell, Islamic scholars preserved and propagated much of the wisdom of
the classical world, including the teachings of Galen. Translations of Galen from Arabic works
introduced Galen’s thought to Medieval Europe, where his ideas became the medical orthodoxy
of the day.
Medieval artisans crafted surgical instruments from iron, steel and wood. Metal instruments,
including scalpels and saws, often had wooden handles. Unlike the corrosion-resistant bronze
favored in Antiquity, these materials easily succumbed to the passage of centuries, which helps
explain why fewer medieval instruments have been found than their Greco-Roman counterparts.
The Renaissance
The Renaissance brought a resurgence of learning, creativity and innovation to Europe. The
invention of the printing press allowed for faster and more widespread dissemination of ideas,
old and new. This enabled a surge of scientific activity that advanced medicine and surgical
instruments.
The Italian scientist Andreas Vesalius, celebrated as the father of anatomy, published the first
accurate book about the human body. Others would build on his work, to the present, inviting
new surgical techniques and instruments.
Even as knowledge flourished among intellectuals, barbers conducted most day to day civilian
surgery, using the same tools for giving a close shave as for performing an operation. Most
surgical innovation was born on the battlefield, where Vesalius’s findings were put to the test.
The spread of firearms in warfare led to the production of specialized probes and forceps for
extracting bullets. Emergency amputations from gun and cannon fire inspired surgeons to
introduce ligature for binding hemorrhages.
The first book featuring surgical instruments drawn to scale, enabling skilled craftsmen to
reproduce them, appeared in France in 1594.
Once the bailiwick of blacksmiths and armorers, the manufacture of surgical instruments passed
to pewter workers, cutlers and silversmiths in Europe during the 17th century. Decorative
Surgery became a profession in the 17th and 18th centuries. In Sweden this occurred with the
development of a professional, royally recognized Society of Surgeons that branched from the
national guild of barbers. The training of surgeons also moved to the universities in the 1700s.
The establishment of medical schools and clinical education in France following the French
Revolution furthered the trend toward professionalization. Paris would remain a center for
surgical innovation.
The first catalog by a professional, referring to himself as a “surgical instrument crafter” was
produced in London in 1798 by J.H. Savigny. Sklar would perfect the surgical instrument catalog
in 1892 and beyond.
Nineteenth Century
The mid-1800s brought radical changes to the surgical field, dramatically increasing the demand
for a wide variety of instruments. With the advent of anesthesia, internal surgery became
possible. The use of anesthetic gas – first ether and then chloroform – beginning in 1846,
allowed for more invasive procedures and more time to perform delicate operations and as a
result, the number and type of surgical instruments increased.
At this time, there was widespread acceptance in the U.S. and Europe of the germ theory of
disease, as a result of the experiments by Louis Pasteur and Robert Koch. Knowledge of germs,
now taken for granted by everyone who applies hand sanitizer, has saved countless lives. An
early application of this theory was the antiseptic practice of spraying carbonic acid on a wound
and wrapping it in carbonic bandages to kill germs.
Between 1885 and 1910, the grand scale awareness of the role germs play in disease, led to the
thermal sterilization of surgical instruments. For the first time, surgical instruments could be
used to help a patient heal without the risk of introducing bacteria and viruses that may cause the
patient more harm than the condition being treated.
The 20th century of the Common Era saw more scientific and technological progress than any
period of recorded history. In this climate of change, surgical instruments completed the
millennia- long journey from stone to stainless steel.
The practice of sterilization created many new possibilities for internal surgical procedures,
increasing demand. It also put an end to the crafting of surgical instruments out of wood or
decorative materials, which did not hold up to the heat of steam sterilization. The corrosio n of
steel instruments was also a challenge. Chrome and nickel plating offered a partial solution to
corrosion, at the end of the 1800s, but the advent of stainless steel finally provided an answer.
Several engineers on both sides of the Atlantic independently developed variations of stainless
steel in the early 20th century. Mayer and Company created the first stainless steel surgical
instruments in 1916 for a British otolaryngologist. Less than a decade later, Sklar catalogs
offered stainless surgical instruments which steadily replaced their plated forebears. It remains
the most common alloy in use today.
The era of stainless steel brought with it the mass production of surgical instruments. The ancient
artisanal model of handcrafting every aspect of an instrument could no longer meet the demand
for both quantity and consistency that the 20 th century required. Plastics were created in the
1920s and created a “disposable revolution” during the decades to follow. Factories began
turning out scores of familiar, single use surgical implements, including plastic catheters,
dressing forceps, needles, suture material, tubing and more. Plastics proved indispensable in a
host of other 20th century surgical innovations, from the pacemaker to advanced prosthetics.
In the early 21st century, new techniques like minimally invasive procedures, stem cell therapy,
laser surgery and robotics continue to provide surgeons and patients with greater options than
ever before. As history has shown, technological progress leads to new surgical instruments that
serve humanity’s eternal pursuit of health and wellbeing.
The materials used in the manufacture of surgical instruments today include: metals (titanium,
copper, silver, etc.), metal alloys, silicone, latex, plastics and other synthetic products. These
materials can also be used in combination to enhance specialty instrument applications. With the
increase in disposable instrumentation; advances in robotics; electronic and computerized
components; and image guided systems, new materials and new surgical instruments are being
developed every day that will revolutionize the way surgery is performed.
However, most types of surgical instruments are still made from stainless steel. Stainless steel
(also known as inox steel) is a steel alloy with a minimum of 10.5% chromium content by mass.
Unprotected carbon steel rusts easily when exposed to the elements, but stainless steel contains
enough chromium to block oxygen diffusion to the steel surface, forming a passive film of
chromium oxide which prevents surface corrosion. Stainless steel also has special mechanical
features: it is strong and hard and absorbs energy without breaking.
Stainless steel is not actually “stainless” or fully stain-proof. It is stain resistant and does not
easily spot, corrode or rust with water the way ordinary, carbon steel does. Stainless steel is
ideally suited for the surgical suite, because it is rust resistant, it can be honed to an extremely
sharp edge or fine point, and it can be hardened to maintain the delicate, yet precise requirements
of the surgeon. Proper care and handling will ensure that instruments made of stainless steel will
last from two to five years, or longer, depending on the grade of the steel and bonding used.
There are over 150 grades of stainless steel, and several grades of stainless steel are used to
produce surgical instruments with special requirements for hardness, sharpness or malleability.
The primary grades used in the manufacture of instruments are Austenitic and Martensitic steels.
Austenitic stainless steel is the softer, more malleable type within the 300 Series; Martensitic is
the hardened steel within the 400 Series.
The 300 Series is used for probes, dilators, retractors and basins. It has the following
characteristics:
The 400 Series is used for hemostats, needle holders, scissors, clamps, forceps, etc. It has the
following characteristics:
The highest quality, 410 grade stainless is used for gripping instruments like forceps, tweezers,
retractors, dressing forceps, etc. 420 grade stainless is used for cutting instruments such as bone
rongeurs, chisels, gouges, and scissors.
Gold plating on an instrument means that tungsten carbide has been introduced – tungsten
carbide is an extremely hard metal that is used to laminate high grade stainless steel to increase
and maintain sharpness, strength and gripping capability and shelf life.
Surgical instruments are manufactured in response to the ever increasing need for variety and
efficiency in the surgical arena. As there are thousands of instrument patterns, the production
processes for various instruments differ (there are literally hundreds of manufacturing processes),
but once the raw materials are in place the manufacturing process can begin. Following are the
major manufacturing steps utilized to create surgical instruments:
Forging: The all- important process of stamping a rough outline of the instrument from a
blank block of stainless steel. There are two types of forging – “hot forged” and “cold
forged”. The majority of instruments are heat forged; the excess material (called the
flash) is trimmed to a more desirable shape and cooled. One of the advantages of stainless
steel is its ability to be fabricated by all types of manufacturing techniques – Austenitic
steels can be folded, bent, roll formed and hot or cold forged, etc.
Surgical instruments are specially designed tools or devices that perform a variety of procedures
or operations. The overall design of an instrument is based on the function it will ultimately
perform. All instruments have a basic design and are augmented and enhanced (length and
curvature of blades, teeth, serrations, etc.) to provide additional functionality or to accommodate
physician requirements and preference.
The size, length and width of a surgical instrument usually determines the type of surgery
intended. For example, 12” scissors and forceps are used for cardio, thoracic and gynecology. 4”
delicate scissors and forceps are used for pediatric, ophthalmic and plastic surgeries.
Instrument designs include: tips; jaws or blades; spring joints; screw joints or box locks; ratchets;
shanks; and finger rings.
Dressing Forceps
Volkman Retractor
Instrument Categorization
Surgical instruments are one of the most important components of a surgical procedure, and they
are quite literally an extension of the practitioner’s hands. When the surgical team is
appropriately acquainted with the name, function and proper handling of the multitude of
instruments available to them, it not only enhances the surgical procedure, but it positively
shapes the entire experience for the ultimate end user – the patient.
All instruments are categorized by function. The nine categories are: Accessory; Clamping and
Occluding; Cutting and Dissecting; Grasping and Holding; Dilating and Probing; Exposing and
Retracting; Aspirating and Suctioning; Stapling and Suturing; and Viewing.
Accessory: An accessory is any instrument that does not fit into a category, but is an
important part of the surgical procedure and has a specific function. Examples of
accessories are: mallets, harmonic scalpels and guide pins.
Clamping and Occluding: Used to compress or close blood vessels or hollow organs,
for hemostasis or occlusion. Examples are: Crile hemostatic forceps and tube occluding
clamps.
Cutting and Dissecting: Used to separate or incise, dissect or excise soft or compact
tissue with a variety of cutting edges and designs. Examples are: scalpels, Iris scissors
and curettes.
Grasping and Holding: Grasping and holding instruments are designed to grip,
manipulate and stabilize body tissues. They may also be used to extract foreign bodies.
Examples are: Allis tissue forceps, and Backhaus towel clamps.
Dilating and Probing: These instruments are used to probe, expand, examine or create
an anatomic passage; to enlarge or open a stricture or introduce another instrument.
Examples are: Hank uterine dilator, Sklar mini-dilators/OS finders and probes with eyes.
Exposing and Retracting: Designed to pull aside or hold back wound edges and other
tissues to gain access to the surgery or operation site. These instruments are usually
called “retractors,” with blunt “blades” that may be curved or angled, or with sharp or
dull prongs. Blades vary in size, and some retractors are double ended or come in a
Other Names: Dissecting scissors, suture scissors, heavy tissue scissors, Mayos
Category: Cutting and Dissecting
Uses: A versatile instrument used in multiple procedures and settings; the straight version is
primarily used for cutting surface tissue or sutures, but both straight and curved may be used
interchangeably depending on procedure and physician preference.
Description: With a standard beveled blade, Mayos are straight or curved, and have a variety
of lengths, a selection of special features and are made with blunt tips.
Notes: These scissors are used for cutting tissue. The screw must be securely tightened;
check for signs of wear and sharpen regularly as needed.
Other Names: Dissecting scissors, suture scissors, heavy tissue scissors, Mayos
Category: Cutting and Dissecting
Uses: These scissors are versatile and used in multiple procedures and settings; the curved
version are commonly used for cutting or dissecting deep or dense tissue, but both straight
and curved Mayos may be used interchangeably depending on procedure and physician
preference.
Description: With a standard beveled blade, Mayo scissors are straight or curved, have a
variety of lengths, a selection of special features and are made with blunt or sharp tips.
Notes: The screw must be securely tightened; check for signs of wear and sharpen regularly
as needed.
Shown: Sklar OR Grade - 6 ¾” curved, smooth, blunt/blunt tips - Product # 15-2567
Uses: Used to lift, hold and retract slippery or dense tissue that is being removed; commonly
used with tonsil, vaginal, breast and thyroid tissue.
Notes: Check to make sure teeth are properly aligned; inspect box lock and ratchet.
Uses: These scissors are used for dissecting and cutting delicate tissue and blunt dissection.
Description: Longer, thinner scissors; with a relatively long shank to blade ratio; may have
straight or curved blades, and blunt tips.
Notes: Designed for cutting delicate tissue only; not designed for cutting sutures, drains or
heavy tissue.
Uses: Commonly used in surgical procedures to hold gauze that absorbs excess fluids and
blood from a surgical site or hemostasis. Often used in bariatric surgeries because of their
longer length. The curved version may be used for removing the placenta in OB/GYN
procedures.
Description: The ratcheted locking mechanism of these finger ring forceps securely grip the
gauze into place. They have oval, fenestrated, serrated tips with opposing faces.
Notes: Inspect ratchet, box lock and check for proper alignment.
Instrument Sets
Instrument sets, surgery trays and brush sets are assembled for convenience, according to
practice specialty, procedure to be performed and the need for economy of time and cost.
Instrument sets are often stored for later use and organized according to procedure, major or
minor designation and/or specialty area. Examples of Basic Surgery Sets are:
Uses: Cleaning brushes are used in the instrument decontamination process: cleaning brush sets
contain the most common implements for all types of cleaning procedures, from the smallest
hand held instruments to suction tubes and endoscopes.
Description: Includes: Cannula Cleaning Brush 12” 3mm, 3 pack; Cannula Cleaning Brush 18”
5mm, 3 pack; Cannula Cleaning Brush 24” 7mm, 3 pack; Cannula Cleaning Brush 24”10mm, 3
pack; Suction Tube Brush 6” 1.6mm, 3 pack; Suction Tube Brush 8” 2.6mm, 3 pack; Suction
Tube Brush 8” 2mm, 3 pack; Suction Tube Brush 8” 3.3mm, 3 pack; Tube Brush 8” 4mm, 3
pack; Surface Cleaning Brush, 3 pack; Double End Brush Nylon, 3 pack; Brush Stainless Steel
Bristle, 3 pack; Brush Nylon Bristle, 3 pack – set.
Notes: Non-sterile and latex free (stainless steel/plastic/nylon).
Shown: Product # 10-1426
Uses: Ready to use surgery trays contain the most common instruments and supplies needed for
particular functions, procedures or operations.
Description: Includes: Scalpel #15”; Mosquito Hemostats, straight and curved; Mosquito
Hemostats, straight and curved; Webster Needle Holder; Iris Scissors, curved; Kelly Forceps,
straight; OR Scissors, Adson Tissue Forceps; Dressing Forceps; Gauze Sponges; Blue Linen OR
Towels; Clear Utility Drape; Instrument Trays.
Notes: Cases of 10, disposable, individual sterile packages.
Shown: Sklar Sterile Grade – Product # 96-1744
Uses: Specialized surgical packs contain the most common instruments needed for a particular
function, procedure or operation.
Description: Scalpel Handles #3 and #4; Yankauer Suction Tube; Mayo Dissecting Scissors,
curved 5 ½”, 6 ¾”; Halsted Mosquito Forceps, straight 5”; Halsted Mosquito Forceps; Crile
Forceps, straight; Crile Forceps, curved; Dressing Forceps; Tissue Forceps 1x2 teeth; TC Mayo-
Hegar NH, serrated; Sklarlite Operating Scissors S/S, straight”; Sklarlite Mayo Scissors, curved;
Probe Double End 6”; Allis Tissue Forceps 4x5 teeth; Adson Brown Tissue Forceps; Backhaus
Towel Clamps; Frazier Suction Tube 8 French; Goelet Retractor Double End; US Army
Retractors; Zalkind Ribbon Retractors; Senn Retractors, sharp and blunt; Metzenbaum Scissors
curved; Foerster Sponge Forceps straight and curved.
Shown: Minor Basic Surgery Set – Sklar Premium OR Grade – Product # 98-1002
All surgical instruments are designed for a particular purpose. Whether an instrument is curved
or straight, long or short, disposable or reusable, it is built and categorized by the function it will
ultimately perform. Hemostats are used to occlude vessels, scissors c ut and dissect tissue and
retractors hold a wound open to expose an operating site.
The volume of different instruments (19,000 items in the Sklar catalogues) and the subtle
nuances in their construction can be daunting to those who are new to the surgical team. It is
important to remember that learning the name, category, specialty area and parts of an instrument
are vital, but the primary focus should always be - how the instrument is used and how it will
enhance the surgical procedure and affect the quality of life of the patient.