Instruments

SECTION 8 Instruments
Chapter
21 Instruments
In examination, proper identification of instrument is very important. Mention the complete

name of the instrument, e.g. medium sized curved hemostatic forceps. In next part of the
examination it is usually asked, where have you used/seen to have been used this instrument.
Try to name some operations where a particular instrument is used and at what step of the
operation. "en mention about what are the other uses of this instrument.
Sterilization of the instrument is usually asked. "ere are various methods for sterilization
of instruments. Mention about one method of sterilization best for the particular instrument.
If examiner asks about other methods of sterilization then mention about other methods of
sterilization.
What is sterilization?
Sterilization is a process by which all microorganisms like bacteria, fungi, viruses and the
bacterial spores are killed.
What is disinfection?
Disinfection is the process by which microorganisms are killed or removed excepting the
bacterial spores. Disinfection may be:
Low level disinfection: Decreases the overall number of microorganisms. "e tubercle bacilli
and bacterial spores are not killed.
Intermediate level of disinfection: Kills tubercle bacilli and other microorganism, most viruses
and fungi.
High level disinfection: Kills almost all microorganisms but does not kill the bacterial spores.
What are the different techniques of disinfection of instruments?

Boiling: Boiling at 100°C for 5 minutes at normal pressure.
Formaldehyde vapour: Instruments kept in formaldehyde vaporizer at 50°C.
Glutaraldehyde solution: Instruments kept dipped in 2% glutaraldehyde solution for
15–20 minutes.
Low temperature steam: Exposure to dry saturated steam at a temperature of 73°C for
20 minutes at subatmospheric pressure.
870 Section 8 Instruments
Sterilization of instruments
"ere are various techniques for sterilization of instruments:
1. Autoclaving: Autoclaving is a method of sterilization using steam under high pressure.
Standard autoclaving: Involves sterilization at a temperature of 121°C at 15lb/sq inch
pressure for 30 minutes for metallic instruments and 15 minutes for rubber goods (Catheters,
gloves, drains, etc.).
High pressure autoclaving: In central sterilization unit for bulk sterilization high pressure
autoclaving is suitable. "is involves sterilization at a temperature of 134°C at a pressure of
30 lb/sq inch for 3 minutes.
2. Boiling: Boiling for half an hour kills all the bacteria and its spores. Boiling of the instruments
should be continued for half an hour after water achieves a temperature of 100°C.
"is is not suitable for sharp instruments as there is loss of sharpness due to boiling and
there is formation of crust over the instruments.
3. Chemical sterilization: A number of chemicals are used for sterilization of instruments.
Sharp instruments are particularly sterilized by keeping them dipped in chemicals.
a. 2% Glutaraldehyde solution (Cidex): For sterilization, the instruments should be kept
immersed in glutaraldehyde solution for 4 hours.
However, for disinfection of instruments, dipping for a period of 15–20 minutes is
adequate. Fiberoptic instruments like laparoscope, laparoscopic hand instruments.
cystoscopes are sterilized by keeping them in glutaraldehyde solution. In between cases
a period of 15–20 minutes of dipping is adequate for disinfection.
b. Lysol: "is is used for sterilization of sharp instruments. Dipping in concentrated lysol for
1 hour is adequate for sterilization. If dilute lysol is used the instrument should be kept
immersed for 24 hours.
c. 70% alcohol: Needles, unused sutures may be kept immersed in 70% alcohol for 12 hours
for subsequent use.
d. Sterilization by peracetic acid (Steris): "is is effective against all microorganisms including
the bacterial spores. "e method involves immersion of the instrument in the chemical
peracetic acid at a temperature of 50–56°C for 12 minutes.
4. Gas sterilization:
a. Ethylene oxide gas: A special ethylene oxide gas chamber is required for sterilization of
instruments using ethylene oxide gas. Instruments are kept in the chamber exposed to
ethylene oxide for 12 hours, i.e. overnight.
Large ethylene oxide gas chambers are also used for industrial sterilization.
b. Formaldehyde gas: Formalin tablets placed in a formalin vaporizer lead to formation of
formaldehyde gas. Optical instruments like cystoscope, laparoscope may be sterilized by
keeping them in formalin vaporizer for 1 hour.
5. Plasna sterilization
6. Others:
a. Gamma irradiation: "is is not applicable for sterilization of instruments in operative
theater setup but is useful for large scale industrial sterilization.
Chapter 21 Instruments 871
b. Direct flaming: In case of urgency when an instrument has fallen down from the operation
table and is urgently required, it may be sterilized by direct flaming. "e instrument is kept
in a bowl and some amount of rectified spirit is poured and flamed. Direct flaming may
achieve a temperature as high as 1400°C. However, direct flaming is damaging for sharp
instruments.
c. Hot air oven: Ward articles like glass syringes, test tubes may be sterilized in a hot air oven.
Keeping the instruments in hot air oven at a temperature of 160°C for 2 hours is adequate
for sterilization by this technique.
All the metal instruments are sterilized by autoclaving. All the rubber articles like gloves and
catheters are sterilized by autoclaving for 15 minutes instead of 30 minutes required for metal
instruments.
Sharp instruments like scissors, needles, scalpel blades are kept dipped in lysol or
glutaraldehyde solution for sterilization.
Parts of an instrument (Fig. 21.1A): A typical surgical instrument consists of:
a. Two finger bows for holding the instrument.
b. A pair of shaft or body of the instrument.
c. A catch or a ratchet—Once the rachets are pressed the blades are kept in a closed position.
d. Blades—A pair of blades constitutes the terminal part of the instrument.
e. Joint—"e two parts of the shaft and the blades are kept attached by a joint. "is joint may
be either a box joint or a pivot joint.
• In box joint there is a slot in one shaft and the other shaft is passed through this slot (Fig. 21.1B).
• In pivot joint the two shafts are attached at one point by a screw (Fig. 21.1C).
A B
C
Figures 21.1A to C: Parts of an instrument
1. RAMPLEY’S SWAB HOLDING FORCEPS
B C
Figures 21.2A to C: Swab holding forceps
"is is a long instrument (average 9%" in length). "e instrument is provided with finger bows
and a pair of long shaft. "e shaft has a rachet, a joint and a pair of blades. "e blades are oval,
fenestrated and provided with serrations on the inner aspect. "is instrument may be straight
or curved (Figs 21.2A to C).
Uses
Used for cleansing the skin with swab dipped in antiseptic solution during all operations.
Used for holding a swab which is used to clean the blood during dissection of Calot's triangle
during cholecystectomy.
"e swab held up in the forceps is also used for cleaning the blood in the suture line during
gastrojejunostomy, small and large gut anastomosis.
"e swab held up in the forceps is also used to strip off the peritoneum from the fascia
transversalis while approaching the retroperitoneum for kidney exposure or during lumbar
sympathectomy.
It is used for removing the laminated membrane and the daughter cysts during operation
of hydatid cyst.
"is may be used to hold the fundus and Hartmann's pouch of the gall bladder during
cholecystectomy.
"is may be used as ovum forceps.
"is may be used to swab an abscess cavity.
"is may be used as a tongue holding forceps.
Sterilization
By autoclaving
Why is the instrument long?
"e instrument is made longer to enable the surgeon to apply the antiseptic solution to the
skin without touching the unsterile field of operation (Figs 21.2A to C).
"e swab held up in between the blades may be used for swabbing at a depth.
How will you remove hair from the skin?

"e skin hair may be removed by shaving or application of epilation cream. Shaving is not a good
procedure as it may cause microscopic cuts in the skin where bacterial proliferation may occur
overnight. If shaving is to be done at all it should be done in the morning of day of operation.
Application of epilating cream is a better choice.
How will you do antiseptic cleansing of skin before operation?
During all operations the skin needs to be cleansed with antiseptic solution. For abdominal
operation the skin from midchest to midthigh should be cleaned. Various antiseptic solutions
are used for skin preparation:
Application of 2–3 layers of povidone iodine which is 2% iodine in polyvinylpyrrolidone.
Povidone iodine releases iodine slowly and provides longer duration of antiseptic effect. It
is effective against both bacteria and fungus.
Cleansing with spirit, tincture iodine and spirit.
Cleansing with Savlon (Cetrimide solution) and spirit.
What area should you clean for an abdominal operation?

An area from midchest to midthigh is to be cleaned with antiseptic solution for abdominal
operation.
2. TOWEL CLIPS
B C
Figures 21.3A to C: Towel clips
A. Doyens’ Cross Action Type Towel Clip

"is is a pincer like instrument, on pressing the shaft the instrument opens up and on releasing
the shaft the instrument closes and the two clips meet each other and provide the pinching
action (Fig. 21.3A).
B. Backhaus’ Towel (Corner) Clip

"is instrument is provided with finger bows, a rachet, a pair of shaft and two sharp hooks.
On closing the rachet the two clips are apposed and on releasing the rachet the clips open up
(Fig. 21.3B).
Uses
Used for fixing the draping sheets.
Used for fixing the diathermy cables, suction tubes, laparoscopic camera cables and fiber-
optic light cables to the draping sheets taking care not to pierce any of these with the towel clip.
May be used as a tongue holding forceps.
May be used as cord holding forceps.
May be used for holding the ribs while elevating a flail segment of chest.
Sterilization
By autoclaving
What is draping?
Draping is suitable placement of sheets to isolate the area of operation from the rest of the body.
Draping of the operative site reduces the contamination from the adjacent skin areas.
3. BARD PARKER’S HANDLES
A B
C D
Figures 21.4A to D: Bard Parker’s handle
Bard Parker’s handle is a flat stainless steel instrument with one end narrower with a slot on
either side for attaching the scalpel blade. A number is written on the handle. "e numbers may
be 3, 5, 7 and 4 (Figs 21.4A to C).
In scalpel handle no. 4 (Fig. 21.4D) the site for attachment of the blade is little wider than the
handle number 3, 5 and 7 where it is little narrower.
Sterilization
By autoclaving
4. SURGICAL BLADES
Figures 21.5A and B: Surgical blades
Blades number 10, 11, 12 and 15 fit in BP handle number 3, 5 and 7 (Fig. 21.5A).
Blades number 18, 19, 20, 21, 22, 23 and 24 fit in B.P handle number 4 (Fig. 21.5B).
"e blades are detachable and a new blade is used for every patient, so there is no problem
with sharpness of the blade.
Sterilization
Supplied in presterilized pack.
What are the uses of BP handle and blade?
It is used to make skin incisions for any operation. "e blade numbers 20, 21, 22, 23 and 24
have wide shaft and are used for larger incisions and dissections.
"e blade number 15 has a narrow shaft and is used for smaller incisions, while excising a
sebaceous cyst or during venesection.
It is used for incision and drainage of an abscess. "e blade number 11 is also known as stab
knife and is used to incise the skin for drainage of an abscess.
It is used to incise the skin for inserting drains.
Apart from making skin incisions where else is the scalpel used?
"e scalpel is also used for sharp dissection to raise skin flaps during mastectomy, incisional
hernia repair, during thyroidectomy and radical neck dissection.
"e scalpel is also used to divide the cystic duct and artery during cholecystectomy after
these are ligated.
The renal and splenic pedicle may also be divided by a scalpel after ligature during
nephrectomy and splenectomy.
Blade number 11 is used for incision and drainage of abscess.
What are the different abdominal incisions?
"e different abdominal incisions (Fig.
21.6).
1. Midline incision:
• Upper (above the umbilicus).
• Lower (below the umbilicus).
• Mid-midline (midline incision
centreing the umbilicus).
Indicated in emergency exploratory
laparotomy, gastric operations,
colonic resection, abdominoperineal
resection and anterior resection.
2. Paramedian incision:
• Right paramedian incision—
Vertical incision 2.5 cm to the right
of midline. Indicated in gall bladder
surgery, right hemicolectomy. Figure 21.6: Abdominal incisions
• Left paramedian incision—Same
incision to the left of midline.
Gastric operations, left hemicolectomy and splenectomy.
3. Mayo Robson’s incision: Right upper paramedian incision extended like a hockey stick to the
midline. Indicated in cholecystectomy.
4. Subcostal incision:
• Right subcostal incision (Kocher's subcostal incision)—Oblique incision 2 cm below and
parallel to the right costal margin, extending from midline to beyond the tip of the costal
cartilage. Indicated in cholecystectomy, CBD exploration, biliary enteric bypass.
• Left subcostal incision—Same incision on the left subcostal region. Indicated for
splenectomy.
• Roof top or chevron incision—Bilateral subcostal incision joined in the midline. For
pancreatic surgery—Whipples’ operation, pancreaticojejunostomy and for liver resection.
5. Transverse incision:
• Upper abdominal transverse incision. Indicated for gallbladder surgery and gastric
operations.
• Infraumbilical transverse incision. Indicated for exploratory laparotomy in children.
• Suprapubic transverse incision (Pfannensteil incision). For pelvic operations and
prostatectomy.
6. McBurneys’ gridiron incision: Indicated for appendicectomy.
7. Lanzs’ incision: Used for appendicectomy.
8. Inguinal incision: Incision at the inguinal canal running parallel to the inguinal ligament.
Used for hernia operations.
9. Loin incision or lumbar incision:

Incision from the lateral border of erector spinae downward and forward midway between
the 12th rib and the iliac crest upto the lateral border of rectus abdominis. Used for operations
in kidney.
10. Mercedez Benz incision: Bilateral subcostal incision with vertical incision extending from
center of the ∧-shaped cut to the xiphoid process
5. HEMOSTATIC FORCEPS
Figures 21.7A to D: Hemostatic forceps. In Spencer Well’s variety note the transverse serrations in the
whole length of the blade. In Kelly and Adson’s variety the transverse serrations are in distal part of
the blade
A. Spencer Well’s hemostatic forceps are provided with finger bows, rachet, a pair of shaft and a
pair of blades. "e blades are usually half the length of the shaft. "e full length of the blades
are provided with transverse serrations. "e tips are conical and non toothed. When the rachet
is closed the blades are apposed (Figs 21.7A and B).
B. Kelly’s hemostatic forceps are longer. "e blades are long and the transverse serrations are not
present along the whole length of the blades (Fig. 21.7C).
C. Adson’s hemostatic forceps. "e blades are smaller in comparison to the shaft. "e transverse
serration are present in the terminal part of the blades (Fig. 21.7D).
How will you differentiate it from a needle holder?
"e hemostatic forceps is a lighter instrument. "e blades are longer and there are transverse
serrations in the blades.
"e needle holder is a relatively heavier instrument. "e blades are smaller and there are criss
cross serrations in the blade and there may be a groove in the center of each blade.
Uses of Hemostatic Forceps

1. It is used during all operations. It is used to hold bleeding vessels while cutting through
different layers of tissues.
2. While making abdominal incisions and during the closure of the incision the hemostatic
forceps is used to hold the cut margins of the rectus sheath, linea alba, external oblique
aponeurosis and the surgical peritoneum.
3. During appendicectomy through McBurney’s Gridiron incision the hemostatic forceps
may be used to split the internal oblique and transversus abdominis muscle. May be used
to crush the base of appendix during appendicectomy.
4. While doing intestinal resection and anastomosis, the mesenteric vessels are held in between
hemostatic forceps and the desired line of mesentery is divided.
5. It may be used to dissect the vein while doing venesection in the arm (Basilic or cephali
vein) or in the leg (great saphenous vein).
6. It may be used for blunt dissection while doing lymph node biopsy, excision of lipoma
sebaceous cyst.
7. May be used to open an abscess by Hilton’s method.
8. May be used to hold the end of a ligature while suturing.
9. May be used to tie a knot after suturing.
10. May be used as a dressing forceps.
Sterilization
By autoclaving.
While making incisions how will you control bleeding?
Bleeding from the incision site may be controlled with—
Simple pressure: Fine capillary bleeding may be simply controlled by pressure with a mop.
Crushing: "e bleeding may be controlled by simply crushing the bleeding point with a
hemostatic forceps. Crushing causes curling of tunica media and intima inward and causes
occlusion of the lumen of the vessel.
Electrocautery: "e bleeding point held by a hemostatic forceps may be coagulated with
diathermy.
Ligature: "e bleeding point held by a hemostatic forceps may be ligated with chromic catgut
sutures.
What is primary hemorrhage?

Bleeding during operation or at the time of injury.
What is reactionary hemorrhage?
Reactionary hemorrhage occurs within 24 hours following operation or injury after the primary
hemorrhage is controlled.
"is may be due to slippage of a ligature or dislodgment of a clot. Resuscitation from shock
may increase the blood pressure and may cause reactionary hemorrhage.
What is secondary hemorrhage?
Secondary hemorrhage usually occurs 7–14 days following the operation or injury. "is is usually
due to infection and sloughing of vessels.
"e secondary hemorrhage is often proceeded by ‘warning hemorrhage’ which are brighi
red stains of hemorrhage from the wound followed by sudden and severe hemorrhage.
What are the characteristics of arterial, venous and capillary bleeding?
Arterial bleeding: Bright red bleeding in spurts which rise and fall with the pulse wave.
Venous bleeding: Dark red bleeding occurring steadily and if large veins are injured flow may
be copious.
Capillary bleeding: Bright red, continuous, often rapid ooze.
What are the approximate blood volume in an adult and an infant?
In adult normal blood volume is approximately 7% of body weight. So a 70 kg adult has a blood
volume of 5 liters.
"e blood volume in a child is approximately 8–9% of body weight (80–90 mU/kg of body
weight).
What are the different grades of hemorrhage?
Class I hemorrhage: Blood volume loss up to 15%.
In uncomplicated situation:
• Slight tachycardia, no change of blood pressure or pulse pressure.
• No fluid replacement is required.
• Transcapillary refilling and other compensatory mechanisms restore the blood volume
in 24 hours.
Class II hemorrhage: Blood volume loss of 15% to 30%.
• Tachycardia (Heart rate above 100 in an adult), hypotension and decrease in pulse pressure.
Decrease in pulse pressure is due to increase in peripheral resistance due to the circulating
catecholamines causing an increase of diastolic pressure. Systolic blood pressure may not
change initially.
• Urinary output is mildly affected (20–30 mU/hour in an adult).
"ese patients may be initially managed with crystalloid infusion but some of these
patients may require blood transfusion.
Class III hemorrhage: Blood volume loss of 30–40% (Approximate loss of about 2000 mL, of
blood in an adult).
Classic signs of inadequate perfusion:
• Marked tachycardia and tachypnea.
• Measurable fall of systolic blood pressure.

• Changes in mental state and oliguria.
In addition to crystalloid infusion these patients will always require blood transfusion.
Class IV hemorrhage: Blood volume loss more than 40%.
• Life threatening hemorrhage.
• Marked tachycardia, severe hypotension.
• Urinary output is negligible or anuria.
• Mental state is markedly depressed.
• Cold and pale skin.
How will you treat hemorrhage?
"e basic principles for treatment of hemorrhage are:
Stop hemorrhage
Replace the volume lost.
Replacement of blood loss: Initial fluid bolus is administered as rapidly as possible. "e initial
usual dose is 1–2 L of crystalloid solution in an adult and 20 mLlkg. in child.
Patient with class I hemorrhage may not require any fluid replacement. Patient with class III
and class IV hemorrhage requires blood transfusion in addition to initial fluid therapy. Patient
with class II hemorrhage may be managed only with crystalloid solution infusion but some may
require blood transfusion.
What is 3 for 1 rule?
"is is a rough guideline for replacement of crystalloid for blood loss. 3 mL of crystalloid solution
replacement is required for loss of each mL of blood.
What are the possible response to the initial fluid therapy?
"e potential response to initial fluid therapy may be—
Rapid response:
• Patient becomes hemodynamically normal following initial fluid administration and when
the fluid administration is slowed to maintenance level.
• No blood transfusion or further fluid bolus is required.
Transient response:
• Patients respond to initial fluid therapy.
• Starts showing deterioration as the initial fluid administration is slowed down.
• Most of these patients have class Il or III hemorrhage.
• "ese patients have continuing hemorrhage and require blood transfusion and may
require surgical intervention.
No response or minimal response:
• Failure of response to adequate fluid or blood replacement indicate exsanguinating
hemorrhage.
• Most cases require immediate surgical intervention to control hemorrhage.
• Rarely failure of response may be due to pump failure due to cardiogenic shock or cardiac
tamponade.
6. KOCHER’S HEMOSTATIC FORCEPS
Figures 21.8A and B: Kocher’s hemostatic forceps. Note the transverse serration and tooth and grove in
the terminal part of the blade
Kocher’s hemostatic forceps are more or less similar to a Spencer Wells’ hemostatic forceps
except (Figs 21.8A and B):
"e blades are slightly longer than in a Spencer Well's type of hemostatic forceps.
At the tip of the blades there is a tooth in one blade and a groove in the other blade where
the tooth fits when the rachet is closed. "is type of forceps is suitable for holding vessels in
tough structures like palm, soles and the scalp where the vessels tend to retract in the deep
fascia. "e teeth at the tip of blades help to hold the retracting vessels securely.
Uses
1. Used during appendicectomy operation to crush the base of appendix.
2. Used to hold perforating vessels during mastectomy.
3. Used to hold the meniscus during menisectomy.
4. During subtotal thyroidectomy a series of Kocher’s hemostatic forceps are applied around
the margin of thyroid gland lobe before excision of the enlarged thyroid lobe.
5. Used for holding vessels in the scalp while raising a skin flap for craniotomy.
6. Used to hold bleeding vessels while operating on palm and sole.
7. Used in obstetrics for artificial rupture of membrane.
Sterilization
By autoclaving.
7. MOSQUITO HEMOSTATIC FORCEPS
Figures 21.9A and B: Mosquito hemostatic forceps. Note the serrations in the whole length of the blade
"is instrument is very light, small and delicate. "e blades are smaller in comparison to Spencer
Well’s type of hemostatic forceps and there are fine transverse serrations in the blades. "e tip of
the blades are conical and are non-toothed. "is instrument is used to hold the small bleeding
vessels (Figs 21.9A and B).
Uses
1. Used to hold fine bleeding vessels during cleft lip operation.
2. While doing appendicectomy the mesoappendix is punctured at an avascular site by a
mosquito forceps and a ligature passed around the mesoappendix and tied before division
of the mesoappendix.
3. While inverting the base of the appendix by a purse string suture the stump of the appendix
is held by a mosquito forceps and pushed inward as the purse string suture is tied.
4. Used as hemostatic forceps for operations in infants and children where the vessels are delicate.
5. Used during circumcision. "ree pairs of mosquito forceps are applied one pair on either
side of the preputial orifice and one at the midline raphe where frenulum is attached. "e
prepuce is then divided starting in the dorsal midline. "e skin over the shaft of the penis is
retracted and the small vessels on the shaft of the penis are held by mosquito forceps and
ligated.
Sterilization
By autoclaving.
8. MAYO’S PEDICLE CLAMP
Figure 21.10: Mayo’s pedicle clamp. Note the curved blade and vertical serrations
"is is a stout and large forceps. "e blades are long and angled to provide a good view at a
depth. "ere are vertical serrations in the blades (Fig. 21.10).
Uses
Used during nephrectomy to hold the renal pedicles before division
May be used during splenectomy to hold the splenic pedicle.
Sterilization
By autoclaving
9. LISTER’S SINUS FORCEPS
Figure 21.11: Lister’s sinus forceps. Note no ratchet and transverse serrations in terminal part of the
blade
"is is a long slender instrument with a pair of small blades with transverse serrations. "ere is
no ratchet in the handle (Fig. 21.11).
Uses
For incision and drainage of abscess by Hilton’s method.
May be used to hold a gauge swab to clean the abscess cavity.
Sterilization
By autoclaving.
What is an abscess?
What are the different techniques for abscess drainage?
Abscess at different locations and management—See Minor Surgical Procedure, Page No. 840-
852, Chapter 20.
What is Hilton’s method for drainage of abscess?
During drainage of abscess situated in important areas like axilla, groin there is chance of injury
to the underlying major vessels and nerves if adequate care is not taken. In drainage of abscess
in such location the skin and the subcutaneous tissues are incised with a knife. "e deep fascia
is not incised with a sharp knife but is pierced by thrushing a sinus forceps through the deep
fascia and the sinus forceps is then opened up to enlarge the opening in the deep fascia for easy
drainage of pus. "is is Hilton’s method of drainage of abscess.
10. ALLIS’ TISSUE FORCEPS
A B
Figures 21.12A and B: (A) Allis’ tissue forceps; (B) Note the teeth and grove in the terminal part of the blade
"is is a light instrument. "e blades are longer and there is a gap between the blades which
can accommodate some amount of tissue. "e tip of the blades are provided with sharp teeth
with grooves in between. When the ratchet is closed the teeth of the one blade fits in the groove
of the other blade and vice versa (Figs 21.12A and B).
Uses
1. During laparotomy through midline incision, skin margins may be retracted by applying Allis
tissue forceps to the skin margin while linea alba is incised. "e linea alba may be lifted up
by applying Allis tissue forceps while incising the peritoneum.
2. While closing the midline incision the linea alba may be held up by Allis tissue forceps during
suturing.
3. Used to hold the skin margins during incisional hernia operations to raise the skin flaps. May
be used to hold the margins of the fascial gap while dissecting the hernial sac.
4. Used during thyroid operations, neck dissection to hold the margins of the skin while raising
skin flaps.
5. Used to hold the cut margins of the bladder during transvesical prostatectomy or suprapubic
cystolithotomy.
6. Used to hold the neck of the bladder during bladder neck resection.
7. Used to hold the galea aponeurotica while raising a skin flap during craniotomy.
8. Used to hold the skin flaps while excising a lipoma, sebaceous cyst or lymph node.
Sterilization
By autoclaving.
11. BABCOCK’S TISSUE FORCEPS
Figure 21.13: Medium sized Babcock’s tissue forceps. Note the curved fenestrated blade with ridge
in one blade and grove in other blade
"is is a light instrument. "e terminal part of the blades are curved and fenestrated. "e tip is
provided with a ridge in one blade and groove in the other. When the rachet is closed the ridge
of one blade fits into the groove of the other blade. As there are no teeth this is a non-traumatic
forceps. "e fenestration in the blade allows some soft tissue to be accommodated in the hollow
while holding it (Fig. 21.13).
Uses
1. Used during appendicectomy. Usually three pairs of Babcock’s forceps are required during
appendicectomy. One pair holds the appendix near its tip, one pair holds the body of the
appendix and the third pair holds the base of the appendix.
2. Used during gastrectomy, gastrojejunostomy to hold the margins of the stomach while
applying an occlusion clamp.
3. Used during small and large intestine resection anastomosis to hold the margins of the gut
before applying an intestinal occlusion clamp. In open method of resection anastomosis,
intestinal occlusion clamps are not applied. "e cut margins of the gut are held up with
Babcock‘s tissue forceps and sutured.
4. Used during gastrostomy or jejunostomy to hold the gut while applying purse string suture.
5. Used during choledochoduodenostomy to hold the duodenum before making an incision
in the first part of the duodenum.
6. Used to hold the cut margins of the bladder during transvesical prostatec tomy or suprapubic
cystolithotomy.
Sterilization
By autoclaving.
12. LANES’ TISSUE FORCEPS
Figure 21.14: Lanes’ tissue forceps. Note the curved stout blade with fenestration and heavy tooth in
terminal part of the blade
"is is a thick and heavy instrument. "e terminal part of the blades are curved and fenestrated.
At the tip there is a heavy tooth in one blade with groove in the other blade and with the ratchet
in closed position, the tooth and the groove in the blade fits in. Because of stout teeth at the tip
this holds tissues firmly but it is traumatizing (Fig. 21.14).
Uses
Used during submandibular or parotid gland excision to hold the gland during dissection
from the adjacent structures.
During mastectomy it may be used to hold the breast while dissecting it off from the pectoral
fascia.
May be used to fix the draping sheets and also to fix the suction tube and the diathermy cable
to the draping sheets as an alternative to towel clip.
Sterilization
By autoclaving
13. PLAIN DISSECTING FORCEPS
Figures 21.15A to C: Plain dissecting forceps. Note transverse serrations and no tooth in the blade
"ere are grooves on the shaft of the instrument which allows easy gripping. "e two limbs of the
shaft are so designed that it provides a spring action and the blades are kept apart. Pressing the two
limbs of the shaft of the instruments brings the two blades closer and helps in gripping the tissues.
"ere are transverse serrations at the tip of the blades which helps in lifting the tissues and the
needle during suturing. "ere are no tooth at the tip (Figs 21.15A to C).
"e plain dissecting forceps are also available as small and long plain dissecting forceps.
Uses
Used during almost all operations to hold delicate structures like peritoneum, vessels, nerves
and muscles during dissection and suturing.
1. Used during appendicectomy to bring out the cecum and to deliver the appendix when it is
held by the Babcock’s tissue forceps.
2. Used during gastrojejunostomy, gut resection anastomosis to hold the gut margin during
suturing.
3. Used to hold blood vessels, nerves during dissection.
4. Used to hold the peritoneum during closure of midline or paramedian abdominal incision
5. Used during hernia operation to hold the hernial sac during dissection of the sac from the
cord structures.
6. Fine tipped forceps is used during nerve repair and vascular anastomosis.
7. Used in pediatric patient to hold the delicate structures during suturing.
Sterilization
By autoclaving.
14. TOOTHED DISSECTING FORCEPS
Figures 21.16A to D: Toothed dissecting forceps. Note the transverse serratrons and tooth in the blade
"e design is same as the plain dissecting forceps but there is a tooth at the tip of one blade and
a groove at the tip of the other blade. When the blades are approximated the toothed tip fits into
the groove. Because of the presence of the tooth, the tissues may be better gripped and there is
less chance of slipping (Figs 21.16A to D).
Uses
Used during almost all operations to hold tough structures like skin, fascia and aponeurosis.
1. Used to hold the cut skin margins during suturing.
2. Used to hold the linea alba or the rectus sheath during closure of abdominal incision.
3. Used to hold the scalp during closure of scalp incision.
4. Fine tipped toothed dissecting forceps is used to hold the cut margins of the prepuce for
suturing during circumcision.
Sterilization
By autoclaving
15. NEEDLE HOLDERS (FIGS 21.17 A TO F)
A B
C D
Figures 21.17A to F: Needle holders. Note the criss-cross serrations and groove in the blades
"e blades of the needle holder are smaller in comparison to the shaft of the instrument.
"ere are criss cross serrations in the blade and there is a longitudinal groove in the center
of the criss cross serration which allows firm gripping of the needle. However, the groove may
not be there in all needle holders. "e blades of the needle holders may be fine or heavy.
"e needle holders with fine blades are used to hold finer needles (2/0, 3/0, 4/0 atraumatic
catgut, vicryl, mersilk).
"e small sized needle holders are used for suturing on the surface.
"e long needle holders are used for suturing at the depth inside the abdomen, pelvis or chest.
"e curved needle holders are used for suturing in a cavity or at a depth for better visualization.
Uses
Used to hold the needle for suturing. "e needle holders are used in all operations for suturing.
Sterilization
By autoclaving.
Where do you hold the needle with the needle holders for suturing?
Ideally the needle should be held by the needle holder at the junction of the anterior two thirds
and the posterior one third for ease of suturing.
What other instruments will be required for suturing a skin wound?
A part from a needle holder following instruments will be required:
A swab holding forceps for antiseptic cleaning.
A toothed dissecting forceps.
A curved cutting needle.
Suture material—silk or nylon.
A scissor for cutting the ligatures.
16. NEEDLES
Figure 21.18A: Needles

Figures 21.18B and C: Needles
Figure 21.19: Round bodied needle— Figure 21.20: Conventional cutting

Cross-section needle—Cross-section
Figure 21.21: Reverse cutting needle Figure 21.22: Tapper cut needle
Needles are made of stainless steel. "ere is a sharp pointed tip at one end and an eye at the
other end for threading a suture. Atraumatic needles are eyeless. "e needles may be curved
or straight. Depending on the type of sharp end the needles may be:
Round bodied (Fig. 21.18A)
Cutting (Fig. 21.18B)
Reverse cutting (Fig. 21.21)
Taper cut or (Fig. 21.22)
Blunt (Fig. 21.23)
What are the characteristics of a round

bodied needle?
In round bodied needle, the needle is uniformly
round on cross section with a tapering tip. Round Figure 21.23: Eyed and eyeless needles
bodied needles are designed to separate tissue
fibres rather than cut them as it passes through
the tissues and are suitable for suturing soft tissues
where easy splitting of tissue fibres are possible, e.g. muscles, intestines, vessels. After the needle
passes, the tissue closes tightly around the suture material thereby forming a leak proof suture
line (Figs 21.18A and 21.19).
What are the characteristics of cutting needle?
Cutting needles are required for penetration of tough structures like fascia, aponeurosis, linea
alba and skin.
"e sharp end of conventional cutting needle has a triangular cross section with the apex on
the inside of the needle curvature. "e effective cutting edges are restricted to the front section
of the needle and runs into a triangulated body which constitutes for half of the length of the
needle (Fig. 21.20).
"e reverse cutting needle is also triangular in cross section having the apex of the cutting
edge on the outer surface of the needle curvature. "is improves the strength of the needle and
particularly increases the resistance to bending (Fig. 21.21).
What are taper cut needles?
"is needle combines the initial penetration of a reverse cutting needle with the minimized
trauma of a round bodied needle. "e cutting tip is limited to the point of the needle, which
then tapers out to merge smoothly into a round cross section. "ese needles are used mostly
in vascular surgery (Fig. 21.22).
What are the characteristics of an atraumatic or eyeless needle?
"e eye of the needle with two layers of sutures causes trauma to the tissues through which it
passes (Fig. 21.23A).
A needle without an eye is called an atraumatic or eyeless needle. "e suture is inserted at
the end of the needle by a special technique, so that a single layer of suture is attached at the
end of the needle (Fig. 21.23B). "is technique of imbrication of the suture at the end of the
needle was first devised by Mr George Merson of England and in his memory most of these
sutures are called Mersutures.
What are the advantages of using an eyeless needle?

As the needle is eyeless it causes minimal trauma to the tissues.
"is is a disposable needle—so there is no problem with loss of sharpness.
"is is supplied in a presterilized pack—so sterilization before use is not required.
Faster, more e%cient surgery.
What are intestinal needles?
"ese are smooth, delicate eyeless needles and allows easy penetration through the soft tissues
like stomach, intestines, ureter and peritoneum.
What are blunt pointed needles?
"ese needles with a blunt tip is designed for suturing
friable vascular tissues like, liver, spleen and kidneys
(Fig. 21.24).
What are the parts of a surgical needle?
Needle point or sharp apex of the needle
Figure 21.24: Blunt pointed needle—
(Fig. 21.25). Cross-section
Body: Which may be straight or curved.
Eye: For threading a suture. In atraumatic
needles there are no eyes.
Needle length: It is the circumferential length
of the needle.
Needle chord length: "is is the linear distance
between the pointed tip and the end of the needle.
What do you mean by a 1/4, 3/8, 1/2 and
5/8th circle of a needle? Figure 21.25: Parts of a surgical needle
"is indicates the type of curvature of the needle.
One fourth circle needle means the needle is
curved like one fourth circumference of a circle.
"ree eighth circle needle means curvature is more
wide and equals three eighth circumference of a
circle. Half circle means the needle is curved like
half the circumference of a circle. Five eighth circle
needle means curvature is more wide and equals
five eighth circumference of a circle (Fig. 21.26).
What is the weakest part of the needle?
"e part of the needle near the eye is the weakest
part of the needle.
Figure 21.26: Shapes curvatures of needles
Uses
1. "e curved round bodied needles are used to suture muscle, peritoneum, and other delicate
structures.
2. "e curved cutting needles are used to suture skin and other tough structures like linea alba,
anterior rectus sheath, external oblique aponeurosis.
3. "e straight cutting needles are used for suturing skin and other tough structures on the
surface.
4. "e atraumatic needles (eyeless needle) with the sutures imbricated at one end is used
for suturing during intestinal resection anastomosis, gastrojejunostomy, bilioenteric,
pancreaticojejunal anastomosis and for vascular and nerve anastomosis.
Sterilization
Needles are sterilized by keeping them dipped in concentrated lysol for 1 hour or in dilute lysol
for 24 hours. Boiling or autoclaving damages the sharpness of the needle.
17. SKIN CLOSURE CLIPS AND ACCESSORIES
D E
C
Figures 21.27A to E: Skin closure clips and accessories
Michel clips are provided with sharp-pointed spike at either end (Fig. 21.27A).
"e Michel clips are supplied in a Michel clip magazine (Fig. 21.27B). Michel clip magazine
is loaded into a rack which is attached to a toothed dissecting forceps used to hold the skin
margins during application of the clips (Fig. 21.27C).
"e Michel clip applicator resembles a dissecting forceps and there is a groove on either
blades near its tip (Fig. 21.27D). "e Michel clip is held in this groove and one clip is removed
from the magazine holding the clips. Once the Michel clip applier is pressed the shaft of the
clips gets bent in the middle and the spike on either side pierces the skin and keeps the skin
margins apposed.
With availability of preloaded skin staplers these clips are no longer used.
Sterilization
By autoclaving.
How will you apply these clips?

Michel clips are used for skin closure.
"e skin margins are properly apposed and lifted up by holding with the toothed dissecting
forceps. One clip is taken from the magazine with the Michel clip applier and the clip is applied
to the skin margin by pressing the Michel clip applier. "e clip gets bent in the middle and
the spike pierces the skin margin on either side keeping the skin margins apposed.
While applying the clips the skin margins has to be apposed properly taking care so that the
skin margins does not get inverted.
Where do you apply these clips?
"ese clips may be applied for skin incision closure in the neck, abdomen or other sites.
Skin closure with clips is cosmetically better and time required for closure is less. However,
these are costly and if not applied properly may cause inversion of skin margins.
How will you remove these clips?
"ese clips are removed by Michel clip extractor. Michel clip extractor is an instrument without
any rachet. "e blades are curved. In the lower blade there is a groove and in the upper blade
there is a ridge (Fig. 21.27E).
For extraction of the Michel clip the lower blade is passed below the middle of the shaft of
the applied clip and the instrument is closed. As the upper blade is pressed the clip gets bent
outwards and the spikes come out of the skin and the clip is thus removed.
18. SKIN STAPLERS
Figure 21.28: This is a proximate plus skin stapler containing 35 skin staples
Different skin staplers containing preloaded skin staples are available. "ese staplers contain
preloaded staples and are available in presterilized pack (Fig. 21.28).
Uses
For skin approximation in different skin incisions.
19. MAYO’S SCISSORS (FIGS 21.29A TO D)
A B
C D
Figures 21.29A to D: Mayo’s scissors. Mayo’s scissors are usually long and stout scissors
Uses
Used for cutting sutures.
Used during appendicectomy to split the internal oblique and transversus abdominis muscle.
After incising the external oblique aponeurosis, the scissors is thrushed through the internal
oblique and transversus abdominis muscle with the blades in closed position and then the
blades are opened up and the muscles are thus split up.
Used to cut tough structures like linea alba, external oblique aponeurosis, anterior and
posterior rectus sheath during entry into the abdomen by a midline, paramedian or sub-
costal incision.
May be used to cut dressings.
May be used to cut a corrugated rubber sheet drain.
20. MCINDOE SCISSORS
Figure 21.30: McIndoe scissors. Note the fine, delicate,

sharp and small blades
"ese are fine scissors. "e blades are delicate and smaller than in Mayo’s scissors and are used
for tissue dissection and cutting delicate structures (Fig. 21.30). In Metzenbaum scissors the
blades are long in comparison to the shaft.
Uses
Used during appendicectomy to cut the external oblique aponeurosis and peritoneum. "e
mesoappendix is cut after being ligated.
Used during herniorrhaphy:
• To cut the external oblique aponeurosis to expose the inguinal canal.
• To dissect the hernial sac from the cord structures and to open the fundus of the hernial sac.
Used during thyroidectomy:
• To raise the upper and lower skin flaps by sharp dissection. "e upper skin flap is raised
upto the upper border of the thyroid cartilage and the lower skin flap raised up to the
suprasternal notch.
• To cut the investing layer of the deep cervical fascia in the midline.
• To cut the pretracheal layer of the deep cervical fascia investing the thyroid gland.
• To divide the thyroid vessels (Middle thyroid vein, superior thyroid vessels and the inferior
thyroid artery and vein) after their ligature.
Used during mastectomy and incisional hernia operation to raise the skin flap by sharp
dissection.
Used during radical neck dissection to raise skin flaps by sharp dissection.
Used during splenectomy, nephrectomy to cut the pedicles after ligature.
Used during cholecystectomy to cut the cystic duct and the artery after they are ligated.
21. METZENBAUM SCISSORS
A C
Figures 21.31A to C: Metzenbaum scissors
"is is a long fine scissors with long blades in comparison to the shaft of the instrument. "is
instrument may be straight or curved (Figs 21.31A to C).
Uses
"e Metzenbaum scissors are used for dissection at the depth. May be used in above situations
as an alternative to McIndoe scissors.
Used during vagotomy to divide the nerves after ligature.
Used during cholecystectomy to divide the cystic duct and artery after ligature.
22. HEATH’S SUTURE CUTTING SCISSORS
A B
Figure 21.32A and B: (A) Heath’s suture cutting scissors. (B) Note the curved sharp blades
"is is a fine scissors curved on angle type. "e blades are small, sharp and at the tip there are
serrations. "e serrations at the tip allow gripping of the suture material (Figs 21.32A and B).
Uses
"is is used to cut the sutures on the skin or mucosal surface. "e suture is held up by a dissecting
forceps and one blade of the stitch cutting scissors is inserted into the loop of the suture. "e
suture is cut close to the entrance of the suture into the skin and then the suture is pulled outside.
"e exposed part of the suture does not pass through the depth of the wound during removal of
the suture.
"e serration at the tip of the blade helps in holding of the suture during removal.
Sterilization
Heath’s suture cutting scissors are sterilized by keeping them dipped in concentrated lysol
for 1 hour or in dilute lysol for 24 hours. Boiling or autoclaving damages the sharpness of the
instrument.
23. LANGENBACH’S RETRACTOR
A B
Figures 21.33A and B: Langenbach’s retractor
"e single bladed Langenbach’s retractor has a handle, a long shaft and a flat solid blade. "e
blade is curved at right angle to the shaft. "e tip of the blade is curved at right angle for better
retraction of the tissues (Fig. 21.33A).
In double bladed retractor there is another flat solid blade at the other end of the shaft
(Fig. 21.33B).
Retractors placed suitably help in better visualization of the operative field. "e tissue handling
may also be minimized. Bleeding may be better seen and controlled with placement of retractors.
24. CZERNEY’S RETRACTOR
Figure 21.34: Czerney’s retractor
In Czerney’s retractor at one end there is a flat blade at right angle to the shaft with the tip curved
at right angle while the other end has a biflanged hook (Fig. 21.34).
25. MORRIS’ RETRACTOR
Figure 21.35: Morris’ retractor
"e design is like L. "e handle is wider and the blade is also wider and the lower end of the
blade is curved inward at right angle (Fig. 21.35).
Uses
"ese retractors are used for tissue retraction during different operations.
Used during appendicectomy to retract the layers of the abdominal wall while making the
incision. After incising the peritoneum the abdominal wall is retracted with this retractor to
visualise the caecum and deliver the caecum and appendix out.
Used while making and closing different abdominal incisions for ease of working in deeper
layers of the abdominal wall.
Used during thyroidectomy to retract the strap muscles and the sternomastoid for dissection
and ligation of the thyroid vessels.
Used during modified radical mastectomy for retraction of pectoralis major muscle for better
visualization during axillary dissection.
Used during inguinal hernia operation for retraction of different layers for proper visualization
during repair of the posterior wall of the inguinal canal.
Used during radical neck dissection for retraction of skin flaps, sternocleidomastoid muscle
for better visualization at depth.
Sterilization
"ese retractors are sterilized by autoclaving.
26. HOOK RETRACTORS
A B
Figures 21.36A and B: Hook retractor
"ere is a shaft with handle. "ere is a single (Fig. 21.36A) or double hook (Fig. 21.36B) at the
tip. "e tip of the hook may be sharp or blunt.
Uses
Used for operation at the surface—for retraction of skin flap for excision of sebaceous cyst
and lipoma.
Used during venesection for retraction of skin.
Used during tracheostomy for retraction of skin and thyroid isthmus.
Sterilization
By autoclaving.
27. CAT’S PAW OR VOLKMAN’S RETRACTOR
Figure 21.37: Cat’s paw or Volkman’s retractor
"ere are multiple hooks with pointed edges (Fig. 21.37). "e pointed edges are helpful for
firm retraction. "is is used for retraction of skin flaps or fascia for operation at the surface, e.g.
excisions of sebaceous cyst, lipoma, dermoid, etc.
Sterilization
By autoclaving.
28. FISCH NERVE HOOK
Figure 21.38: Fisch nerve hook
"is is a delicate instrument with a blunt hook at the tip of the shaft (Fig. 21.38).
"is is used for retraction of the nerve during dissection.
Ilioinguinal nerve may be retracted during inguinal hernia operation.
Spinal accessory, hypoglossal, and ansa cervicalis nerve may be retracted during radical
neck node dissection.
Sterilization
By autoclaving.
29. DEAVER’S RETRACTOR
Figure 21.39: Deaver’s retractor
A large curved retractor which is shaped like “S”. It is available in different sizes depending on
its width (Fig. 21.39).
Uses
Used during cholecystectomy for retraction of right lobe of liver.
Used during truncal vagotomy for retraction of left lobe of liver.
Used during gastrectomy for retraction of liver.
Used during pancreaticojejunostomy for retraction of stomach.
Used during right or left hemicolectomy to retract the abdominal wall while mobilizing the
colon from the paracolic gutter.
Used during kidney operation to retract the abdominal wall.
Used during anterior resection of rectum or abdominoperineal resection to retract the urinary
bladder in male or uterus in female during dissection in the pelvis.
Sterilization
By autoclaving
30. SELF-RETAINING ABDOMINAL RETRACTOR (BALFOUR’S TYPE) WITH

PROVISION FOR ATTACHMENT FOR THIRD BLADE
A C
Figures 21.40A to C: Self-retaining abdominal retractor (Balfour’s type) with

provision for attachment of third blade
"ere is a horizontal bar on which one of the two blades of the retractor slides. "e sliding
retractor can be fixed to the horizontal bar by means of a screw. "ere is another screw inbetween
the blades which keeps the third blade in position (Figs 21.40A to C).
While applying, the two blades are kept closer and after the abdominal incision is made up
to the peritoneum the blades are inserted into the abdomen and blades are separated to retract
the abdominal wall. Fixation of the screw in the sliding blade keeps the retractor self retaining.
"e third blade is usually used to retract the costal margin or is used toward the pelvis during
pelvic operations.
While a self retaining retractor is used assistant’s hands become free as he does not need to
hold the retractor in his hands.
Uses
Used to retract the abdominal wall during a number of operations requiring good retraction of
the abdominal wall for proper exposure.
Gastric operations (Vagotomy and gastrojejunostomy, gastrectomy).
Operations on pancreas (Whipple's pancreaticoduodenectomy, pancreaticojejunostomy).
Intestinal operations (Small gut resection and anastomosis, hemicolectomy, abdominoperineal
resection, anterior resection.
Liver operations (Hepatic resection, excision of hydatid cyst).
Operations on adrenal—adrenalectomy.
Excision of intraperitoneal cysts or sarcomas.
Sterilization
By autoclaving.
31. MILLIN’S SELF-RETAINING BLADDER RETRACTOR WITH A PROVISION

FOR ATTACHMENT OF THIRD BLADE
A C
Figures 21.41A to C: Millin’s self-retraining bladder retractor with a provision for

attachment of third blade
Two blades are fitted on horizontal bars which can slide and may be fixed by screws.
Inbetween these two blades there is another screw which may attach the third blade when
required. When finger bows are separated the blades are lying closer. When finge bows are
approximated the blades are separated (Figs 21.41A to C).
"is retractor is used during transvesical prostatectomy. After prostate gland is enucleated,
the prostate cavity is packed with roller gauge. Before removal of the pack the self retaining
retractor is inserted into the bladder and the retractor is opened. "e third blade retracts the
fundus of the bladder. "is keeps the bladder wide open and allows proper inspection of the
prostate cavity and hemostasis under vision.
Sterilization
By autoclaving.
32. JOLL’S THYROID RETRACTOR
Figure 21.42: Joll’s thyroid retractor
"ere are two towel clip like forceps at either end. "e two flanges can be adjusted by means of
a screw mechanism (Fig. 21.42).
"is is also a self retaining retractor used during thyroid operations to retract the skin flaps.
After the skin incision is made, the platysma is incised in the same line. "e upper and lower
skin flaps are dissected and raised. "e upper skin flap is raised up to the upper border of
the thyroid cartilage and the lower skin flap is raised up to the suprasternal notch. Once the
skin flaps are raised the upper and the lower skin flaps are held by the towel clip like forceps
attached to the retractor and the retractor is opened by the screw mechanism attached to
the retractor.
Sterilization
By autoclaving.
33. KOCHER’S THYROID DISSECTOR
Figure 21.43: Kocher’s thyroid dissector. Note

the vertical groove and the eye
The instrument has got a handle and a blade. There are grooves on the handle for firm
gripping. The sides of the blade are blunt and there are longitudinal grooves on the upper
surface of the blade. There is an eye near the tip of the blade which is meant for passing a
ligature (Fig. 21.43).
Uses
"is instrument is used during thyroid operations. "e dissector may be used to dissect the
superior thyroid pedicle and the dissector is passed around the superior thyroid pedicle
close to the gland. A ligature is passed through the eye in the blade of the dissector and as
the dissector is withdrawn the suture is passed around the thyroid pedicle. "ree sutures are
passed around the superior thyroid pedicle and tied. "e superior pedicle is divided keeping
two ligature toward the upper pole.
"e inferior thyroid veins may also be tackled similarly.
Sterilization
By autoclaving.
34. CORD HOLDING FORCEPS
Figure 21.44: Cord holding forceps
In addition to finger bows and shaft there are two semicircular blades and when the rachet is
closed the blades are apposed and makes a circular opening in the blade (Fig. 21.44).
Uses
Used during hernia operation to hold the spermatic cord so that the cord can be retracted during
repair of the posterior wall of the inguinal canal.
Sterilization
By autoclaving.
What is hernia?
What are the different types of hernia?
What is the boundary of inguinal canal?
What is Fruchaud’s myopectineal orifice?
What are the parts of a hernia?
What are the coverings of a complete indirect inguinal hernia?
What do you mean by incomplete and complete inguinal hernia?
What is sliding hernia?
What is bubonocele?
What is funicular hernia?
What is herniotomy?
What is herniorrhaphy?
What is hernioplasty?
What is Bassini’s technique of herniorrhaphy?
See long case on inguinal hernia, page 24.
35. MALLEABLE OLIVE POINTED PROBE
Figure 21.45: Malleable olive pointed probe

with an eye
"is is a metallic probe with an olive at the tip and the probe is malleable and there is an eye at
the other end (Fig. 21.45).
"e instrument is malleable so it can be bent in different ways. "e olive point minimized
trauma and reduces the chance of false passage. "e eye is meant for passing a ligature which
may be passed around a high fistula tract.
Uses
Used during fistulectomy operations. "e probe is passed from the external opening to emerge
from the internal opening. "e probe is then bent and an incision around the probe helps in
complete excision of the fistulous tract around the probe.
May be used to pass a ligature through a high fistula in ano for Seton treatment. "e malleable
probe is passed through the external opening of the fistula and the olive tip emerges from
the internal opening. A no. 1 or no. 2 polypropylene suture is passed through the eye of the
probe and the probe along with the suture is brought out through the internal opening. By
this technique the suture goes through the fistula tract and the two ends of the thread are tied
which cuts through the fistula tract gradually and allows healing of the high fistula.
May be used during fistulotomy or opening a sinus tract. "e probe is introduced into the
fistula or the sinus tract and the sinus or the fistula is laid open over this probe.
May be used in assessing the penetrating trauma abdomen to ascertain the depth of the
wound and whether it has penetrated the peritoneum or not.
May be used to assess the length and depth of a sinus tract.
May be used to sound a sinus tract to ascertain presence of any foreign body.
Sterilization
By autoclaving
Fistula
What is a fistula?
Fistula is a tract, usually lined by granulation tissues with openings at both ends of the tract. A
fistula in ano is a tract lined by granulation tissue and has an external opening at the perianal
skin and internal opening at the anal canal or rectum.
What do you mean by low anal fistula?
When the internal opening of the fistula lies below the anorectal ring then it is called a low anal
fistula. If this fistulous tract is laid open there is no chance of anal incontinence.
What do you mean by high anal fistula?
When the internal opening of the fistula lies at
or above the anorectal ring then it is called a
high fistula. Fistulectomy or fistulotomy in such
cases may result in incontinence due to division
of anorectal ring.
A B
What are the different types of anal
fistula?
The different types of anal fistula include
(Fig. 21.46A):
1. Subcutaneous fistula: External opening at the
perianal skin and the internal opening at the
skin lined part of the anal canal. Figures 21.46A and B: Different types of anal
fistula
2. Submucous fistula: "is is more like a sinus than a fistula. "e internal opening is at the anal
canal and the tract traverses upto the submucous coat.
3. Low anal fistula: "e external opening is at the perianal skin and the internal opening lies at
the anal canal below the anorectal sling.
4. High anal fistula: When the internal opening of the fistula lies at or above the anorectal sling.
5. Pelvirectal fistula: In this case the fistulous tract traverses through the levator ani muscle and
the internal opening of the fistula is at the rectum.
What is Park’s classification for perianal fistula?
1. Intersphincteric: "e fistulous tract runs between the internal and the external sphincter.
Depending on the internal opening it may be high or low intersphincteric fistula (Fig. 21.46B).
2. Trans sphincteric fistula: From the external opening at the perianal skin the fistulous
tract traverses through both the external and the internal anal sphincter. Depending on
the position of the internal opening at the anal canal this may also be low or high trans
sphincteric fistula.
3. Supralevator fistula: "e fistulous tract traverses through the levator ani muscle and the
internal opening is into the rectum.
How perianal fistula develops?
Perianal fistula develops secondary to:
Perianal abscess (most common cause) which has ruptured spontaneously or is incised late.
Associated with specific diseases like tuberculosis or Crohn’s disease.
What is Goodsall’s rule?

When the external opening of the fistula lies in the anterior half
of the anal opening, then the fistulous tract tends to be straight.
When the external opening of the fistula lies in the posterior
half of the anal opening, then the fistulous tract is usually curved
and the internal orifice usually lies in the posterior midline.
There may be multiple external openings but the internal
opening is usually single (Fig. 21.47).
What investigations may help to map out course of
perianal fistula? Figure 21.47: Goodsall’s rule
TRUS (Transrectal ultrasonography) or MRI may be
helpful in delineation of a complex fistula.
Fistulogram is not very helpful for delineation of perianal fistulous tract.
What is watercan perineum?
Perianal fistula with multiple external openings are called watercan perineum. "ere may be
discharge of pus from multiple openings.
What are the important causes of multiple perianal fistula?
Multiple perianal fistula is often associated with tuberculosis, Crohn’s disease or lympho-
granuloma inguinale.
Hidradenitis suppurativa may be associated with multiple perianal sinuses.
What is the treatment for low anal fistula?
Fistulectomy or fistulotomy is the standard surgical treatment for low anal fistula.
Why fistulectomy and fistulotomy is not suitable for high fistula?

"is will result in anal incontinence.
A staged procedure is advisable in such situation.
Colostomy for fecal diversion.
Fistulectomy and repair of sphincter.
Colostomy closure after 8 weeks.
Alternatively Seton treatment may allow healing of the fistula. Under anesthesia a nylon,
prolene or silk is threaded on to the eye of the malleable probe is passed through the fistula
tract and is tied. At regular intervals the thread is tightened as it cuts through the fistulous tract.
36. OLIVE POINTED FISTULA DIRECTOR WITH FRENUM SLIT
Figure 21.48: Olive pointed fistula director

with frenum slit
"is is a metallic probe with an olive at the tip. On the upper aspect there is a groove. "e base
is broad and flat and there is a slit in the middle (Fig. 21.48).
Uses
Used during fistulotomy. "e fistula director is passed through the fistula tract from the
external to the internal opening and the fistulous tract is incised over the groove in the probe.
In stricture urethra operation the strictured segment may be slit over this probe.
May be used during tongue tie operation to release the frenulum.
Sterilization
By autoclaving.
37. PILES HOLDING FORCEPS
Figure 21.49: Piles holding forceps. Note the oval blade with fenestration and groove in the terminal
part of the blade
"e instrument has finger bows, a catch and a pair of shaft with a pair of blades. "e blades are
oval with a central fenestration. "ere is a complete groove on the inner aspect of each blade
(Fig. 21.49).
Uses
"is instrument is used during piles operation to hold the pile mass.
Sterilization
By autoclaving.
How will you differentiate it from a swab holding forceps?
"e swab holding forceps is longer and the blades are provided with transverse serrations.
Piles
What are piles?

Piles are condition of dilated veins occurring in relation to the internal venous plexuses of anal
canal with an enlarged and displaced anal cushion.
What are the different types of piles?
Depending on the location the piles may be:
Internal piles—When the pile mass is lined by the anal mucous membrane and lies internal
to the anal orifice.
External piles—When the pile mass is lined by the skin of the anal canal and lies external to
the anal orifice.
Interno external piles—Combination of internal and external piles.
Depending on the etiology the piles may be:
Primary piles—When no obvious cause could be found for development of piles.
Secondary or symptomatic piles—When the piles develops secondary to some other causes.
What are the important causes of secondary piles?

During pregnancy: "e important factors for development of piles in pregnancy include:
• Compression of superior rectal veins by the gravid uterus.
• Relaxing effect of progesterone on the vein walls.
• Increased pelvic circulatory volume.
BPH or stricture urethra: Increased straining at micturition.
Carcinoma of rectum: Compression of superior rectal vein may give rise to secondary piles.
Chronic constipation with increased straining at defecation.
What are anal cushions?
"e anal cushions are mucosal lining which are gathered predominantly at three places in
relation to the three terminal branches of superior rectal artery. "e anal cushions are necessary
for full continence. Straining at stool leads to downward descent of these anal cushions. Once
these anal cushions descend beyond the anal sphincters there is compression of these anal
cushions by the anal sphincters resulting in engorgement of the veins of the internal rectal
venous plexus leading to formation of internal piles.
What are the primary and secondary sites of piles?

"e primary sites of internal hemorrhoids are at 3,
7 and 11 o’clock position. Inbetween these primary
hemorrhoids there may be smaller secondary
hemorrhoids (Fig. 21.50).
What are the different grades of piles?
Depending on size and prolapse of the piles it may be:
First degree piles—Piles that bleeds but does not
prolapses outside the anal orifice. Figure 21.50: Sites of primary and secondary
Second degree piles—Piles that prolapses outside piles
the anal orifice during defecation and reduces
spontaneously or has to be manually replaced and then stay reduced.
Third degree piles—Piles that remain permanently prolapsed outside the anal orifice.
What are the usual presentation of patients with piles?

Painless bleeding per rectum.
Prolapse of the piles mass outside the anal orifice.
Mucus discharge.
Anemia.
May present with complications.
What are the complications of piles?
Strangulation.
"rombosis.
Ulceration and gangrene.
Portal pyemia and septicemia.
Fibrosis.
What are the nonoperative treatment of piles?
Injection sclerotherapy: Indicated in first degree and early second degree piles.
• Sclerosants used: 5% phenol in almond or olive oil, sodium tetradecyl sulfate or
ethanolamine oleate.
• Injection is done at the submucosa of the pedicle of the pile mass (See Minor Surgical
Procedures, Page No. 840-852, Chapter 20).
Barron' s banding: Same indication as above.
"e pile mass is brought into the hollow of the band applicator and on firing the instrument
the band is slipped into the pedicle of the pile mass. "e band causes ischemic necrosis of
the pile mass which sloughs off in a few days.
Cryosurgery: Application of liquid nitrogen (temperature—196°C) causes coagulative necrosis
of the pile mass.
Photocoagulation: Application of infrared rays may also cause regression of the pile mass.
What are the indications of surgery for piles?
"ird degree piles.
Internoexternal piles with a large external piles.
Failure of non operative treatment.
"rombosed piles.
What is Milligan-Morgan technique of hemorrhoidectomy?

"is is also called open hemorrhoidectomy. "e pile mass is ligated and excised. "e cut margins
of the anal mucosa and anal skin is left open to heal by granulation.
What is closed hemorrhoidectomy?
In this technique after ligation and excision of the pile mass the cut margins of the anal mucous
membrane and the skin are sutured to close the resulting wound.
38. RIGHT ANGLED FORCEPS (LAHEY’S FORCEPS)
Figure 21.51: Right angled forceps (Lahey’s forceps). Note the 90° angulation and transverse
serrations in the blade
Like a hemostatic forceps this instrument has finger bows, a catch, a pair of shaft and a pair of
blades. "e terminal part of blades are bent at right angles to the shaft of the instrument and
there are transverse serrations in the blade (Fig. 21.51).
Uses
"is is usually used to dissect pedicles of important organs and a ligature may be passed
around the dissected vessels. "is may also be used as a hemostatic forceps to hold a bleeding
vessel at a depth.
"is is used during cholecystectomy to dissect the cystic duct and the artery and to pass a
ligature around these structures.
Used during gastrectomies to dissect and pass ligatures around the left gastric artery, right
gastric artery, gastroepiploic vessels before their divisions.
Used during vagotomy to dissect the anterior and posterior vagus nerves and pass ligatures
around these structures before their division.
Used during splenectomy to dissect the splenic artery and the vein and to pass ligature
around them.
Used during nephrectomy to dissect the renal vessels and to pass ligature around them.
Used during thyroidectomy to dissect the middle thyroid vein, superior thyroid pedicle and
the inferior thyroid vessels and to pass ligature around them.
Sterilization
By autoclaving.
39. CHOLECYSTECTOMY FORCEPS
Figures 21.52A and B: Cholecystectomy forceps
"ese are stout and heavy instruments. In addition to the finger bows and catch there is a pair
of long shafts with a pair of relatively small blades with blunt tips. "e long instrument helps
working at a depth.
In Moynihan’s forceps the blade is slightly angled to the shaft and there are transverse
serrations in the blade (Fig. 21.52A).
In Henry Gray’s forceps the blade is longer than in a Moynihan’s forceps which is angled at
almost right angle to the shaft and there are critical serrations in the blade (Fig. 21.52B).
Uses
Used during cholecystectomy. One pair of forceps is used to hold the fundus of the gall-
bladder and one pair to hold near the Hartmann’s pouch. If the gallbladder is long, a third
pair of forceps may be used to hold the body of the gallbladder.
"e cystic duct and artery may be dissected by Moynihan’s forceps. But usually a right angled
forceps (Lahey’s forceps) is preferred for dissection of the cystic pedicle.
Sterilization
By autoclaving.
What are the complications of cholecystectomy?
Immediate complications:
• Anaesthetic complications—Respiratory and cardiac complications.
• Complications due to the procedure:
& Bleeding.
& Bile leakage:
» Acute biliary peritonitis (Waltman-Walters syndrome).
» Biloma (Localized bile collection).
& Bile duct injury:

» Lateral tear.
» Complete transection.
» Partial ligature.
» Complete ligature.
» Slippage of cystic duct stump ligature.
Delayed complications:
• Biliary stricture.
Discussion on gallstone disease
See Long Case, Page No. 125-129, Chapter 3.
40. DESJARDIN’S CHOLEDOCHOLITHOTOMY FORCEPS
Figure 21.53: Desjardin’s choledocholithotomy forceps. Note no ratchet. Blades having fenestration
with groove in the terminal part
"is is a long and slender instrument. "ere are finger bows but no catch. "e shafts are curved,
in some it is a gentle curve and in other varieties there are different degrees of curvature. "e
blades are small and fenestrated centrally. "ere are no serrations in the blade (Fig. 21.53).
Uses
"is is used during choledocholithotomy. "e common bile duct is identified by aspirating
bile from the bile duct. Two stay sutures are applied in the bile duct by a 3-0 atraumatic catgut
suture and a choledochotomy is made in between the stay sutures. "e Desjardin’s forceps
is then introduced into the bile duct and the stones are removed by holding the stones in
the fenestrated blade.
"is is used during laparoscopic cholecystectomy. While extracting the gallbladder through
the epigastric or umbilical port, as the gallbladder is partially delivered through the port
wound, it usually gets stuck if there are large stones in the gallbladder or there are multiple
small stones in the gallbladder. "e gallbladder is partially delivered through the wound.
"e gallbladder is opened and the stone removed from the gallbladder by the Desjardin’s
choledocholithotomy forceps.
It may also be used during removal of kidney, ureteric or bladder stone.
Sterilization
By autoclaving.
Why there is no catch in this instrument?
As this instrument is used for holding stones during its removal, it is not provided with catch.
Otherwise stone would be crushed during removal.
41. KEHR’S T-TUBE
Figure 21.54: No. 14 PVC Kehr’s T-tube
No. 14 PVC (polyvinyl chloride) Kehr’s T-tube (Number 12, 16 and 18 are also available). Silastic
and latex T tube are also available (Fig. 21.54).
"ere is a short horizontal limb which is inserted into the bile duct and a long vertical limb
which is brought outside.
Uses
Following choledochotomy, the bile duct is closed over a T-tube, as primary closure of bile
duct is associated with higher incidence of leakage.
Used to drain the bile duct following repair of bile duct injury. "e T-tube acts as a stent and
is usually kept for about 4–6 weeks.
May also be used to stent a choledochojejunostomy or choledochoduodenostomy
anastomosis.
May be used as a stent following repair of ureteric injury.
Sterilization
By autoclaving.
T-tube cholangiography
See X-ray Section, Page No. 705-707, Chapter 17.
Management of bile duct stones (see Long Case, Page No. 146-150, Chapter 3).
How T-tube is inserted?
"e short limb is cut to a desired length. "e limb passing toward the lower end of the bile duct
is kept about 3–4 cm and the limb passing toward the hepatic duct is kept about 2–3 cm. A slit
is made in the short limb so that the two openings are connected by the slit and a rim of tube
is cut away along the slit made.
"e short limb is then inserted into the bile duct. "e choledochotomy is then closed with
interrupted sutures so that the T-tube fits snugly in the bile duct taking care not to take any bite
of the suture in the T-tube.
"e long verical limb of the T-tube is brought out through a stab wound in the skin in lateral
abdominal wall and is fixed to the skin by a stitch.
How will you take care of T-tube?
"e T-tube is connected to a closed system of drain into a urobag
"e bile is collected in the urobag, measured and evacuated every morning
A T-tube cholangiogram is done on 8th postoperative day
If T-tube cholangiogram is normal, the T-tube is clamped overnight and if patient has no
problem, on next morning the T-tube is removed by a smart pull. "ere may be slight leakage
of bile for 1–2 days and the tract closes spontaneously.
42. GASTRIC OCCLUSION CLAMPS
Figures 21.55A to C: Gastric occlusion clamps
A. Moynihan’s gastric occlusion clamp: "is is a long instrument with finger bows, a rachet and
a pair of long shaft provided with a pair of long stout blades. "ere are transverse serrations
in the blade with a linear fenestration along the center of each blade extending near the tip
of the blade. "e fenestration makes the blade lighter and prevents crushing of tissues. "is
instrument may be curved (Fig. 21.55A) or straight (Fig. 21.55B).
B. Kocher’s gastric occlusion clamp: Kocher’s gastric occlusion clamp is also a long instrument
with finger bows, a rachet, a pair of shaft and a pair of long blades. "e blades are provided
with vertical serrations and there are no fenestration in the blades. "is instrument may be
straight (Fig. 21.55C) or curved.
Uses
Used during gastrojejunostomy to clamp the stomach side for gastrojejunal anastomosis
Used during gastrectomy. "e line of resection is decided. Two pairs of gastric occlusion
clamps are applied along the proximal line of resection and the tomach is divided in between
the two gastric occlusion clamps. Two pairs of intestinal occlusion clamps are applied toward
the duodenal end and the stomach is divided inbetween.
Sterilization
By autoclaving
What are the advantages of using an occlusion clamp?
Prevents spillage: When the clamps are applied during gastrointestinal anastomosis, it
occludes the lumen of the gut and prevents the spillage of gut contents.
Prevents bleeding: Properly applied clamp also occludes the blood vessels and prevents
bleeding during anastomosis.
Easier anastomosis: "e applied clamps on either side of anastomosis can be held together
and the cut margins are kept closer for easier anastomosis.
What do you mean by closed and open gastrointestinal anastomosis?
When anastomos is performed by occluding the lumen of the gut by using a occlusion clamp
then it is called a closed type of anastomosis.
In open anastomosis, no clamps are applied. "e corners of the cut margins are kept steadied
by holding with Babcock’s tissue forceps or stay sutures and anastomosis is done.
43. LANE’S PAIRED GASTROJEJUNOSTOMY CLAMPS
A B
E F
Figures 21.56A to F: Lane’s paired gastrojejunostomy clamps
"is is a paired instrument. Each instrument is provided with finger bows, a catch, a pair of shaft
and a pair of long blades provided with longitudinal serrations. Near the tip of one instrument
there is a hook which fits the other blade and there is an arrangement of screw in the other blade
which fixes the adjacent blade. When properly applied the two instruments are kept side by
side keeping the stomach and jejunum apposed. "is instrument may be curved (Fig. 21.56A)
or straight (Fig. 21.56B).
Uses
"is instrument is used during gastrojejunostomy. One pair of clamp is applied to the stomach
and one pair is applied to the jejunum. As the two instruments are kept side by side and the
screw is tightened the stomach and the jejunum is kept steadied and anastomosis is done easily.
Sterilization
By autoclaving.
What are the indications of gastrojejunostomy?
Gastrojejunostomy is anastomosis of stomach to the jejunum either by using a loop of jejunum
or by using a Roux-en-Y loop of jejunum. "e anastomosis may be done to the anterior wall of
stomach (Anterior GJ) or to the posterior wall of stomach (posterior GJ). "e jejunal loop may
be brought up either anterior to the colon (antecolic GJ) or posterior to the colon (retrocolic
GJ). "e indications are:
Treatment of peptic ulcer:
• Gastrojejunostomy is done as a drainage procedure along with truncal vagotomy for
treatment of peptic ulcer disease.
• Gastrojejunostomy may be done as a sole procedure in patients with peptic ulcer disease
with very poor general condition.
• Pyloric stenosis due to corrosive acid poisoning causing gastric burn and subsequent
fibrosis leading to pyloric stricture.
• Carcinoma of stomach:
Following lower radical gastrectomy, continuity is maintained by gastrojejunostomy.
In inoperable carcinoma of stomach causing gastric outlet obstruction.
• Chronic pancreatitis causing gastric outlet obstruction.
• Following Whipple's pancreaticoduodenectomy for periampullary carcinoma or
carcinoma of head of pancreas, gastric continuity is maintained by gastrojejunostomy.
What is an ideal gastrojejunostomy?
A retrocolic, short or no loop, no tension, isoperistaltic gastrojejunostomy with a vertical stoma
is considered as an ideal gastrojejunostomy.
A Roux-en-Y gastrojejunostomy has been claimed to be superior as there is no chance of bile
reflux gastritis which is common with loop gastrojejunostomy.
Describe the steps of truncal vagotomy and gastrojejunostomy.
See Page No. 978, Chapter 22.
44. INTESTINAL OCCLUSION CLAMPS
Figures 21.57A and B: Doyen’s intestinal occlusion clamps. Note the delicate long blades with vertical
serrations
Figures 21.58A and B: Carwardine’s twin intestinal clamp. Note the screw, slot and the delicate
blades with vertical serrations
A. Doyen’s intestinal occlusion clamps:
"is instrument has finger bows, a pair of shaft with a pair of long blades. "e blades are lighter
and there are vertical serrations in the blade. "ere is a rachet, which when closed bring the
blades in apposition. "is instrument may be curved (Fig. 21.57A) or straight (Fig. 21.57B).
B. Carwardine’s twin intestinal occlusion clamps: "is is a paired instrument. "ese are smaller,
lighter instrument than Doyen’s intestinal occlusion clamps. In addition to finger bows, rachet
and a pair of shaft and blades, there is a slot on the side of one shaft of one instrument and
a screw on the shaft of the other instrument. When applied properly the slot and the screw
fits and this keeps this instrument side by side, so that the intes tinal loops are kept side by
side during anastomosis (Figs 21.58A and B).
Uses
"ese instruments are used for gut resection and anastomosis.
Sterilization
By autoclaving
What are the indications of intestinal resection and anastomosis?
"e important indications are:
Strangulated hernia with devitalization of gut
Intestinal obstruction with strangulation causing devitalization of a segment of gut
Intestinal trauma causing intestinal laceration or devitalization of a segment of a gut due to
mesenteric tear
Intussusception which is irreducible or has caused strangulation of a segment of gut
Intestinal neoplasm
Meckel's diverticulum requires excision with a wedge of ileum
Crohn's disease with stricture or fistula
Ulcerative colitis not responding to medical treatment
Intestinal tuberculosis with stricture formation
Neoplastic lesion in gut either benign or malignant.
What are the different types of intestinal anastomosis?

Intestinal continuity may be maintained by:
End to end anastomosis
End to side anastomosis
Side to side anastomosis.
What are the different techniques of intestinal anastomosis?

Standard two layer anastomosis: Consisting of:
• Inner layer of suture taking the full thickness of the bowel wall—posterior and anterior
through and through layers.
• Outer seromuscular layer—posterior and anterior seromuscular layers.
Single layer anastomosis: "ere are different techniques of applying single layer suture:
• Simple interrupted suture through the full thickness of the intestine with knot placed
towards the mucosal aspect.
• Gambee stitch—suture passed through all layers of the intestine with a loop on mucosa
on each side of the anastomosis for better mucosal inversion.
• A single layer extramucosal stitch—suture passed from the serosal aspect and emerges
through the submucosa and making a loop on submucosa on each side of the anastomosis.
Which suture material will you prefer for intestinal anastomosis?
In two layer anastomosis: Posterior through and through and anterior through and through
with absorbable suture—polyglactin (vicryl), polydioxanone (PDS), polyglecaprone
(Monocryl) or catgut.
Posterior seromuscular and anterior seromuscular with mersilk, polyglactin or polydioxanone
suture.
In single layer anastomosis either mersilk or polyglactin sutures are used.
"e size of the suture material for gut anastomosis is 2-0 or 3-0.
Small Gut Resection Anastomosis

Technique of small gut resection anastomosis
Following laparotomy, the area of gut to be resected is selected. "e vessels supplying this
segment of the gut is to be ligated and divided. A V shaped area in the mesentery is marked
with the apex pointing towards the root of the mesentery. "e vessels supplying the segment of
the gut is held by a series of hemostatic forceps and the mesenteric vessels divided in between
the hemostatic forceps.
Two pairs of intestinal occlusion clamps are applied on each side of the intestine which is to
be resected. A gauge swab is placed behind the gut and the intestine is divided in between the
occlusion clamps on either side. "e escaping gut contents are sucked and swabbed off with
the gauge piece. "e loop of the intestine is now removed with two pairs of intestinal occlusion
clamps still attached to the intestine.
Anastomosis: "e occlusion clamps with cut ends of the intestine are approximated so that the
cut ends of the bowel lies in close apposition. "e anastomosis is done in two layers—a layer of
seromuscular sutures and a layer of through and through sutures.
Posterior seromuscular suture is started at the anti mesenteric border with 2-0 polyglactin
sutures taking bites through the seromuscular layers and continued upto the mesenteric border
of the gut and the suture is tied at this end, the suture is kept for continuation of this suture as
anterior seromuscular layer.
"e posterior through and through suture with 2-0 polyglactin is started at the antimesenteric
border and continued around the circumference of the bowel to come back to the starting point
as anterior through and through layers. "e running sutures should be interlocked at intervals
to prevent purse string effect. "e suture line is inspected for any bleeding and if necessary
additional stitches may be applied.
"e anterior seromuscular suture is now continued inverting the through and through layer
(Lambert suture).
"e gap in the mesentery is apposed with interrupted sutures taking care not to take any bite
through the mesenteric vessels.
Drains are not indicated routinely. If there had been perforation of the gut causing peritoneal
contamination, then a drain may be inserted.
45. PAYRS’ CRUSHING CLAMPS
Figure 21.59: Payrs’ gastric crushing clamps.

Note the long heavy blades with vertical
serrations
A. Payrs’ Gastric Crushing Clamps

"is is a heavy instrument. "e handles are stout and there is a double lever arrangement. "e
blades are long and heavy and there are vertical serrations in the blade (Fig. 21.58).
"e lever arrangement magnifies the pressure of the handle closure to the blades so that it
produces a crushing effect, whereby the mucosa is crushed and it curls up.
Uses
Used during partial gastrectomies. However, most of the surgeons do not use this crushing
clamps during gastrectomies. If at all these clamps are used, these clamps are used towards
the side of the stomach that is to be resected and the proximal stomach is held up by a gastric
occlusion clamp.
Sterilization
By autoclaving.
What are the indications of partial gastrectomy?
Chronic gastric or duodenal ulcer
Anastomotic ulcer following gastrojejunostomy
Gastric carcinoma
Gastrointestinal stromal tumors
Along with Whipple's pancreaticoduo denectomy, distal stomach is removed. However, in
pylorus preserving pancreaticoduodenectomy distal stomach is not removed.
What are the indications of total gastrectomy?
Total gastrectomy involves resection of whole of the stomach with Roux-en-Y esophago-
jejunostomy. "e important indications are :
Proximal gastric cancer involving the fundus and cardia
Cancer involving the midbody of the stomach
Generalized linitis plastica
Corrosive stricture involving the whole of stomach
Zollinger-Ellison syndrome.
How does the crushing clamps functions?

When the crushing clamp is applied it crushes the muscle and the mucous coat which curls
inwards and blocks the lumen. "e sutures are placed well over the crushed muscle.
Crushing clamps are used at sites where the stump is to be closed, e.g. duodenal stump during
gastrectomy and appendix stump during appendicectomy. Crushing clamps should not be used
where anastomosis is to be done.
B. Payrs’ Intestinal Crushing Clamps
Figure 21.60: Payrs’ intestinal crushing clamps
These instruments resemble gastric crushing clamps, but the blades are smaller and the
instrument is little lighter (Fig. 21.60).
C. Payrs’ Appendix Crushing Clamps
Figure 21.61: Payrs’ appendix crushing clamps
"ese instruments resemble gastric crushing clamps, but the blades are much smaller and the
instrument is little lighter (Fig. 21.61).
Uses of intestinal and appendix crushing clamps

May be used to crush the base of the appendix during appendicectomy. However, the base
of the appendix is usually crushed with a hemostatic forceps
May be used to crush the duodenal stump during gastrectomy
May be used during right hemicolectomy.
"e crushing clamp may be used to crush the ends of ileum and the transverse colon. "e
ends are then oversewn with sutures and a side to side anastomosis is done.
For intestinal resection anastomosis, two pairs of intestinal occlusion clamps are used and
crushing clamps are not used usually.
Sterilization
By autoclaving.
46. PYELOLITHOTOMY FORCEPS
Figure 21.62: Pyelolithotomy forceps. Note the curved blades with groove and transverse serrations
"is is a long instrument, consists of finger bows, a pair of shaft and a pair of blades. "e blades
are small and oval with transverse serration on the inner side of the blades with a central groove.
"ere is no rachet in the shaft (Fig. 21.62).
Uses
This instrument is used to hold the stone during nephrolithotomy, pyelolithotomy or
ureterolithotomy.
Sterilization
By autoclaving.
47. SUPRAPUBIC CYSTOLITHOTOMY FORCEPS
Figure 21.63: Suprapubic cystolithotomy forceps. Note the long blades with grooves and elevations in
the blades
"is forceps consists of finger bows—a pair of shaft and a pair of blades. "e blades are longer
and the inner surface of the blades are provided with fine knobs which helps in better gripping
of the stones. "ere are no rachet in this instrument (Fig. 21.63).
Uses
Used for suprapubic cystolithotomy. After the bladder is opened by a suprapubic cystotomy the
instrument is inserted into the bladder and the stone is removed.
Sterilization
By autoclaving.
Discussion on renal calculi
See X-ray Section, Page No. 687, Chapter 17.
48. SIMPLE RUBBER CATHETER NO. 10
Figure 21.64: Simple rubber catheter no. 10
"is catheter is made of India rubber. "e tip is smooth and rounded and there is an opening
at the side near the tip. "ere is an opening at the other end. It comes in variety of sizes—6, 8,
10, etc (Fig. 21.64).
What does number 10 indicates?
"is is an English scale regarding the diameter of the catheter.
"e diameter is expressed in mm as—Number of catheter/2 + 1.
What are the uses of a simple rubber catheter?
Urological use:
To differentiate anuria and retention of urine by catheterization of bladder
To relieve retention of urine by catheterization.
To assess the amount of residual urine after micturition. "is, however, can also be done by
ultrasonography
To collect a specimen of urine in an unconscious patient
For performing cystography. "e catheter is introduced into the bladder and the dye diluted
with normal saline is introduced into the bladder through the catheter
For diagnosis of urinary tract injuries. Catheterization of bladder if revealed hematuria
indicates presence of urinary tract injury
In case of urethral rupture the catheter cannot be negotiated into the bladder.
For administration of intravesical chemotherapy or BCG vaccine for treatment of bladder
carcinoma.
Non-urological use:
For diagnosis of esophageal atresia in a new born. "e catheter cannot be passed into the
stomach.
May be used as a oxygen catheter.
Used during choledocholithotomy for flushing the bile duct with normal saline to remove
the sludge and small stones.
May be used during vagotomy. A catheter is passed around the esophagus to give traction to
the esophagus and to identify the vagus nerve .
May be used to irrigate an abscess cavity.
How will you catheterize a patient presenting with acute retention of urine?
What are the complications of catheterization?
See Minor Surgical Procedure, Page No. 839, Chapter 20.
49. FOLEY’S BALLOON CATHETER
B
B—22 Fr. Three way Foley’s balloon catheter with a balloon capacity of 30–50 mL
Figures 21.65A and B: Foleys balloon catheter. 1—Side channel for inflating the balloon; 2—Main
channel for drainage; 3—Third channel for drainage or irrigation
"is is a variety of self retaining catheter:

A. In two ways Foley’s balloon catheter, the side channel is used to inflate the balloon so that it
is kept indwelling. "ere is a valve in the side channel. "e main channel is for drainage of
urine. "e catheter number (no. 16 Fr.) and the balloon capacity (30–50 mL) is mentioned
on the main or side channel (Fig. 21.65A).
B. In three ways Foley’s balloon catheter, there is an additional third channel for either irrigation
or drainage (Fig. 21.65B).
Uses
For relief of retention of urine by urethral catheterization.
May be used for suprapubic cystostomy
May be used for tube nephrostomy
May be used for urethral catheterization following urethroplasty
May be used for urethral catheterization following open prostatectomy for drainage of bladder
"e three way catheter is favored as there is a side channel for irrigation of bladder
May be used for drainage of bladder to monitor urine output in critically ill patient or following
major operation or major trauma
May be used for gastrostomy or jejunostomy
May be used for tube cecostomy
May be used for cholecystostomy
For tube thoracostomy for drainage of empyema or hemothorax or for pneumothorax.
Sterilization
Supplied in a presterilized pack and is usually sterilized by gamma irradiation.
What do you mean by a 16 Fr. catheter?
"is is a French scale of measurement. "is indicates the circumference of the catheter in
millimeter. Diameter of the catheter in mm is calculated by = No. of catheter in French scale/3.
50. MALAECOT’S CATHETER NO. 30 FR
Figure 21.66: Malaecot’s catheter No. 30 Fr.
"is is a type of self retaining catheter and it is retained after its introduction by its dilated winged
end (Fig. 21.66). "e dilated winged end may be made straight by introducing a Malaecot catheter
introducer or by inserting a hemostatic forceps into the dilated end and straightening it over
the introducer or hemostatic forceps.
Uses
Like Foley’s catheter—except that it is never used for urethral catheterization.
Sterilization
By autoclaving.
How will you change a suprapubic Malaecot catheter?
Suprapubic cystostomy catheter needs to be changed every 3–4 weeks.
Local area is cleaned with antiseptic solution
"e catheter is removed by a smart pull
Another catheter is introduced through the same tract by stretching the tip of the catheter
over a catheter introducer.
51. DE PEZZER’S CATHETER NO. 24 FR
Figrue 21.67: De Pezzer’s catheter No. 24 Fr.
"is is also a self-retaining catheter and it is kept in place after introduction due to its dilated
bulbous end (Fig. 21.67).
Uses
Like Foley’s catheter—except that it is never used for urethral catheterization.
Sterilization
By autoclaving.
How are these self-retaining catheters removed?
Foley’s catheter is removed after withdrawing the water from the balloon.
"e Malaecot and the De Pezzer catheter is removed by a smart pull.
52. CATHETER INTRODUCER
Figure 21.68: Catheter introducer. Note the

groove and curvature of the instrument
"is is a long metal rod curved like a dilator with a groove in the body with a rounded tip (Fig.
21.68).
Uses
It is used to introduce a Foley's catheter through the urethra when the catheter cannot be
introduced in the usual way due either to stricture urethra or prostatic enlargement. But there
is risk of false passage in this technique.
It may be used to introduce a Malaecot or De Pezzer’s catheter. "e introducer is passed
through the catheter and is brought near the tip. "e catheter is stretched at the tip over the
introducer thereby straightening the tip so that the catheter is introduced through a small
opening.
Sterilization
By autoclaving.
53. METALLIC BOUGIE
B C
A
Figures 21.69A to C: (A) Clutton’s metallic bougie no. 12/16 (B) note the handle which is violin shaped
and number difference of 4 and (C) terminal part of the blade which curved and having a rounded tip
B C
A
Figures 21.70A to C: (A) Lister’s metallic bougie no. 11/14, (B) Note the handle which is round and
having a number difference of 3. (C) Note tip which is curved and olive pointed
Characteristics
A. Clutton’s metallic bougie: "is is a solid, cylindrical metallic instrument. "e handle is violin
shaped with a long shaft and the terminal end has a smooth curve with a blunt tip. "e number
written on the handle has a difference of 4. "e denominator number denotes the circumference
in mm at the base and the numerator denotes the circumference in mm at the tip. "is is available
in a set of 12 and the different numbers are 6/10, 8/12, 10/14, 12/16 ........... 28/32 (Fig. 21.69A).
B. Lister’s metallic bougie: "is is identical to a Clutton’s metallic bougie. "e differences are:
"e handle is rounded and the tip is olive pointed. "e number written has a difference of 3
and has same implication as in Clutton’s metallic bougie. "is is also available in a set of 12
(Fig. 21.70).
Uses of Metallic Bougie

Used for dilatation of urethra in urethral stricture
Used for dilatation of urethra prior to introduction of cystoscope
Used during repair of rupture urethra by rail road technique.
Used during choledocholithotomy. "is is used as a sound to ascertain presence of bile duct
stones. "is may be passed through the ampulla of vater to ascertain the patency of ampulla.
Sterilization
By autoclaving.
How will you do urethral dilatation?
Patient lies supine. "e external genitalia are cleaned with antiseptic solution (Savlon). 20 mL
of 2% xylocaine jelly is introduced through the external urethral meatus into the penile urethra.
Wait for 5 minutes.
Stand on the left side of the patient. "e penis is held by the left hand. Start dilatation with a
10/14 dilator. "e dilator is introduced through the external urethral meatus keeping it parallel
to the left inguinal ligament. "e dilator is allowed to pass by its own weight. As the dilator goes
in bring it to the midline of the abdomen in an anticlockwise direction and as it goes further
down bring the dilator down in between the two thighs. Once the dilator goes into the bladder,
it can be rotated easily. "ere should be no pain or bleeding during the procedure.
How will you know if there is any false passage?
"ere is continuous sense of resistance while introducing the instrument
"e handle cannot be pressed between the two thighs
"e instrument cannot be moved freely from side to side
Patient may complain of severe pain
Bleeding per urethra.
For stricture urethra what should be the frequency of dilatation?
For passable stricture urethra, dilatation at regular interval is the treatment of choice.
Initially dilatation is to be done once a week for a month. "en:
Once in a month for a year
Once every 6 months for 3 years
Afterwards once a year for lifelong (birthday dilatation).
What are the complications of urethral dilatation?

False passage
Bleeding
Fistula formation
Infection
Restricture.
When do you consider that a stricture is impassable?

An impassable stricture is one where a smallest size filiform bougie (1 Fr.) cannot be negotiated
through it.
What are the indications of surgical treatment for urethral stricture?
Impassable stricture
Failure of repeated dilatation
When dilatation is required at more frequent interval.
54. FEMALE METALLIC CATHETER
Figure 21.71: Female metallic catheter
"is is a short metallic catheter. "e tip is rounded and there are multiple side holes near the
tip (Fig. 21.71).
Uses
Used during pelvic operations to empty the bladder before the operation to prevent injury to
the bladder. Bladder needs to be emptied while doing laparotomy through a lower midline
incision.
May be used to relieve retention if a rubber catheter cannot be passed.
Sterilization
By autoclaving.
55. MALE METALLIC CATHETER
Figure 21.72: Male metallic catheter. Note the handle with two rings for better grip. Note the tip with
curved and rounded end with a side hole
"is is a long metallic catheter. Like a dilator the terminal part of the catheter is curved. "e
tip is rounded and there are side holes in the catheter near the tip. "ere are two rings near the
base for holding the catheter (Fig. 21.72).
Uses
Used for relief of retention when a simple rubber, Foley’s or Gibbon’s catheter cannot be passed
through the urethra.
Sterilization
By autoclaving.
How will you pass the metallic catheter?
"e patient lies supine and the surgeon stands on the left side of the patient. "e external
genitalia is cleaned with an antiseptic solution. 20 mL of 2% xylocaine jelly is introduced through
the external urethral meatus into the penile urethra and the glans penis is kept pressed for
5 minutes for adequate anesthesia. "e metal catheter is lubricated with the xylocaine jelly.
Penis is lifted up and steadied with the left hand and the catheter tip is placed at the external
urethral meatus keeping it parallel to the left inguinal ligament. Instrument is allowed to go in
by its own weight and the handle of the instrument is gradually brought towards the midline
over the abdomen. As the catheter goes further, the handle of the instrument is now brought
down between the two thighs.
How do you know the catheter has gone into the bladder?
As the catheter goes into the bladder, there is loss of resistance, the handle can be depressed
between the thighs and the instrument can be rotated freely on either side. No bleeding through
the urethra and urine will drain through the catheter.
56. VOLKMAN’S SPOON OR SCOOP
Figure 21.73: Volkman’s spoon or scoop
"is is a long metallic instrument with a spoon like ends with sharp edges larger in size on one
side and small in size at the other end. "e sharp edges allow easy curettage (Fig. 21.73).
Uses
Used to curette a chronic abscess cavity either in bone or in soft tissue
May be used to curette a sinus or a fistulous tract
May be used to curette an aneurysmal bone cyst.
Sterilization
By autoclaving.
57. KELLY’S RECTAL SPECULUM (PROCTOSCOPE)
A B
C
Figures 21.74A to C: (A) Kelly’s rectal speculum
(proctoscope) (B), Speculum proper. (C) Obtu-
rator
"e instrument is about 3 inches long.

"ere is a hollow outer sheath where a handle is attached. "e terminal end of the sheath is
either round or obliquely cut. "e inner rod is called the obturator and its terminal part is smooth
and rounded and fits well with the outer sheath. In some instrument, there is arrangement for
attachment of a light (Figs 21.74A to C).
Uses
"e proctoscope may be used for diagnostic or therapeutic purposes.
Diagnostic use: By proctoscopic examination, it is possible to diagnose following conditions:
• Diagnosis of piles: "e pile mass protrudes into the lumen of the proctoscope
• An anal or a rectal polyp may be seen protruding into the lumen of the proctoscope
• Carcinoma of anal canal or rectum may appear as a proliferative mass or an ulcerating lesion
• Diagnosis of ulcerative colitis: Associated proctitis may appear as red, congested mucosa
which bleeds to touch and in some cases pseudopolyps may be seen
• "e internal opening of a perianal fistula may be seen
• "e apex of an intussusception may be seen in the anal canal through the proctoscope.
"erapeutic uses:
• Used during injection sclerotherapy of piles. "e injection is made at the base of the pile
mass visualized through the proctoscope
• Used during polypectomy
• Used while taking a biopsy from a rectal or an anal growth.
How will you do a proctoscopic examination?
Patient is explained the procedure and a consent is taken for a digital rectal examination and
proctoscopic examination.
Patient is asked to lie in left lateral position. "e left leg is kept straight and the right leg is
flexed at knee and hip and is drawn toward the abdomen. Patient is asked to relax the buttock
and take deep breathing.
"e perineal area is inspected to look for any swelling, fistula, sentinel skin tag or any tear in
the skin lined part of and canal.
A digital rectal examination is done first to exclude any painful condition like anal fissure
or abscess.
"e proctoscope is lubricated with 2% xylocaine jelly and is then introduced into the anal
canal at first directed upwards and forward toward the umbilicus and then pushed upward and
backward toward the sacrum. "e obturator is withdrawn and a light is thrown inside from a
torchlight and the interior of the rectum is inspected. "e sheath is then gradually withdrawn
and rest of the examination is completed.
58. FLATUS TUBE
Figure 21.75: Flatus tube
"is is a thick rubber tube. "ere is an opening at the tip and the tip is rounded and smooth. In
addition there are two side openings. "e other end is conical (Fig. 21.75).
Uses
Used during nonoperative decompression of sigmoid volvulus.
May be used to relieve gaseous distension of large gut due to paralytic ileus.
Sterilization
By autoclaving.
How is the flatus tube inserted?
Patient is explained the procedure. Patient lies in left lateral position or in lithotomy position.
"e flatus tube is lubricated with 2% xylocaine jelly. A digital rectal examination is done
before introduction of the tube to exclude any painful anal condition. "e flatus tube is then
gently passed into the anal canal and then pushed further up. While inserting, in a case of
volvulus, there will be resistance in passage of the tube further up. "e tube is pushed further
up with manipulation and once it goes beyond the point of twist, lots of flatus and feces will
come out and there will be deflation of the dilated sigmoid colon. "e other end of the tube is
kept immersed in a kidney dish containing water.
59. DOYEN’S MOUTH GAG
Figure 21.76: Doyen’s mouth gag
In addition to finger bows there is a rachet lock mechanism in the shaft. "e two blades are
semicircular in shape and bent in the terminal part. When the finger bows are kept apart the
blades are in closed position. When the finger bows are approximated the blades are separated.
"e instrument is kept self retaining, once the rachet is locked (Fig. 21.76).
Uses
Used to open the mouth during intraoral operations like:
Glossectomy
Cleft palate operation
Removal of calculus from subman dibular duct
Excision of an intraoral ranula
Taking biopsy from an intraoral or pharyngeal lesion
Repair of intraoral injuries.
Sterilization
By autoclaving.
60. AIRWAY TUBES
Figures 21.77A and B: Airway tubes

A. Metallic airway tube: Metallic airway tube is a curved stainless steel tube with both ends
open. At one end, there are multiple side holes. At the other end, there is flange. "e flange is
kept outside the teeth (Fig. 21.77A).
B. Rubber/PVC airway tube: In rubber airway tube, at the proximal end, there is a stainless steel
tube fitted inside the rubber tube. "is part is kept inbetween the teeth (Fig. 21.77B).
Uses
Pharyngeal airway tube is used to prevent tongue falling back in an unconscious patient.
"is also prevents tongue bite.
During anesthesia, airway tube is inserted to prevent falling back of tongue while ventilating
with a face mask.
During post-anesthetic recovery, airway tube may be inserted to prevent falling back of
tongue. Oxygen may be administered through the side tube.
Sterilization
By autoclaving.
61. FULLER’S BIVALVED METALLIC TRACHEOSTOMY TUBE
A A
B B
C C
Figures 21.78A to C: Fuller’s bivalve metallic Figures 21.79A to C: Disposable cuffed tracheo-
tracheostomy tube stomy tube No. 6
Fuller’s metallic tracheostomy tube comprises:

An inner tube which is a hollow metallic tube with a terminal rounded opening and an
additional opening in the upper wall of the tube. "e proximal open end of the tube is provided
with a shield to which are attached two metallic rings. "ey are used to hold the tube during
insertion and removal (Fig. 21.78A). "e inner tube is longer than the outer tube and when
inserted into the outer tube it projects beyond the outer tube (Fig. 21.78B).
An outer tube which is wider than the inner tube, the outer tube is biflanged. "e proximal
end of the outer tube is provided with a shield in which there is one opening on either side
which is used to pass a tape to fix the tracheostomy tube around the neck (Fig. 21.78C).
"e other varieties of tracheostomy tubes are:
Cuffed tracheostomy tube usually supplied in a presterilized pack: "is tracheostomy tube may
be kept indwelling by inflating the cuff with air. Cuffed tracheostomy is especifically required
in unconscious patient who requires assisted ventilation (Figs 21.79A to C).
Non-cuffed tracheostomy tube: "is is a curved rubber tube with openings at the either end.
At the proximal end there is a flap with side openings through which tapes are passed to fix
the tracheostomy tube around the neck.
What are the indications of tracheostomy?
"e important indications for tracheostomy are:
Mechanical obstruction to upper airway:
• Laryngeal diphtheria
• Foreign body impacted in larynx
• Acute laryngeal edema
• Ludwig’s angina causing laryngeal obstruction
• Neck, mouth and jaw injuries
• Cut throat wound with laryngeal or tracheal injury
• Carcinoma of thyroid
• Bilateral recurrent laryngeal nerve palsy
• Laryngeal tumors.
In respiratory paralysis : In respiratory paralysis due to Poliomyelitis, Guillain Barrè syndrome,
Bulbar palsy, tetanus and flail chest patient may require mechanical ventilation for prolonged
period.
Tracheostomy is required in such situation for effective tracheobronchial toilet.
Following some radical surgery:
• Laryngectomy
• Laryngopharyngectomy
• Following total thyroidectomy if there is associated tracheomalacia.
For reduction of dead space: Patient with chronic obstructive or restrictive airway disease with
inadequate ventilation may benefit by a 30% reduction of dead space following tracheostomy.
For aspiration of retained secretions:
• When the excessive tracheobronchial secretions in unconscious patient
• In patient with major chest or cervical injury
• When tracheobronchial secretion cannot be cleared by simple suction.
Where do you insert the tracheostomy tube?
Depending on the level of insertion of the tube into the trachea, tracheostomy may be:
High tracheostomy: Tracheostomy done above the level of isthmus of thyroid gland.
Mid tracheostomy: Tracheostomy done at the level of isthmus of thyroid gland .
Low tracheostomy: Tracheostomy done below the level of the isthmus of thyroid gland.
"e thyroid isthmus lies at the level of 2nd, 3rd and 4th tracheal rings.
Describe the steps of tracheostomy?
Patient is kept supine. Neck is extended by placing a sand bag in-between the two shoulders
and head is supported on a head ring.
Antiseptic cleaning and draping. "e area is infiltrated with 2% injection of xylocaine.
About 4 cm. transverse skin incision is made in the neck crease 2 cm above the
suprasternal notch. The platysma is incised in the same line. The upper and lower skin
flaps are raised. The deep fascia is incised in the midline and the strap muscles are
retracted laterally.
"e thyroid isthmus is dissected by incising the pretracheal fascia and lifted up with a blunt
hook. "e thyroid isthmus may be divided between clamps and ligated thereby exposing the
trachea. 0.5 mL of 2% xylocaine is injected into the trachea to minimize the coughing while
introducing the tracheostomy tube. "e trachea is steadied by holding the cricoid cartilage
with a sharp hook and trachea is incised over the 2nd and 3rd tracheal ring. "e opening
is dilated by inserting a tracheal dilator and the tracheostomy tube is inserted. An anterior
flap of trachea over the 2nd and 3rd tracheal ring may be excised for ease of introduction of
tracheostomy tube.
"e deep fascia and the skin is closed. A tape is passed through the rim of the tracheostomy
tube and tied around the neck.
How will you take care of the tracheostomy tube?
Regular suction of the tracheostomy tube maintaining strict asepsis
Inspired air should be adequately humidified
Regular chest physiotherapy
If a metallic tracheostomy is used initially it should be replaced by PVC or rubber tracheostomy
tube after 24–48 hours
A spare tracheostomy tube should be kept ready to replace the tracheostomy tube in case it
gets blocked by viscid secretion.
What are the complications of tracheostomy?
Bleeding due to injury to anterior jugular vein, thyroid isthmus, inferior thyroid vein or
arteria thyroidea ima
Tracheal stenosis: Particularly when patient is using cuffed tracheostomy tube for a prolonged
period
Surgical emphysema in the neck
Mediastinal emphysema
Blockage of tracheostomy tube and respiratory obstruction
Infection.
62. SINGLE BLADED BLUNT HOOK
Figure 21.80: Single bladed blunt hook
"is is used during tracheostomy to retract the strap muscles of the neck and to retract the
isthmus of the thyroid gland (Fig. 21.80).
63. SINGLE BLADED SHARP HOOK
Figure 21.81: Single bladed sharp hook
"is is used during tracheostomy to steady the trachea by holding the cricoid cartilage with the
sharp hook (Fig. 21.81).
64. TRACHEAL DILATOR
Figure 21.82: Tracheal dilator
"is instrument has finger bows, a pair of shaft and two blades. "e tip of the blades are olive
pointed. When the finger bows are kept apart, the blades lie in closed position. When the finger
bows are pressed and apposed the blades get separated (Fig. 21.82).
Uses
Used during tracheostomy. After a stab incision is made over the trachea, the tracheal dilator is
introduced into the trachea in closed position. "e tracheal dilator is then opened up by pressing
the finger bows and the stab wound in the trachea opens up and the tracheostomy tube is then
inserted through the gap. "e tracheal dilator is then closed by releasing the finger bows and
the instrument is withdrawn.
Sterilization
By autoclaving.
65. CORRUGATED RUBBER SHEET DRAIN
Figure 21.83: Corrugated rubber sheet drain

"is is a corrugated rubber sheet which may be cut to a desired size before use as a drain
(Fig. 21.83).
Uses
Used as a drain to drain blood, pus or bile following some operations .
Used following cholecystectomy. "e drain is placed in the subhepatic space and in the
hepatorenal pouch of Morrison.
Used following repair of peptic perforation.
"e drain is kept in the hepatorenal pouch of Morrison.
Used following drainage of subprenic, pelvic abscess. "e drain is placed in the subprenic
space or in the pelvis.
Used following pancreaticojejunostomy or pancreatic resection. "e corrugated rubber sheet
drain is placed in the lesser sac as a prophylactic drain which may drain pancreatic juice if
there is formation of a postoperative pancreatic fistula.
May be used following small or large gut resection anastomosis. "e drain is placed in the
hepatorenal pouch of Morrison or in the pelvis.
May be used following mastectomy. "e drain is kept in the axilla and under the breast flap.
May be used during repair of incisional hernia. One drain is kept in the preperitoneal space
and another drain is kept deep to the skin.
Used in hydrocele operation following eversion of sac. A small corrugated rubber sheet drain
is placed in the scrotum deep to the dartos muscle.
Sterilization
By autoclaving.
66. ANEURYSM NEEDLE
Figure 21.84: Aneurysm needle. Note the curved blade with groove in inner aspect and eye at tip of
the blade
"is instrument has got a handle, shaft and a blade. "e terminal part of the blade is blunt, bent
at about right angle and there is an eye with groove on the undersurface. "e eye is meant for
threading a suture (Fig. 21.84).
Uses
Used during venesection to pass ligature around the vein. One ligature is passed around
the vein to ligate the distal end of the vein. Another ligature is passed around the vein in the
proximal part and is tied after venotomy and introduction of the cannula through the vein.
May be used during thyroidectomy to pass a ligature around the superior thyroid vessels
close to the upper pole of the gland.
May be used during nephrectomy to pass a ligature around the renal vessels.
May be used during splenectomy to pass a ligature around the splenic vessels.
May be used to pass a ligature around an aneurysm at the proximal and distal end of the
aneurysm. It was in fact originally used for this purpose.
May be used during cholecystectomy to pass ligatures around the cystic duct and the cystic artery.
Sterilization
By autoclaving.
Aneurysm
What is an aneurysm?
Localized dilatation of a segment of an artery is called aneurysm.
What are true and false aneurysms?
In true aneurysm, the aneurysm sac wall is lined by all the layers of the arterial wall.
In false aneurysm, the aneurysm sac wall is lined by a single layer of fibrous tissue and the
layers of the arterial wall do not cover the aneurysm. "e aneurysmal sac communicates with
the arterial lumen through a rent in the wall of the artery.
What are the different types of aneurysm?
Depending on the shape, aneurysm may be :
Fusiform: Dilatation of the whole circumference of the segment of the arterial wall.
Saccular: A part of the circumference of the arterial wall projecting as a bulbous mass.
Dissecting: "ere is a breach in the tunica intima and the blood forces in between the tunica
intima and the tunica media leading to occlusion of the lumen of the artery.
What are the important causes of aneurysm?
Atherosclerosis is the commonest cause of aneurysm
Traumatic
Collagen vascular disease
Syphilitic
Mycotic: Due to bacterial infection.
Which vessels may be affected by aneurysm?
Aneurysm may affect both large and small sized vessels:
Aorta: Arch of the aorta, descending thoracic aorta or abdominal aorta.
Carotid, subclavian, axillary, femoral and popliteal arteries.
Smaller vessels like cerebral, mesenteric, splenic and renal arteries.
What are the usual presentations of patient with abdominal aortic aneurysm?
Asymptomatic: No symptom pertaining to the aneurysm. Diagnosed incidentally by clinical
or radiological investigation.
Symptomatic:
• Low backache or upper abdominal pain
• Pain in the groin or thigh due to nerve compression. Lower limb swelling due to venous
compression
• Emboli may cause distal ischemia and gangrene of the lower limbs. Pulsatile mass in
abdomen—showing expansile pulsation
• May present with symptoms and signs of rupture.
How will you diagnose rupture of abdominal aortic aneurysm?
Abdominal aortic aneurysm may expand gradually leading to rupture. "e rupture may occur
into the peritoneal cavity (Anterior rupture) or into the retroperitoneum (Posterior rupture).
Anterior rupture results in massive bleeding into the peritoneal cavity and very few of these
patients survive to reach the hospital
Severe abdominal pain
Severe hypovolemic shock: Rapid feeble pulse, hypotension, cold clammy extremities and
oliguria
Posterior rupture results in an expanding retroperitoneal hematoma. Severe abdominal pain
or severe, backache. Moderate to severe hypotension
"e pulsatile mass is palpable in the abdomen.
What are the important intrinsic features of aneurysm?

"ere is a swelling along the course of the artery
"e swelling shows expansile pulsation
On compressing the artery proximal to the swelling, the swelling diminishes in size and the
pulsation disappears
A thrill may be palpable over the swelling
A bruit may be audible on auscultation over the swelling.
What are the complications of aneurysm?
Thrombosis: "ere may be thrombotic occlusion of the aneurysmal sac leading to distal
ischemia.
Peripheral embolism: "ere may be release of emboli from the thrombus in the aneurysm
leading to distal ischemia.
Rupture of aneurysm: Symptoms and signs will depend on the site of involvement.
Pressure symptoms:
• Venous compression: Distal edema
• Nerve compression: Tingling, numbness or motor paralysis
• Pressure on esophagus may cause dysphagia
• Pressure on trachea may cause dyspnea
• Pressure on the bones may cause bony erosion, bone pain and pathological fracture.
What investigations may help in diagnosis?
Ultrasonography of abdomen: "e aneurysm may be diagnosed and the diameter of the
aneurysm may be assessed.
Aortography: May delineate the proximal and distal extent of the aneurysm. If there is a
circumferential thrombus in the aneurysm the aortography may not be reliable for assessing
the exact diameter of the aneurysm.
Contrast CT scan of abdomen or magnetic resonance imaging of abdomen for better
delineation of the aneurysm.
What is the treatment for unruptured abdominal aortic aneurysm?

Symptomatic aneurysm needs treatment
Aneurysm more than 5 cm in diameter needs treatment.
What is the ideal treatment for abdominal aortic aneurysm?
Aortic bypass graft is the ideal procedure
"e abdominal aorta above and below the aneurysm is dissected. "e iliac arteries are also
dissected
Vascular clamps are applied proximal and distal to the site of aneurysm. "e aneurysm sac
is opened and the thrombus is removed. A dacron or PTFE (polytetrafluoroethylene) graft
is anastomosed to the proximal normal aorta and distally anastomosed to the iliac arteries
or distal aorta depending on the extent of the aneurysm.
What are the postoperative complications?
Hemorrhage is the commonest complication
Respiratory complications: Collapse, consolidation and shock lung
Postoperative renal failure
Aortoduodenal fistula
Spinal cord ischemia
Sexual dysfunction
Infection.
67. SUTURE MATERIALS

Types of suture materials
Depending on the behavior of the suture material in the tissues, the sutures may be :
A. Absorbable sutures: "ese sutures get absorbed in the tissues either by enzymatic digestion
or by phagocytosis. Depending on the source, these sutures may be:
1. Natural absorbable sutures:
& Plain and chromic catgut.
2. Synthetic absorbable sutures:
& Polyglycolic acid (dexon)
& Polyglactin 910 (vicryl)
& Polyglactin 910 rapide (vicryl rapide)
& Polydioxanone suture (PDS)
& Polyglecaprone 25 (monocryl).
B. Nonabsorbable sutures: "ese sutures remain in the tissues for indefinite period.
Depending on the source, these sutures may be:
1. Natural nonabsorbable sutures:
& Linen thread
& Silk.
2. Synthetic nonabsorbable sutures:
& Polypropylene (prolene)
& Monofilament polyamide (ethilon)
& Polyester (ethibond)
& Nylon.
Depending on the number of strands in the suture materials, sutures may be:
Monofilament sutures:
• Sutures consisting of a single strand of fiber are called monofilament sutures.
• "ese sutures are smooth and strong.
• Chance of bacterial contamination is less.
• "e disadvantage is that knot tied may become loose.
• Polypropylene, Polyamide, Catgut, Monocryl, Polydioxanone, Polyglactin finer sizes
6/0-9/0.
Polyfilament sutures:
• Sutures consisting of multiple strands braided together are called polyfilament sutures.
• "ey are easier to handle and the knot tied does not slip.
• "e disadvantage is that the bacteria may lodge in the crevices of the sutures so these
sutures are not suitable in presence of infection, e.g. silk, linen, polyglycolic acid,
polyglactin 910, braided polyamide and braided polyester.
What are the criteria of an ideal suture material?
Should have adequate tensile strength
Should incite minimal tissue reaction
Should have easy handling property
Should have good knotting quality
Should be nonallergenic and noncarcinogenic
Should be easily available and cheap.
Descriptions of Different Labelings in a Foil Pack
1–Thickness of the sutures; 2–Code number; 3–Type of suture;

4–Length of the suture; 5–Name of manufacturer; 6–Lot number/
batch number; 7–Description of the needle; 8–Manufacturing
licence number, manufacturing date and expiry date; 9–Price of
the foil pack.
Figure 21.85: Different labeling in a foil pack
Different surgical sutures are supplied in a sterile pack. "e different labelings in the foil pack
indicates (Fig. 21.85):
1. "e number indicates the thickness of the suture. Depending on the thickness of the sutures,
the number may be 2, 1, 1–0, 2–0, 3–0, 4–0, .............. . Higher the number, thicker is the suture.
0 prefixed by higher numbers are finer sutures, e.g. 3–0 is thinner than 2–0 sutures.
2. Company’s code number for a particular suture. NW4226 means No. 1 atraumatic chromic
catgut suture on 3/8th circle needle with a needle length of 45 mm and suture length of 76
cm. For different specification of suture materials the code number is different.
3. "e type of suture contained in the foil pack—absorbable or nonabsorbable, chemical name
of the suture and brand name of the suture. "e brand name of the suture will vary depending
on the manufacturer.
4. "e length of the suture material contained in the pack. Sutures are available in different
sizes—45 cm, 76 cm, 90 cm, 152 cm ..............
5. "e name of the manufacturer. "is pack is manufactured by ETHIC ON (Division of Johnson
& Johnson). "e other manufacturer of suture materials are—Suture India, Futura, Centennial,
Us Surgical, Aesculap, etc.
6. "e lot number or batch number of the suture.
7. "e description of the needle. "e needles may be of different sizes—16 mm, 22 mm, 30 mm,
40 mm, 45 mm ................ "e needle may be of different curvatures half circle, 3/5th circle
............. "e needle may be straight or curved.
8. Manufacturing Licence no., manufacturing date and expiry date of the suture material.
9. Price of the pack.
Most of the sutures are supplied in a sterilized pack. In examination, mention the following points:
No. of suture—1/0, 2/0, ....
Natural or synthetic
Absorbable or non-absorbable
Type of suture—catgut, polyglycolic acid, polyglactin .....
Whether provided with a needle or not—If there is a needle, description of the needle—length,
curvature, round bodied or cutting.
Length of the suture—45 cm, 70 cm, 90 cm .............. .
A. NATURAL ABSORBABLE SUTURE: CATGUT
A B
C D
Figures 21.86A to D: Catgut sutures

"e natural absorbable surgical suture derived from the submucosa of the sheep is known as
catgut. "is is the brand name of this suture manufactured by Ethicon division of Johnson and
Johnson. "e similar sutures manufactured by other companies includes Trugut, Pro Gut, etc.
(Figs 21.86A to D).
Characteristics of Catgut
Derived from the submucosa of sheep's
intestine or serosa of cattle's intestine. It is
99% collagen.
"is is absorbed by a process of enzymatic
digestion by proteolytic enzymes contained
in the polymorphs and macrophages
Catgut is easy to handle and knots well
Absorption rate depends on the size of the
catgut and whether it is plain or chromicised
Plain catgut loses 50% tensile strength in
tissues in 3 days and loses all tensile strength
in 15 days (Fig. 21.87)
Plain catgut gets absorbed in tissues within Figure 21.87: Catgut—In vivo loss of tensile
60 days (Fig. 21.88) strength
"e chromic catgut loses 50% tensile strength
in 7 days and loses all its tensile strength in 28
days (Fig. 21.87)
"e chromic catgut gets absorbed in tissues
in 90–100 days (Fig. 21.88)
In presence of infection the catgut gets
absorbed earlier.
Uses
a. Plain catgut:
• Plain catgut is used to tie small sub-
cutaneous vessels
• Used to approximate subcutaneous tissues
during closure of an incision
• Used during circumcision to suture the cut
margins of the prepuce Figure 21.88: Catgut—In vivo loss of mass:
Absorption in tissues
• Used in repair of wounds of lip or oral
cavity.
b. Chromic catgut:
• Used to suture muscles, bowel anastomosis, closure of peritoneum.
• Used during appendicectomy. "e mesoappendix is tied with 1-0 chromic catgut suture.
"e base of the appendix is tied with a 1-0 or 2-0 chromic catgut suture. "e stump of the
appendix may be inverted with a Z or a purse string suture applied with a 2-0 atraumatic
catgut suture. "e peritoneum, muscles and the external oblique aponeurosis is apposed
by 2-0 chromic catgut sutures.
• Used during small gut resection anastomosis. In two layer anastomosis, the posterior and
anterior through and through layers are applied with 2-0 atraumatic catgut sutures. "e
seromuscular (anterior and posterior) layer is usually applied with mersilk. Alternatively
all layers may be sutured with 2-0 polyglactin or polyglycolic acid suture.
• Used during gastrojejunostomy for posterior and anterior through and through layers
using a 2-0 atraumatic catgut suture.
• Used during cholecystectomy. Bleeding from the gallbladder bed may be controlled by
suturing the gallbladder bed using 1-0 atraumatic catgut suture mounted on a 45 mm
round bodied needle.
May be used during closure of a subcostal incision—posterior rectus sheath, anterior rectus
sheath and external oblique aponeurosis and muscle may be apposed with 1-0 chromic
catgut sutures.
Synthetic absorbable suture polyglycolic acid and polyglactin is replacing catgut suture for
most of the uses of catgut.
What do you mean by an atraumatic suture?
When a suture is attached to an eyeless needle, it is called an atraumatic suture. "is concept
was first introduced by George Merson of Edinburgh by devising a technique of imbrication
of the suture at the end of an eyeless needle. In his memory, these sutures are also known as
“Mersutures” .
How catgut is prepared?
"is is synthesized from the submucosa of sheep’s intestine or serosa of beefs intestine.
"e layers of the intestine is scrapped off leaving only the submucosa. "is is treated with a
fat solvent to wash off the fat. "e strips of submucosa is then dried off. "e thread so obtained
is then cut into different diameters and length. "is is plain catgut.
"e plain catgut if treated with 20% chromic acid produces chromicised catgut. Treatment
with chromic acid alters its property and it stays longer in tissues maintaining tensile strength
for a longer time.
Catgut is sterilized by gamma irradiation and is supplied in a sterilized pack containing
isopropyl alcohol.
B. SYNTHETIC ABSORBABLE SUTURES

Common Features
Synthesized in laboratory
"ese may be monofilament (monocryl, polydioxanone and finer sizes vicryl) or polyfilament
(vicryl and vicryl rapide)
"ey can be of natural color or can be colored green (dexon) or violet (vicryl)
"ey are twice as strong as compared to natural absorbable suture
"ey are absorbed by a simple process of hydrolysis and evoke minimal tissue reaction
"ey have excellent handling properties. Once tied the knots are secure
"ese are sterilized by ethylene oxide
"ey are available in different sizes, different lengths, swaged into different types of needles
"ey maintain tensile strength in tissues for a longer time and absorbed in tissues after a
variable time.
1. Polyglycolic Acid Suture (Dexon)
A B
Figures 21.89A and B: Polyglycollic acid suture
Characteristics of polyglycolic acid suture:

"is is a synthetic delayed absorbable polyfilament suture (Figs 21.89A and B).
"is is a polymer of glycolic acid
Dexon may be dyed green and may be uncoated or coated with a lubricant to reduce the
coe%cient of friction
Polyglycolic acid maintains tensile strength in tissues for about 30 days and gets absorbed
in 80–90 days (Figs 21.91 and 21.92).
Polyglycolic acid suture manufactured by US surgical is known as dexon. "e polyglycolic
acid sutures manufactured by other companies are available as petcryl and maxon.
2. Polyglactin Sutures (Vicryl)
A B
Figures 21.90A to C: Polyglactin 910 sutures

Polyglactin are synthetic absorbable sutures (Figs 21.90A to C). "ese sutures are available in
different sizes like 1, 1-0, 2-0, 4-0, 5-0, 6-0, 7-0, 8-0, 9-0. "e needle may be of different types 40
mm, 30 mm, 22 mm, 16 mm etc. "e suture length may be 90 cm, 70 cm or 45 cm. "e needles
may be round bodied, cutting or taper cut. "ese sutures may also be available as undyed vicryl
and as coated vicryl. "ese features will be mentioned in the foil pack. Vicryl is the trade name
of the polyglactin 910 suture made by Ethicon (Johnson and Johnson). "e brand names of the
polyglactin sutures made by other companies are—Truglyde, Centicryl, Safil, etc.
Characteristics
Polyglactin 910 are synthetic absorbable polyfilament sutures. "e finer polyglactin sutures
5–0, 6–0 are available as mono-filament sutures and are used in vascular surgery
Polyglactin (Vicryl) is a copolymer of lactide and glycolide (in a ratio of 90% glycolide and
10% lactide)
"ese sutures are digested by hydrolysis and not by enzymatic digestion, hence incites less
tissue reaction
"ese sutures maintains tensile strength in the tissues for about 28–30 days and get absorbed
in 80–90 days (Figs 21.91 and 21.92).
Figure 21.91: Synthetic absorbable sutures—In Figure 21.92: Synthetic absorbable sutures—In
vivo loss of tensile strength vivo loss of mass absorption in tissues
Uses of polyglycolic acid and polyglactin sutures

Indicated in all situations where catgut are used (see above)
No. 1 or 1-0 suture may be used for closure of subcostal, paramedian, Pfannenstial or
McBurney's incision
3-0 or 4-0 sutures on atraumatic needles are used in biliary enteric anastomosis—
choledochoduodenostomy, choledocho-jejunostomy, hepaticodochojejunostomy
3-0 or 4-0 sutures are also used in pancreaticojejunal anastomosis—Puestow's lateral
pancreaticojejunostomy or pancreaticojejunal anastomosis following Whipple's operation
In small gut resection anastomosis—seromuscular (anterior and posterior) and through

(posterior and anterior) layers may be sutured with 2-0 polyglactin or poly glycollic acid
sutures
Single layered anastomosis in large gut may be done with 2-0 polyglactin or polyglycolic
acid suture.
3. Polyglactin Rapide (Vicryl Rapide) Suture
Figue 21.93: Vicryl rapide suture
Characteristics of vicryl rapide sutures

"is is a variety of polyglactin 910 suture (Fig. 21.93). "e rapid absorption characteristics of
vicryl rapide is achieved by exposure of coated vicryl to gamma irradiation. "is results in
material with low molecular weight than coated vicryl.
"is is undyed.
Vicryl rapide maintains tensile strength for 10–12 days and gets absorbed in tissues in 42
days (Figs 21.91 and 21.92).
Uses
May be used for subcuticular sutures
May be used for skin or mucosal closure.
"ese sutures need not be removed, gets spontaneously absorbed.
May be used for circumcision for approximation of cut margins of the prepuce.
4. Polyglecaprone (Monocryl Suture)
A B
Figures 21.94A and B: Polyglecaprone (Monocryl sutures)

What are the characteristics of monocryl sutures?

"is is a synthetic absorbable monofilament suture
"is is composed of a copolymer of 75% glycolide and 25% caprolactone
"is is available as an undyed suture or may be dyed violet
"is has double the strength of chromic catgut
It has excellent handling properties has got very smooth surface and passes through the
tissues with greater ease
"is suture maintains tensile strength in tissue for 21 days (Fig. 21.91)
Monocryl is absorbed by hydrolysis in about 90–120 days (Fig. 21.92)
Monocryl is sterilized by ethylene oxide.
Uses
Monocryl may be used in situations where catgut sutures are used
Used for intestinal anastomosis as an alternative to catgut or polyglactin suture
Used for closure of peritoneum
Subcutaneous tissue apposition
Used in urological procedures—pyeloplasty, ureter repair.
5. Polydioxanone Suture (PDS·II)
A B
Figures 21.95A to C: Polydioxanone suture

(PDS-II)
Characteristics
"is is a synthetic, delayed absorbable, monofilament suture formed by polymerizing the
monomer “paradioxanone”.
"is is dyed violet. PDS II sutures are an improved version of initial PDS suture.
"e soft, pliable and smooth PDS II suture

allows easy passage through the tissues and
the knotting characteristics of this material
is the best among the synthetic absorbable
sutures.
Like polyglactin, it is also available in different
sizes-1, 1-0, 2-0, 3-0, 4-0, ... with different
types of needle and different suture lengths.
Tensile strength : It maintains tensile strength
for a longer periods for about 56 days (Figs
Figure 21.96: Polydioxanone suture (PDS-II)—In
21.91 and 21.96). vivo tensile strength retention
• At 2 weeks—70% tensile strength is
maintained.
• At 4 weeks—50% tensile strength is maintained.
• At 6 weeks—25% tensile strength is maintained.
• At 8 weeks—loses all tensile strength.
"e suture is absorbed by hydrolysis and complete absorption occurs in about 180–210 days
(6–7 months) (Fig. 21.92).
Uses
"ese sutures are used in all situations where catgut, polyglycollic acid and polyglactin
sutures are used.
No. 1 or 1-0 suture may be used for closure of paramedian or midline and other abdominal
incisions.
3-0 and 4-0 sutures are used for intestinal or biliary enteric anastomosis.
C. NATURAL NONABSORBABLE SUTURES: SILK
A B C
Figures 21.97A to C: Black braided silk
Silk are natural nonabsorbable sutures.

Silk may be supplied in sterile pack (sutupak) containing black braided silk which are precut
into different sizes and suture thickness may be 6-0 to 3 (Fig. 21.97A). Silk may also be supplied
as silk reels which are nonsterile and are available in sizes from No. 6-0 to 4 (Fig. 21.97B) and
is sterilized by autoclaving.
Black braided silk mounted on atraumatic needles are available as mersilk. Mersilk are
available in different sizes No. 7-0 to 1, different lengths (45 cm, 76 cm and 90 cm) and with
different types of needles, curvature 1/2 circle, 3/8th circle and needle size of 16 mm, 22 mm,
30 mm and 40 mm) (Fig. 21.97C).
Characteristics
"is is a natural nonabsorbable suture
The silk is derived from the cocoon of silk
worm larvae
"is is basically a protein covered initially by
an albuminous layer. "e albuminous layer
is removed by a process called degumming
during manufacturing of these sutures. "e
suture is braided round a core and coated with
wax to reduce the capillary action
Handling property is best and it knots securely
"is is sterilized by gamma irradiation
"e silk for surgical use is dyed black
Tensile strength: Silk maintains tensile Figure 21.98: Nonabsorbable suture—In vivo
loss of tensile strength
strength for a longer time and the tensile
strength is lost in 2 years time (Fig. 21.98)
Once placed in the tissues it incites a polymorphonuclear reaction and a fibrous capsule is
formed around the silk in 14–21 days.
Uses
No. 1 or 1-0 silk sutures are used as ligature:
Used during cholecystectomy to ligate the cystic duct and cystic artery
Used during small and large gut resection to ligate the mesenteric vessels
Used to ligate the pedicles during nephrectomy and splenectomy
Used during truncal vagotomy to ligate the anterior and posterior vagus nerve before their
division. Two ligatures are applied and the nerve is divided in between
Used for skin closure either with interrupted or continuous suture.
Uses of Mersilk:
2-0 and 3-0 mersilk is used for anterior and posterior seromuscular sutures in small gut
anastomosis and in gastrojejunostomy
May be used to repair the posterior wall of inguinal canal in herniorrhaphy
3-0 mersilk may be used for pancreaticojejunal anastomosis
4-0 mersilk may be used for nerve suture.
What are the characteristics of linen sutures?

"is is a natural non-absorbable suture made from flax and the material is cellulose
"is is twisted to form a polyfilament suture
Tissue reaction is similar to silk
It has excellent knotting properties
It gains 10% tensile strength when wet
It is used for tying of pedicles and as ligatures.
D. SYNTHETIC NONABSORBABLE SUTURES

1. Polypropylene Suture
A B
Figures 21.99A and B: Polypropylene suture
Characteristics
"is is a synthetic, monofilament, nonabsorbable suture (Figs 21.99A and B)
Polypropylene has structural similarity to protocollagen which is a precursor of collagen
"is suture is inert and has an extremely low tissue reactivity and is nonbiodegradable
It has low coe%cient of friction and slides through the tissues readily
It has a peculiar property. "e suture may extend up to 30% before breaking and hence
is useful in situations where postoperatively some give is required on the part of the
suture to accommodate postoperative swelling and thereby helps to prevent tissue
strangulation
Handling is good and knotting is very secured since the material deforms on knotting and
allows the knot to bed down on itself
It is extremely smooth and does not saw through the tissues
Polypropylene sutures are available in a variety of eyeless needles in various sizes from 8-0
to 1. Polypropylene material is also used in polypropylene mesh, which are used for hernia
repair and in rectopexy for rectal prolapse
Maintain tensile strength for indefinite period.
Uses
No. 1-0 or no. 1 suture is used for herniorrhaphy for repair of the posterior wall of inguinal
canal by different techniques
Used for closure of midline abdominal incision
Used for repair of incisional hernia
2-0 or 3-0 sutures are used for repair of tendon injuries
Finer sutures 4-0, 5-0 are used for vascular anastomosis and for repair of nerve injury.
2. Monofilament Polyamide Sutures
Figure 21.100: Monofilament polyamide sutures
Characteristics
"is is a synthetic monofilament nonabsorbable suture and is a variety of nylon (Fig. 21.98)
"is has a very low coe%cient of friction and readily passes through the tissues
"is is an inert suture and incites minimal tissue reaction
Maintains tensile strength for a long time. Tensile strength loss after 1 year of implantation
is 25% (see Fig. 21.100)
Monofilament polyamide suture has a memory and knot security is poor so 4-5 throws are
required for proper knotting
Available in different sizes.
Uses
For closure of skin incision
For closure of abdominal wall incision
For herniorrhaphy
Monofilament polyamide sutures are also available as finer sutures 3–0, 4–0, 5–0 up to 10–0
"e finer sutures are used in vascular surgery.
3. Nylon Sutures
"is is a synthetic nonabsorbable suture, monofilament, white in color. It has high tensile
strength and maintains its tensile strength for indefinite period.
Uses
Same as monofilament polyamide sutures.
E. STAINLESS STEEL WIRE
Figure 21.101: Stainless steel wire
Stainless steel wire is an unique suture material of having very high tensile strength and extreme
inertness. Suturing with stainless steel requires perfect technique and poor technique may
jeopardize the very purpose of suturing. Too tight a suture may cause tissue necrosis and steel
wire can pull or tear out of tissues. Barbs on the end of the steel can traumatise the surrounding
tissues. Kinks in the wire can render it practically useless.
"is is available in different sizes from no. 5-0 to 6.
Uses
In orthopedic operations for suturing bones, e.g. in fracture patella, fracture olecranon
Closure of midline sternotomy incision
Interdental wiring for fracture mandible
Earlier used for herniorrhaphy
Earlier used for "iersch’s operation.
Sterilization
By autoclaving.
68. INSTRUMENTS FOR LAPAROSCOPIC SURGERY

LAPAROSCOPIC INSTRUMENTS
1. Telescope (Figs 21.102A and B)
Telescope is one of the viewing instrument for laparoscopic surgery. "ese are available as:
Diameter: 1.9 to 10 mm.
Lens angulation: 0 degree and 30 or 45 degree.
How will you identify 0 degree and 30 degree telescopes?
In 0 degree telescope, the terminal end of the telescope is rounded and the lens is at the terminal
part. "is is a forward viewing telescope.
In 30 degree telescope, the terminal end of the telescope is oblique and the lens is located
on the undersurface. "is is an oblique viewing telescope.
B
Figures 21.102A and B: (A) 10 mm 30 degree telescope and (B) 10 mm 0 degree telescope
What are the lens system in the telescope?

"is is a rod lens system incorporated in the rigid metallic tube. "is is devised by John Hopkin.
Sterlization:
"ere are variuos ways for sterilization of optical instruments:
Chemical sterilization:
• 2% glutaraldehyde solution for 4 hours for sterilization and 20 minutes for disinfection
• Peracetic acid: Dipping for 12 minutes provides high level of disinfection.
Gas sterilization:
• Ethylene oxide: Keeping in ETO chmaber for 12 hours
• Plasma sterilization.
Autoclaving: "e newer generation telescopes are autoclavable and may be sterilized by
standard method of autoclaving.
2. Veress Needle (Figs 21.103A to D)
A B
C D
Figures 21.103A to D: Veress needle
What are the parts of this needle?

"is is a spring loaded needle. "e outer needle has a sharp end and there is a rounded stillette
inside which projects beyond the sharp tip of the needle by spring action.
What is the use of this needle?

"is is used for induction of pneumoperitoneum during laparoscopic surgery.
How will you hold the needle?
"e needle is held inbetween the thumb and the index and middle finger. "e ring finger is
placed to act as a guard to prevent excessive entry of needle into the peritoneal cavity.
How will you insert the needle?
A subumbilical 10 mm incision is made. "e Veress needle is held inbetween fingers and placed
in the subumbilical incision site at 45 degree angle directed towards the pelvis and the needle is
inserted. Two clicks will be felt once after entry through the linea alba and next as the surgical
peritoneum is penetrated. Too much entry should be prevented once the needle enters into the
peritoneal cavity appreciated by loss of resistance.
What gas is used for creation of pneumoperitoneum?
Carbon dioxide gas is ideal for creation and maintainence of pneumoperitoneum during
laparoscopic surgery.
What other gases may be used for pneumoperitoneum?
Earlier different gases were used for pneumoperitneum-like N2O, oxygen and air. In view of
distinct advantages of carbon dioxide these gases are not used.
What are the advantages of carbon dioxide for use during laparoscopic surgery?
Carbon dioxide is an inert, noncombustible gas.
Electrocautery may be safely used as CO2 does not support combustion.
Carbon dioxide is a highly diffusible and soluble gas. As the carbon dioxide is absorbed from
the peritoneal surface, it remains in soluble form in blood as carbonic acid.
In the lung the carbonic acid splits into water and CO2 and the CO2 gas from the alveloi may
be removed by hyperventilating by the anesthetist.
What is closed technique of induction of pneumoperitoneum?
"e closed technique of induction of pneumoperitoneum involves blind puncture by using a
Veress needle. A 1 cm (5 mm if a 5 mm telescope is to be used) smiling subumbilical incision
is made and the Veress needle is inserted at 45 degree angle pointing towards the pelvis.
Alternatively, the needle may be inserted at a right angle to the abdominal wall.
How will you confirm the correct position of the needle in the peritoneal cavity?
"e needle tip should lie free in the peritoneal cavity. "e position may be ascertained by:
Free movement of the needle both side to side and anteroposteriorly.
Aspirate the needle with a 10 mL syringe. Nothing should come out. If the needle is wrongly
placed inside the lumen of gut or urinary bladder, intestinal contents or urine will come on
aspiration.
Introduce about 10 mL of saline through the needle and after injection try to aspirate back. If
the needle is in peritoneal cavity the saline would flow freely and no saline could be aspirated
back. If the needle tip lies in rectus sheath, the saline may be pushed easily but some amount
may be aspirated back.
Drop test: Place a drop of saline at the needle adapter. If the needle is in the peritoneal cavity
the drop will be sucked into the peritoneal cavity.
Recording the intra-abdminal pressure: Once the end of the needle is connected to the
automatic electronic insufflator the actual intra-abdominal pressure will be seen in
the machine. If the needle is in the peritoneal cavity the intra-abdominal pressure will
be shown as 0–6 mm Hg. If the machine shows very high pressure there will be no gas
flow and the interpretation is either the needle tip is blocked or the needle is not in the
peritoneal cavity.
What are the drawback of closed technique of pneumoperitoneum?
Although safe in experienced hand and quick to perform this is a blind technique and there are
higher incidence of injuries due to blind introduction of veress needle or the 1st trocar insertion.
"ere may be bladder, bowel or vascular injury.
What is open technique of induction of pneumoperitoneum?
"is is a safer technique for creation of pneumoperitoneum. "e technique involves making a
1cm subumbilical incision and the underlying linea alba is exposed. "e linea alba is picked up
by two pairs of Allis tissue forceps and incised under vision."e underlying surgical peritoneum
is incised under vision and Hasson cannula is introduced into the peritoneal cavity. "e trocar
of the hasson cannula is rounded and does not cause injury to the underlying structures. "e
cannula is fixed to the skin by two sutures.
Two sutures are applied on either side of the midline over the rectus sheath. "e linea alba
along with underlying blended parietal peritoneum is incised and the peritoneal cavity is
entered. "is can be confirmed by inserting a finger. A blunt tipped Hasson trocar and cannula
is inserted under direct vision. "e blunt trocar is removed and the cannula is kept in place by
fixing with the sutures already placed.
"is open technique for creation of pneumoperitoneum is safer as there is least chance of
injury to the underlying viscus or vessels.
3. Trocar and Cannula (Figs 21.104 and 21.105)
A A
B B
C C
Figures 21.104A to C: 10 mm metal trocar and Figures 21.105A to C: 5 mm trocar and cannula
cannula
How will you introduce the trocar?

"e top of the trocar rests on the palm and the trocar and cannula is held in between fingers.
Utmost care is required during placement of 1st trocar by blind technique. "e trocar is gradually
inserted by rotatory movement till loss of resistance is felt. After the telescope attached to the
camera is inserted the subsequent trocars are inserted under vision.
What are the uses of trocar and cannula?
"e cannuals are the channels for introduction of the laparascopic instruments. "e inner sharp
trocar is required for smooth introduction of the cannula. In the cannula there is a valve which
prevents leakage CO2 gas so that pneumoperitoneum is maintained well.
"e diameter of the cannula should be 1 mm more than the diameter of the instrument that
is to be introduced.
How many trocar and cannula you will need for lap chole operation?
Two 10 mm and two 5 mm cannula are required for lap cholecystectomy operation.
One 10 mm subumbilical port for telescope attached to the camera.
"is is cannula part one 10 mm epigastric port inserted to the right of falciform ligament just
below the xiphoid. "is is surgeons right hand working port.
One 5 mm right midcalvicular port inserted below the right costal margin at the right
midclavicular line. "is is surgeons left hand working port.
One 5 mm right anterior axillary port inserted at the level of umbilicus at the right anterior
axillary line. "is is the assistant port for holding the fundus of the gallbladder.
4. Maryland Dissector (Fig. 21.106)
Figure 21.106: Maryland dissector
Uses
During laparoscopic cholecystectomy to dissect the cystic pedicle
To make a tunnel arround the cystic duct and artery for application of clips
Used during other laparoscopic operation for dissections.
5. Endograsping Forceps: Toothed (Fig. 21.107)
Figure 21.107: Endograsping forceps—toothed
6. Endograsping Forceps: Non-toothed (Fig. 21.108)
Figure 21.108: Endograsping forceps—non-toothed

Uses
Use to hold tissues.
In laparoscopic cholecystectomy one grasper hold the fundus and another grasper hold the
Hartman’s pauch.
7. Endoscissors: Curved Bladed/Straight Bladed (Fig. 21.109)
Figure 21.109: Endoscissors—curved bladed/straight bladed
Uses
Used for cutting structures during endoscopic procedures
Use to cut cystic duct and artery after clipping during laparoscopic cholecystectomy.
8. Suction Irrigation Cannula (Fig. 21.110)
Figure 21.110: Suction irrigation cannula. Note the two knobs and
two channels, one for suction and one for irrigation
Uses
Used for suction of blood, fluid, pus during laparoscopic procedure
"rough irrigation channel fluid can be used for irrigation of the operative area.
9. Endoscopic Clip Applicator (Fig. 21.111)
Figure 21.111: Endoscopic clip applicator
Uses
Use for applying titanium clips during laparoscoic procedure
Use to clip the cystic duct and artery before dissection
10. Endoscopic Crocodile Forceps (Fig. 21.112)
Figure 21.112: Endoscopic crocodile forceps

Uses
Used as gallbladder extraction forceps bluring laparoscopic cholecystectomy.
11. Endoscopic Spoon Forceps (Fig. 21.113)
Figure 21.113: Endoscopic spoon forceps
Uses
Used during laparoscopic cholecystectomy for picking up spilled out stones.
12. Endoscopic Diathermy Hook (Fig. 21.114)
Figure 21.114: Endoscopic diathermy hook
Uses
Used for diathermy dissection during laparoscopic procedure
Used to dissect the gallbladder from the liver bed.
13. Endoscopic Diathermy Spatula (Fig. 21.115)
Figure 21.115: Endoscopic diathermy spatula
Uses
Same as endoscopic hook.
14. Endo Needle Holder (Fig. 21.116)
Figure 21.116: Endo needle holder
Uses
Used in laparoscopic procedure requiring suturings, e.g. during laparoscopic gastro-
jejunostomy, choledochoduodenostomy, and gut ressection and anastomosis.
15. Liga Clip – LT 300 (Fig. 21.117)
Figure 21.117: Liga Clip – LT 300
16. Liga Clip – LT 400 (Fig. 21.118)
Figure 21.118: Liga clip – LT 400
Uses
"ese are titanium clips used during laparoscopic procedure. "ese are used to clip a vessel
before division. "e cystic duct is clipped with this titanium clip before division.

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SECTION 8 Instruments

In examination, proper identification of instrument is very important. Mention the complete

What are the different techniques of disinfection of instruments?

1. RAMPLEY’S SWAB HOLDING FORCEPS

Figures 21.2A to C: Swab holding forceps

How will you remove hair from the skin?

What area should you clean for an abdominal operation?

Figures 21.3A to C: Towel clips

A. Doyens’ Cross Action Type Towel Clip

B. Backhaus’ Towel (Corner) Clip

3. BARD PARKER’S HANDLES

Figures 21.4A to D: Bard Parker’s handle

Figures 21.5A and B: Surgical blades

9. Loin incision or lumbar incision:

Uses of Hemostatic Forceps

What is primary hemorrhage?

• Measurable fall of systolic blood pressure.

6. KOCHER’S HEMOSTATIC FORCEPS

7. MOSQUITO HEMOSTATIC FORCEPS

8. MAYO’S PEDICLE CLAMP

9. LISTER’S SINUS FORCEPS

10. ALLIS’ TISSUE FORCEPS

11. BABCOCK’S TISSUE FORCEPS

12. LANES’ TISSUE FORCEPS

13. PLAIN DISSECTING FORCEPS

14. TOOTHED DISSECTING FORCEPS

15. NEEDLE HOLDERS (FIGS 21.17 A TO F)

Figure 21.18A: Needles

Figures 21.18B and C: Needles

Figure 21.19: Round bodied needle— Figure 21.20: Conventional cutting

What are the characteristics of a round

What are the advantages of using an eyeless needle?

17. SKIN CLOSURE CLIPS AND ACCESSORIES

Figures 21.27A to E: Skin closure clips and accessories

How will you apply these clips?

18. SKIN STAPLERS

19. MAYO’S SCISSORS (FIGS 21.29A TO D)

20. MCINDOE SCISSORS

Figure 21.30: McIndoe scissors. Note the fine, delicate,

21. METZENBAUM SCISSORS

Figures 21.31A to C: Metzenbaum scissors

22. HEATH’S SUTURE CUTTING SCISSORS

23. LANGENBACH’S RETRACTOR

Figures 21.33A and B: Langenbach’s retractor

24. CZERNEY’S RETRACTOR

Figure 21.34: Czerney’s retractor

25. MORRIS’ RETRACTOR

Figure 21.35: Morris’ retractor

26. HOOK RETRACTORS

Figures 21.36A and B: Hook retractor

27. CAT’S PAW OR VOLKMAN’S RETRACTOR

Figure 21.37: Cat’s paw or Volkman’s retractor

28. FISCH NERVE HOOK

Figure 21.38: Fisch nerve hook

29. DEAVER’S RETRACTOR

Figure 21.39: Deaver’s retractor

30. SELF-RETAINING ABDOMINAL RETRACTOR (BALFOUR’S TYPE) WITH

Figures 21.40A to C: Self-retaining abdominal retractor (Balfour’s type) with

31. MILLIN’S SELF-RETAINING BLADDER RETRACTOR WITH A PROVISION

Figures 21.41A to C: Millin’s self-retraining bladder retractor with a provision for