Clamping and occluding instrument

Surgical Instruments

1. SURGICAL INSTRUMENT Clamping and occluding instruments Presented by: Aziyah & Wan Syazwani

2. Learning Outcomes At the end of this session, students will be able to: Describe types of instrument. Identify the use and function of each type of surgical instrument. State the anatomy of each type of instrument. Demostrate the assembly and appropriate methods for passing each type of surgical instrument.

3. Clamping and occluding instruments The instruments that clamp and occlude are used to apply pressure. Some clamps are designed to crush the structure as the instrument is applied and are considered traumatic. The clamped crushed structure is usually sewn, clipped, or electrocoagulated and then removed.

4. Cont… Clamping and occluding instruments Other clamps are noncrushing (atraumatic) and are used to occlude or secure tissue, which is restored to patency at some point during the surgical procedure. For instance, clamping and occluding intruments are used to compress blood vessels or hollow organs for haemostasis or to prevent spillage of contents.

5. Types of instrument Crushing Clamps Haemostatic Clamps Haemostats Noncrushing Clamps

6. Haemostatic Clamps Most clamps used for occluding blood vessels have two opposing jaws (with or without serrations or teeth), ringed handles, and lock with rachets. Most ring-handled clamps have a common design. The length and shape of the shanks or jaws may vary according to the intended fuction of the instrument. Function: To clamp and restrict arteries or tissue, to control the flow of blood.

7. Haemostats Haemostats are the most commonly used surgical instruments and are used primarily to clamp blood vessels. They have a crushing action. Haemostats have either straight or curved slender jaws that taper to a fine point. The serrations are longitudinal or horizontal inside the jaws.

8. Haemostats Haemostat clamps. Jaws may be straight or curved. Tips may be pointed or rounded. Serrations may be horizontal or longitudinal. Jaws and handles may be long or short.

9. Cont…Haemostats List of haemostats Satinsky clamps are designed to patially occlude the wall of a vessel over a distance. Kocher forcep Kelly forcep Crile forcep Halsted mosquito forcep Rochester pean forcep Mixter “right angle” forcep Spencer wells artery forcep Rankin forcep

10. Cont…Haemostats A Mosquito Transversely serrated. It is smaller in size and is used to clamp small blood vessels. Its jaws may be straight or curved.

11. Cont…Haemostats A Kelly Transversely serrated. The most basic clamp. The also feature a locking mechanism to allow them to act as clamps. They are used to clamp larger vessels and tissue. Available in short and long sizes either curved or straight. Other names: Rochester Pean

12. Cont…Haemostats A Burlisher Is used to clamp deep blood vessels. Burlishers have two closed finger rings. Burlishers with an open finger ring are called tonsil haemostats. Other names: Schnidt tonsil forcep, Adson forcep.

13. Cont…Haemostats A Right Angle Is used to clamp hard-to-reach vessels and to place sutures behind or around a vessel. A right angle with a suture attached is called a “tie on a Passer”. Other names: Mixter

14. Cont…Haemostats A Haemoclip Applier with Haemoclips Applies metal clips onto blood vessels and ducts which will remain occluded.

15. Hemostats…Micro Instrument Bulldog Clamp (Small metallic vascular clamp) Useful instrument for stopping blood flow to a particular organ of interest. One of the most common applications where a bulldog clamp can be used is during coronary surgery where blood flow must be stopped. In general, the bulldog clamp, with its many angled varieties and surgical applications, is an essential tool during surgery where blood flow to an organ must be stopped or controlled.

16. Bulldog clamp application

17. Type of bulldog clamp Debakey bulldog toothing clamps Debakey bulldog clamps cvd Mini bulldog clamp cvd Mini bulldog clamp STR Hopkins Bulldog Clamp

18. Debakey ring handle bulldog clamp

19. Crushing Clamps Many variations of hemostatic forceps are used to crush tissues or clamp blood vessels. The jaws may be straight, curved, or angled, and the serrations may be horizontal, diagonal, or longitudinal. The tip may be pointed or rounded or have a tooth along the jaw such as on a Heaney clamp or hysterectomy clamps. The length of the jaws and handles varies. Many forceps are named for the surgeon who designed the style, such as the Kocher and the Ochsner clamps. Some instruments are designed to be used on specific organs.

20. Cont…Crushing Clamps The features of the instrument will determine its use. Fine tips are needed for small vessels and structures. Longer and sturdier jaws are needed for larger vessels, dense structures, and thick tis- sue. Longer shanks are needed to reach structures deep in body cavities. Tissue that has been crushed is usually sutured or stapled. Function: to prevent leakage and to minimize trauma when clamping bowel, vessels, or ducts that are to be reanastomosed.

21. Cont…Crushing Clamps Heaney clamp with teeth along crosshatched jaw Hysterectomy clamp with longitudinal jaw and crosshatched tips

22. Cont…Crushing Clamps Kocher Intestinal Clamp

23. Noncrushing Clamps Noncrushing clamps are used to occlude bowel or major blood vessels temporarily, which minimizes tissue trauma. The jaws of these types of clamps have opposing rows of fine serrations, but have a softer hold on tissues. The jaws may be straight, curved, angled, or S-shaped.

24. Cont…Noncrushing Clamps Doyen Intestinal Clamp

25. Cont…Noncrushing Clamps DeBakey Atraumatic Clamp

26. Anatomy of the Instruments Clamps are instruments specifically designed for holding tissue or other materials, and most have an easily recognizable design. They have finger rings, for ease of holding. Shanks, whose length is appropriate to the wound depth. Ratchets on the shanks near the rings, which allow for the distal tip to be locked on the tissue or object grasped. Joint, which joins the two halves of the instrument and allows opening and closing of the instrument. Instruments made up of two halves have one of three types of joints.

27. Jaw and Tip Surgical jaw surfaces These jaw surfaces have teeth (serration) and hooks at the functional ends, permitting firm grasping of tissue.

28. Cont…Jaw and Tip Anatomical jaw surfaces Instruments with anatomical jaw surfaces are used in areas where there is a risk that the teeth of surgical jaw surfaces could damage tissues, e.g. the mucous membranes of the stomach or intestines.

29. Cont…Jaw and Tip Atraumatic jaw surfaces These are instruments whose jaw surfaces have a special serrated (toothed) profile. The particular type of serration and arrangement of the teeth prevent damage to tissues or organs when the jaws close.

30. Types of Joint Box Lock The most common joint is the box lock, where one arm has been passed through a slot in the other arm and is riveted or pinned. This joint is needed where accurate approximation of the tips is necessary, and it is basic to most ringed instruments. Adson Artery Forcep Box lock

31. Cont…Types of Joint 2. Screw Joint The second type is the screw joint. The two halves are aligned and placed on top of each other, connected only by a screw. The joint must be checked and tightened periodically because the screw may become loose. Screw-joint instruments are easy to make and comparatively inexpensive. Robert Artery Forcep Screw joint

32. Cont…Types of Joint 3. Semibox/Aseptic Joint The final and least common type is the semibox, or aseptic joint. One arm passes through slot but the arm can be separated. It has the advantage that the two halves can be separated for easy cleaning. Semibox / Aseptic joint

33. Shanks The part of a key between the handle and the bit. Runs from the joint to the finger ring. Shank

34. Ratchet Interlocking parts between the finger rings of surgical instruments which lock to keep the instruments closed.

35. Finger ring-handle Control the jaws of the instruments. Ergonomics The ring-handle design more evenly distributes pressure, which helps reduce the potential for intraoperative hand fatigue and temporary digital nerve compression. Versatility The ring handle allows a precision or palm grip. The thumb actuation ridges promote efficiency and easy use. And the enlarged, 360° rotation knob is conveniently reachable by your forefinger. 

36. Method for Passing Instrument Pass ringed forceps with the ratchet closed to the first tooth or step. The surgeon will open the ratchet before use. Pass pickup designed forceps with the two sides squeezed closed. Pass with the working end positioned for immediate use by the surgeon. Pass curved instruments with the point facing the surgeon’s midline. Recognize your error in passing because the surgeon will make an orientation adjustment before using it. Observe and correct any errors.

37. Hand signal by surgeon to pass a hemostat or clamp Pass ringed forceps or clamps

38. Quiz Name the anatomy of the following instruments. Box Lock Finger ring Handle

39. Satinsky haemostatic clamp Box lock Shank Finger ring handle Serrated jaw Rachet

40. Screw Lock Shank

41. Ratchet Finger Ring Handle

42. References Hauser, G. (2009). Fundamentals of instrumentation . Retrieved from https://wfhss.com/wp-content/uploads/wfhss-training-1- 07_en.pdf Phillips, N. (2017). Berry & Kohn's operating room technique . (13th ed.). St. Louis, Missouri: Elsevier.