Basic methods and instruments
From Primary Surgery
Appropriate surgical technology: the equipment you need
You may step into a beautifully organized theatre, or you may have to create it from scratch. To help you in this task we have listed everything you might need to do the procedures we describe, down to the last needle and cake of soap. To minimize the tediousness of long lists we have distributed the equipment through the text, and summarized it in Appendix A. We have included everything which you could reasonably have[md]but may not have at the moment. For example, many district hospitals don't have skin grafting knives, pneumatic tourniquets, simple bone drills, Kirschner wire, or manometers for measuring the central venous pressure (A 19.2)[md]but you could reasonably have them, so we have included them. Some of the special methods we describe don't need any extra equipment[md]for example, the plastic bag method for burnt hands (58.29). Learn to recognize the instruments you use and to know them by their names. When you first arrive at a hospital check the theatre equipment and find out what is missing!
When you order equipment that is not listed here try to make sure that: (1) It will work reliably without needing to be returned to the makers to be mended. (2) It will work well in your hands. (3) You can afford both its initial and its running costs. (4) Spares are available. (5) You can easily learn how to use it and teach other people to do the same.
If you want to be well supplied, encourage and motivate your storeman. Look at what he has and how he does things. Don't forget to visit your central medical stores; you may find things you need, which the storeman there cannot identify, and you can make good use of. The equipment we list is the equipment he should stock, so do your best to see that government does this.
You will certainly have to improvise. If you don't have the standard stainless steel instruments, don't hesitate to use ordinary steel ones, if you can buy, adapt, or make them. Before stainless steel came into routine use in the 1920s, all surgical equipment was made of ordinary steel, and had to be dried and carefully wiped with an oily rag after each operation. For example, you can use an ordinary steel carpenter's drill instead of a bone drill, and a sterile pair of ordinary pliers may be the best way to remove a plate. If you have no Kirschner wires you may be able to use sharpened bicycle spokes. Don't store instruments of ordinary steel sterilized in packs or drums. The interior of these is damp and they will rust rapidly.
STORES AND EQUIPMENT QUANTITIES OF ITEMS. The quantities of each item we suggest are those appropriate to an initial stock. The quantities of each item we list are sufficient to make all the sets suggested in Section 4.12. You will probably have to make do with less.
CATALOGUE NUMBERS. Where an item is available from UNICEF, we have given its UNIPAC number. We have given the suppliers of a few items which are difficult to get. These have been listed with three letters in brackets, for example, (EVE) for the Everett Needle Company, and the supplier's names are listed in full in Appendix B.
SUPPLY CYCLES. If your supply period for a consumable item is X' months, try to keep three times the quantity of it you consume during this period in stock, so that one indent can go astray without causing disaster.
ORDERING EQUIPMENT. When you order equipment, try to include the catalogue number. Where possible write to the supplier and ask for a proforma invoice' giving the exact details and costs, etc. This will make ordering much easier.
WHERE THE EQUIPMENT IS DISCUSSED. The anaesthetic equipment is in Primary Anaesthesia, the obstetric equipment is in Section 15.1a and in Primary Mother Care .
The theatre. Theatre furniture and lighting, gowns, gloves and drapes (2.1 and 2.3), drains and tubing (4.10). Miscellaneous smaller items of theatre equipment (4.11).
Preventing sepsis. Sterilizing equipment (2.3), antiseptics and disinfectants (2.5).
Preventing bleeding. Haemostats and arterial clamps (3.2), tourniquets (3.9).
Cutting and holding tissues. Scalpels and dissectors (4.2), scissors (4.3), forceps (4.4), retractors (4.5), suture materials (4.6), needles and their holders (4.7).
Special procedures Operating on bones and joints (7.4), intestinal surgery (9.3), obstetrics (15.1), proctology (22.1), urology (23.1), eye (24.1), ENT (25.1), dentistry (26.1), first aid equipment (50.3), tracheostomy (52.1), skin grafting (57.1), neurosurgery (63.1), chest aspiration (65.1), plastering (70.1), bone traction (70.9).
Scalpels and dissectors
A sharp scalpel cuts tissue with less trauma than any other instrument. There are two ways of holding one: (1) If you need force to make a big bold cut, grasp it with your index finger along the back, as in Fig. 4-1. (2) If you want to cut more gently, hold it like a pen. The size of a blade does not change the way you use it, but its shape does. A small blade allows you to make precise turns. Stab the point of a No.11 blade into an abscess and then sweep it upwards in an arc. Experienced surgeons do a lot of knife dissection beginners find other instruments safer for many purposes.
SCALPEL, solid forged, size No.1, 30 mm, and size No.5, 40 mm, two scalpels only of each size. If your disposable blades are exhausted, you can use a solid scalpel and resharpen it (Appendix A), whereas you cannot resharpen a disposable blade. A solid blade is essential for symphysiotomy (18.4).
HANDLE, scalpel, Bard Parker, No.4, eight only. This is the standard handle for blades 20, 21, 22, 23, and 24. Get good quality handles, because poor ones may not fit the blades.
HANDLE, scalpel, Swan Morton, No.5, four only. This long elegant handle fits blades 10, 11, 12, and 15.
BLADES, scalpel, disposable, Bard Parker or Swann Morton type, stainless steel in dispenser containing 100 blades. (a) Type 10, ten dispensers only. (b) Type 11, five dispensers only. (c) Type 15, five dispensers only. (d) Type 22, two dispensers only. (e) Type 24, two dispensers only. The medium-sized curved blade 10, the small curved blade 15, and the pointed blade 11, all fit into the long No.5 blade holder. The big curved blades 22 and 24 fit into the standard No.4 handle. If necessary, you can autoclave these blades and use them for 3 or 4 operations.
OILSTONE, hard Arkansas pattern, 150[mu]70[mu]30 mm, one only. Use this to sharpen scalpels and scissors. A very blunt instrument needs a carborundum stone first.
DISSECTOR, MacDonald, one only. A blunt dissector is often safer than a scalpel. This is a blunt general purpose dissector, with one straight flat end and one round curved end, neither of which are likely to injure anything.
Scissors
The tips of a pair of surgical dissecting scissors are usually rounded; scissors in which both tips are pointed are only used for very fine dissection. Look after your scissors carefully. Use straight scissors near the surface and curved ones deeper inside. Hold them with your index finger resting on the blades. Use the tips for cutting.
You can also use scissors for blunt dissection by pushing their blades into tissues and then opening them. This will open the tissues along their natural planes, and push important structures, such as nerves and blood vessels, out of the way. This is the push and spread' technique shown in B, Fig. 4-8. If there is something nearby which it would be dangerous to cut, blunt dissection is always safer. But remember that even blunt dissection can injure veins, and that venous bleeding can be very difficult to control.
Remember: (1) Don't use sharp-tipped scissors in dangerous places, or cut what you cannot see. (2) Don't use scissors which are longer than the haemostats you have, or you may find yourself cutting a vessel which you cannot reach to clamp. (3) Mayo's, McIndoe's, and Metzenbaum's scissors are intended for cutting tissues, so don't use them for anything else. Use other scissors for cutting sutures and dressings.
Buy good quality scissors, and don't autoclave them with the other instruments. Instead, keep them in a covered tray of antiseptic (2.5). The very best ones have tungsten carbide inserts, which make their cutting edges last much longer. These are four times more expensive, but justify their extra cost.
SCISSORS, operating, Mayo, straight, bevelled, 200 mm, one pair only. Use these for cutting sutures.
SCISSORS, operating, Mayo, curved, bevelled blades, 170 mm, one only. These tissue scissors are curved in the plane of the blades.
SCISSORS, operating, McIndoe's, curved, with rounded tapering blades, 180 mm, one only. These elegant tapering tissue scissors are curved perpendicular to the plane of the blades.
SCISSORS, operating, Metzenbaum, curved 275 mm, one pair only. These have long handles and quite narrow blades. Use them for dissecting at the bottom of a deep wound.
SCISSORS, Aufrecht's, light, curved, 140 mm, one pair only. This pair of scissors is for the set of instruments for hand surgery.
SCISSORS, straight with fine sharp points, Glasgow pattern, 100 mm, stainless steel, two pairs only. Use these very fine scissors for cutting down on veins.
SCISSORS, suture cutting, assistant's scissors', rounded ends, four pairs only. Keep these in spirit with the other scissors. Your assistant needs a pair; so does the scrub nurse.
SCISSORS, suture wire cutting, 130 mm, one pair only. If you cut suture wire with ordinary scissors, it will ruin them.
SCISSORS, bandage, angular, Lister, 180 mm, one only. These have a blunt knob at the end of one blade which goes under the bandage to protect the patient. Insert them away from the wound; if they become soiled or wet, clean and sterilize them before you use them on someone else.
IN DANGEROUS PLACES BLUNT DISSECTION IS SAFER THAN SCISSORS
Forceps
Dissecting (thumb) forceps can be short for working close to the surface, or longer for working more deeply. They can be plain, or toothed with an odd number of teeth on one jaw, and an even number on the other, either one into two teeth, or three teeth into four, etc. Toothed forceps hold tissue so firmly that only a little pressure is necessary; but they can easily puncture a hollow viscus or a blood vessel. Strong, plain, straight forceps without teeth are even more useful for blunt dissection than they are for holding tissues.
Tissue (locking) forceps have a ratchet which keeps them closed. Some have teeth (Allis') and some have none (Babcock's). The blades of Allis' forceps meet together, and inevitably injure the tissues a little, whereas Babcock's have bowed jaws with a gap between them. This makes them gentler but less secure. When you use Allis' forceps for retracting a skin flap, apply them to the subcutaneous tissue or fascia, and not to the skin itself, which may be injured. Kocher's forceps are stronger, and even more traumatic; they are for clamping wide vascular pedicles, so that the vessels do not slip out (3.2).
FORCEPS, dissecting, thumb, blunt, non-toothed, Bonney's, 180 mm, three only. These are strong dissecting forceps without teeth.
FORCEPS, dissecting, thumb, toothed, Treves', 1[mu]2 teeth, 130 mm, five only. These are the standard toothed dissecting forceps.
FORCEPS, dissecting, thumb, fine, Adson's, (a) plain, (b) 1[mu]2 teeth, 120 mm, two only of each. These have broad handles and fine points and are particularly useful for the eye.
FORCEPS, dissecting, thumb, Duval's, 150 mm, with non-traumatic teeth on triangular jaws, two only. These are thumb forceps for general use.
FORCEPS, dissecting, thumb, toothed, 180 mm, one only. These are long fine dissecting forceps.
FORCEPS, dissecting, thumb, Maingot's, 280 mm, one only. These are large toothed forceps with fenestrated sides that are easy to hold.
FORCEPS, dissecting, McIndoe's, plain, 150 mm, one only. These are for the hand set.
FORCEPS, dissecting, ophthalmic, Silcock's, 100 mm, one only, This is a fine pair of forceps for operating on the eye or the hand.
FORCEPS, tissue, locking, Allis', box joint, 150 mm, 5[mu]6 teeth, eight only.
FORCEPS, tissue, locking, Babcock's, box joint, 160 mm, two only. These have a bar on each blade that comes together gently without damaging the tissues. Use them to hold gut.
FORCEPS, tissue, Lane's, 15 cm, two only. These have curved jaws, teeth and a ratchet.
FORCEPS, sinus, Lister, box joint 150 mm, two only. You can use these for many other purposes besides exploring sinuses. Use them for packing the nose, or putting a drain into an abscess cavity.
FORCEPS, cholecystectomy, curved jaws with longitudinal serrations, Lahey's, box joint, 200 mm, one only. These forceps are useful for other purposes besides dissecting out the cystic duct. If you put them into the tissues and separate them, you can use their rounded ends to define arteries, veins and ducts.
FORCEPS, intestinal, Dennis Browne, 180 mm, two only. Use these to pick up the gut during an abdominal operation, or a hernia repair.
FORCEPS, Moynihan, box joint, 220 mm, four only. Use this massive pair of crushing forceps for wide vascular pedicles, such as those which contain the uterine vessels at hysterectomy.
FORCEPS, Desjardin's, screw joint, one only. Use these for removing stones from the bile duct.
FORCEPS (clamps), hysterectomy, curved, box joint, one into two teeth, 23 cm, Hunter or Maingot, four but preferably six only. Hysterectomy is difficult without several long curved clamps for big vessels, preferably with longitudinal serrations and teeth at their tips.
Retractors and hooks
You cannot work inside a patient if the rest of him gets in your way. To clear the field, you will have to use retractors. There are two kinds. One has to be held by an assistant, the other holds itself. Any blacksmith should be able to make you the simpler ones from ordinary steel. Strong retraction causes trauma, especially to the edges of the wound. So avoid it by appproaching deep areas through larger incisions.
RETRACTOR, Volkmann's rake, sharp, 4 prong, 220 mm, two only. These have sharp teeth like a cat's paw. Take care that they do not injure anything important.
RETRACTOR, Langenbeck, 13[mu]44 mm, two only. These are fairly small narrow deep retractors.
RETRACTOR, Czerny, double ended, four only. These have a flat blade at one end and two deep prongs at the other. They are thus more versatile than Langenbeck's retractors.
RETRACTOR, Lane's modified by Kilner, double ended, 150 mm, two only. This is a light general-purpose retractor with short shallow hooks at one end and a tongue at the other.
RETRACTOR, Gelpie, 170 mm, two only. A pair of these are very useful as general purpose retractors.
RETRACTOR, Morris, double ended, three only. This is a double ended abdominal retractor. Some surgeons prefer single-ended ones which are easier to hold.
RETRACTOR, Deaver's, plain handles, set of five sizes, one set only. These inexpensive general purpose abdominal retractors nest together, and so are easy to store.
RETRACTOR, malleable copper, set of 4 sizes, one set. These are strips of copper that you can bend into any shape to suit your needs.
RETRACTOR, Meydering, 178 mm, two only. These are for hand surgery and are used as a pair.
RETRACTOR, self-retaining, West's, straight, sharp-pronged, one only. This is a small self retaining general-purpose retractor.
RETRACTOR, abdominal, self-retaining, two-blade, adult, Gosset's, one only. The three blades of this large abdominal retractor can be arranged so that they support one another, and do not have to be held.
RETRACTOR, universal, Denis Browne, with (a) one frame 300[mu]240 mm, (b) one frame 300[mu]240 mm, (c) 3 hook-on retractors 50[mu]65 mm, (d) ditto 80[mu]90 mm, (e) ditto 98[mu]50 mm, (f) ditto 105[mu]35 mm, one set only. This is a useful but expensive retractor. It has a notched ring and hooked prongs, as in Fig. 4-4.
HOOKS, tendon, Harlow-Wood, 114 mm. These are for the hand set (4.12).
Suture materials
If you bring two soft tissues together and hold them there for about 10 days they will join. Most surgery depends on this. The easiest way to hold them is to sew them. You can use: (1) absorbable sutures which are absorbed by the tissues so that you need not remove them. (2) Non-absorbable ones which you leave indefinitely if they are deep, or remove if they are on the skin.
Absorbable sutures can be plain catgut (from the submucosa of sheep, not cats!), which usually holds its strength for about 10 days. Or catgut can be treated with chromic acid (chromic sutures) which slows its absorption and makes it keep its strength for 20 days. Sepsis speeds the dissolution of catgut, especially plain catgut, so that it may dissolve in 2 or 3 days. You can also use absorbable sutures of synthetic material such as polyglycolic acid (Dexon').
Catgut is soft and holds knots well, but not so well as a non-absorbable multifilament, such as linen or cotton. If a suture material does not hold knots too well, knots made of it need longer ends. So leave knots in catgut with 5 mm ends, unless you are using it for fine superficial vessels. You can cut linen or cotton 2 mm from the knot.
While catgut is being absorbed it makes a good culture medium and may promote sepsis. So don't use more than is necessary, don't leave the ends of ligatures unnecessarily long and avoid thick No. 2 or 3 catgut. Monofilament sutures, especially fine ones, don't have this risk, which is why so many surgeons like them.
If necessary, you can use almost any suture material almost anywhere, especially on the skin. But, always use use catgut for: (1) The urinary and the biliary tracts because non- absorbable sutures can act as the focus around which a stone can form. (2) The mucosa of the stomach, where a non-absorbable suture may be the site of an ulcer later. (3) The mucosa of the uterus (less important). (4) Sutures close under the skin, where non-absorbable sutures may work their way to the surface.
Plain catgut does not hold its strength for very long, so never use plain catgut for: (1) Tying larger vessels (use linen, cotton or silk). (2) Suturing the gut (use chromic catgut).
One problem with catgut is that it may be of poor quality, and so give way early and perhaps disastrously. This is another reason for using monofilament where you can.
Non-absorbable sutures can be polyamide (Nylon'), polypropylene (Prolene'), polyethylene (Courlene'), linen, cotton, silk, or stainless steel wire. You can use the first three as a single (mono)filament, or as multiple filaments which are braided or twisted together. Whenever we refer loosely to monofilament', we mean a non-absorbable suture of nylon, polyethylene, or polypropylene, or a similar synthetic material as a single filament. It is the most useful general purpose suture material. Although non-absorbable sutures remain as permanent foreign bodies, monofilament nylon, polyethylene, and steel are less likely to promote infection than catgut, or multifilament cotton, linen, or silk.
Unfortunately, a single thicker filament makes less reliable knots than a many finer ones braided or twisted together, except for steel wire, which is always used as a single filament, and which knots superbly but is difficult to work with. So, always tie monofilament with a surgeon's knot (4.8).
Apart from the indications for catgut given above, you can use monofilament for almost anything, but silk, cotton, or linen threads, are better than monofilament for tying larger vessels. Braided silk may cause troublesome stitch abscesses. Don't use it immediately under the skin, because it may work its way through to the surface, long after healing is complete. If it does become infected, you may have to remove it piece by piece. Even monofilamant can come to the surface, so keep it well buried, and use catgut close under the skin.
The strength of sutures is measured in two systems. In the old system the finest ones are measured in zeros' and the thicker ones are numbered. From finest to thickest the sequence is[md]6/0, 5/0, 4/0, 3/0, 2/0, 0, 1, 2, 3, 4. Although attempts are being made to replace the old system by a metric one from 0 to 8, most surgeons still use the old one. So do we.
Use the thinnest sutures you can[md]they need only be as strong as the tissues they are holding together. You can do most operations with sutures between 3/0 and 1 on the old scale. Only very occasionally will you need sutures which are thicker or thinner than this, except for fine work such as nerve or tendon repairs, and for eye and plastic surgery. If you do need a thicker suture, you can double up a thinner one.
The cost of sutures can significantly increase the cost of an operation. In the industrial world they are now sold in individual disposable packs, which are expensive to make and waste much suture material each time a pack is opened. This, combined with the use of atraumatic needles, means that the needles and sutures for one operation may cost $20. But if you buy monofilament in rolls, and use ordinary needles, the suture materials for a single operation cost almost nothing. Monofilament suture material in packets is 20,000% more expensive than in reels, and with needles swaged on is 30,000% more!
Never let the lack of suture materials be the reason for not doing an urgent operation. Either use ordinary nylon fishing line, which is exactly the same material as that used for surgical sutures. Or, if necessary, you can use ordinary linen or cotton thread almost anywhere.
SUTURES, polyamide (Nylon'), or polyethylene (Courlene'), monofilament, strengths 5/0, 4/0, 3/0, 0 and 1, reels of 1000 metres, preferably each size a different colour (PEA), two reels only of No. 1, one reel only of the other sizes. No. 1 is the most generally useful size. Use 4/0 monofilament as your basic suture material for fine skin sutures.
SUTURES, catgut, plain, 3/0, in boxes of 12, five boxes only. Plain catgut is soft. Use it for suturing the mouth, tongue, and lip.
SUTURES, catgut, chromic, strengths 3/0, 2/0, 0, 1 and 2, boxes of 12, ten boxes only of each strength. This is the most commonly used form of catgut.
SUTURES, catgut, chromic, atraumatic, (a) 2/0 on half circle 30 mm needles, ten boxes only. (b) 2/0 on 5/8 circle 30 mm needles, ten boxes only. (c) 4/0 on 16 mm curved needle, ten boxes only. These sutures have needles swaged on to them. Use them for the gut, the gall-bladder, and the stomach, held in a needle-holder. The smaller needles (c) are for children.
SUTURES, prolene, atraumatic, (a) 4/0 on 16 mm half circle, round-bodied needles, (b) 8/0 on 3 mm 3/8 circle atraumatic needles, two boxes only of each size.
SUTURES, linen, No. 1, five reels only. Use linen for tying vessels. It holds knots well and is stronger than cotton.
SUTURES, nylon or virgin silk, 8/0, one box only. These are for suturing the cornea.
WIRE, monofilament, soft stainless steel, (a) 5/0, (b) 0.35 mm, (c) 1.0 mm, one reel only of each thickness. Surgical wire must be soft and malleable because springy wire is difficult to work with. Autoclave the whole reel. (a) Fine 5/0 wire is cheap, and is excellent for the skin, if you can learn to use it efficiently. (b) 0.35 mm wire is for wiring the teeth (62.10) and for hemicirclage (72.18). (c) Tension 1.0 mm wire in a stirrup and use it for exerting traction (70.12). These wires and the equipment to use them (70.9) are essential. One of the advantages of wire is that, unlike more massive pieces of metal, it does not promote infection, so that you can if necessary put it though infected tissues. You can wire tissues in the presence of sepsis; for example, when you repair a burst abdomen (9.13).
Fasten wire by passing its ends through any convenient tube, such as that from a ball pen, and then grasping the ends and twisting them. Finally, cut the twisted ends of the wire short. This will prevent it from coiling up in an inconvenient way.
WALL BRACKET, stainless steel, to hold rolls of monofilament, as in Fig. 4-5, one only. Fix this to the wall, and pull lengths of monofilament from it. If you cannot get one of these brackets, make it.
REELS, stainless steel, egg shaped (eggs'), for holding suture material, five only. Wind monofilament into these, autoclave them and cut off the length of suture material you require.
Dr JAMES MUKOLAGE was horrified to find in his village a woman with an abdominal wound from which gut was protruding. He was only recently qualified and had not operated on one of these cases before. He had few facilities, but he managed to find some local anaesthetic solution and some linen thread in the shops. A few instruments from the local health centre were boiled up; he washed the wound thoroughly, and anaesthetized the tissues round it with lignocaine. Fortunately, her gut had only a minor cut in it which was easily repaired. When he had returned her gut to her abdomen he was able to close it with linen thread. She survived. LESSON Improvisation can save lives.
Needles and their holders
Needles can be round-bodied, or they can have cutting edges. They can be thin or thick, large or small; straight, or curved into 3/8, half, or 5/8 of a circle. Curved needles are for working in confined spaces. The smaller ones have to be held in a needle holder. Use a 3/8 circle needle in a shallow space, and a 5/8 needle in a deep one. The narrower and deeper the hole the smaller and more curved the needle has to be. If necessary, you can try to bend a half curved needle into a 5/8 circle. If you don't have a suture needle, you can bend the wire stylet of an intramuscular needle into a loop, push both ends back into the neeedle, crimp them with a pair of pliers, and then bend the needle into any kind of curve you want, as in K, Fig. 4-6.
A needle can have an eye, or the suture material can be fixed to it to form an atraumatic needle. These are expensive, but they make smaller, neater holes, because the suture material is not doubled through the extra thickness of the eye. Use atraumatic needles to suture gut, the urinary tract, blood vessels, nerves, the cornea and the face, especially the eyelids. For anything else they are unnecessary and wasteful. Unfortunately, because atraumatic needles are so extensively used in the industrial world, needles with eyes may be difficult to get.
Always use a cutting needle for the skin, either a straight one or a large curved one held in your hand, or a smaller curved one held in a needle holder. Use a cutting needle for tough fascia. Mayo's needle is a hybrid[md]it has a trocar point and a curved round shank. Use it for big wide vascular pedicles and tough tissues, such as ligaments. Use round-bodied needles for most other tissues. If you have difficulty getting needles, we list a supplier in Appendix B (SHO). Resharpen cutting needles on a stone (Appendix A).
You will want a needle-holder to hold small needles and suture in a confined space. Use a holder with a short handle near the surface, and a long one deeper inside. Use big needles in big holders, and small needles in small holders. A large needle can break a fine needle-holder such as Derf's, so treat it with care. Needle-holders can have plain jaws, or tungsten carbide inserts which prevent the hard steel of the needles wearing them away. These cost twice as much, but last more than twice as long. Quality counts in needle-holders, so get good ones.
NEEDLES, suture, 3/8 circle, curved, triangular point, sizes 4, 12, and 18, 25 needles of each size. These are the standard curved needles. Hold the largest ones in your hand and the smaller ones in a holder.
NEEDLES, suture, 1/2 circle curved, triangular, sizes 2, 8, 14 and 20, 50 needles of each size only. Use these strong, triangular cutting needles for the scalp.
NEEDLES, suture, round bodied, 3/8 circle curved, sizes 4, 10 and 18, 25 needles of each size only. Use these for suturing soft tissue such as the peritoneum and broad ligament.
NEEDLES, Moynihan, 5/8 circle curved, round bodied, fine, sizes 1, 4, and 6, 50 needles only of size 1, 25 needles only of sizes 4 and 6. Hold the larger ones in your fingers for suturing stomach and intestine. Use the small ones in a needle holder for suturing deep in a wound.
NEEDLES, Mayo, intestinal, round-bodied, half circle curved with sharp perforating ends, 23 mm, size 20, 100 needles only. Use this small curved needle in a holder.
NEEDLES, suture, round bodied, half circle curved, sizes 1, 4, 10, 15, and 20, 25 needles of each size only. Hold these in a holder and use them in the depths of a wound.
NEEDLES, suture, Moynihan, Lance point, 5/8 circle, 115 mm, twenty five needles only. Use these large curved needles for sewing up the abdomen as described in Section 9.8.
NEEDLES, suture, curved, tension, Colt, 102 mm, five needles. This is a very large curved needle used for putting tension sutures into the abdomen (9.8).
NEEDLES, straight triangular, cutting, 35 mm, 20 needles only. Hold these in your hand and use them for suturing tendons.
NEEDLES, suture, Jameson Evans, triangular, curved, 10 mm, 25 needles only. These small curved needles have flattened shafts, triangular points and lateral eyes. Use them for delicate sutures, such as repairing the eyelids.
NEEDLES, suture, Dennis Brown, round pointed, 5/8 circle, 16 mm, 25 needles only. Hold these small curved needles in a needle holder, when you are working at the bottom of a narrow deep hole, such as the bottom of a burr hole.
NEEDLES, suture, 1/2 circle, catgut, Mayo, sizes 1 and 3, 25 needles of each size only. These are strong needles for tough tissues. They have short cutting edges, so you can use them to repair an artery.
NEEDLE, Deschamps, angled to the right, five only. This is the only needle (not illustrated) in this list which you can use to thread wire, to close the abdomen (9.8), or to wire the patella (79.12).
NEEDLE HOLDER, Boseman, 210 mm, ratchet and box joint, tungsten carbide jaws, two only. This is the standard needle holder for medium and large needles.
NEEDLE HOLDER, Mayo's, with ratchet and box joint, tungsten carbide jaws 185 mm, one only.
NEEDLE HOLDER, Mayo Dunhill, 160 mm, ratchet and box joint, tungsten carbide jaws, three only.
NEEDLE HOLDER, Mayo's with narrow serrated jaws, box joint, tungsten carbide jaws and ratchet, 185 mm, three only.
NEEDLE HOLDER, Derf, box joint and rachet, tungsten carbide jaws, 115 mm, two only. This is an expensive fine needle holder for tiny needles.
Suture methods
You will have to suture two kinds of wound: (1) Those caused by trauma, which are described in Chapter 54. (2) Those which you make yourself when you operate. You can sew up both in much the same way. Here, we are mostly concerned with the skin, the special sutures for other structures are described elsewhere[md]arteries (55.6), nerves (55.9), tendons (55.11), the scalp (63.6), and the gut (9.3).
Over-and-over' sutures are the most common ones, and can be continuous (A, Fig. 4-7) or interrupted (B). Each interrupted suture needs its own knot; each knot can act as a nidus for infection; and each takes time to tie. So continuous sutures are quicker, but they are also less reliable, because, if the knot on a continuous suture unties, or the suture breaks, the whole wound may open up, whereas the loss of a single interrupted suture matters little. A beginner usually finds interrupted sutures easier. If you wish, you can lock a continuous skin suture to make it more secure; you can lock every stitch (G, Fig. 4-7), or every few stitches.
Vertical mattress sutures (C, Fig. 4-7) take a superficial bite to bring the skin edges together, and a deeper one to close the deeper tissues; so they are useful for deeper wounds, but they leave scars: they are always interrupted. Horizontal mattress sutures may be interrupted (D) or continuous, superficial or buried (E), and are merely alternatives to over- and-over' sutures without any special merit, except that they are better at everting the skin edges.
A subcuticular suture brings the skin edges together accurately, and is particularly useful in plastic surgery. It can be interrupted (F, Fig. 4-7) or continuous (I, and J, Fig. 61-2). If it is continuous, both ends have to be anchored, either with a button, or with split lead shot clamped to the suture.
G, and H, in Fig. 4-8 show a simple mattress suture contrasted with a figure of eight suture. Use this to stop bleeding from soft bulky tissue when there is no obvious vessel to tie. This sometimes happens when you have closed the uterus after Caesarean section with the usual two layers of sutures and the wound is still bleeding at one end[md]put a figure of eight suture through it.
KNOTS AND SUTURES SUTURING. Hold a straight needle in your hand. Hold a curved one in a holder about 2/5ths of its length from the eye.
You will also have to hold the tissue you are sewing. Hold a hollow viscus, such as stomach or gut, with plain forceps; hold skin or fascia with toothed ones. If the needle is curved, move the holder through an arc, so as to follow its curve.
In the skin, insert the needle about 5 mm from the edge of the wound, and place sutures about 5 mm apart. Include an equal amount of skin on each side of the wound.
Set knots down so that they lie square, and don't tie them too tight[md]just tight enough to bring the skin edges together. The skin will swell during the following day, and if the knots are already tight, they will become even tighter and impair the circulation, leading to necrosis.
CAUTION ! (1) Don't insert the needle at different depths, or the edges of the wound will overlap. (2) Don't leave dead spaces, or they will fill with fluid which may become infected. (3) Suture towards you. (3) When you suture two tissues together, one of them may be mobile and the other fixed (because you are holding it). Suture from the mobile tissue towards the fixed one. (4) Continue in the curve of the needle.
KNOTS. Tie reef (square) knots, not granny knots'. These are both made from two half hitches[md]in a reef knot they go in opposite directions, in a granny knot they go in the same direction. Pull equally on both ends, pull horizontally, and watch the knot go down. If one end is tense and the other loose, you will get a slip or sliding knot.
A surgeon's knot is merely a reef knot with a third half hitch in the same direction as the first one. This third half hitch makes the knot less likely to undo. Some surgeons tie three hitches in all suture materials.
Some suture materials undo more easily than others. Non- absorbable multifilament makes the safest knots. Knots in catgut seldom undo, but knots in monofilament undo much more easily. So always use a surgeon's knot when you tie monofilament. For important knots put two (or more) turns on the first and second hitches. With multifilament a single turn is enough on each hitch.
Practise these knots with string or your shoelaces, until you can do them quickly, and do them blind. Learn the various ways of doing them in the following order.
REEF KNOTS can be tied in several ways. The first method, as in Fig. 4-9, is the surest way of tying a knot and is the one to use if you want to exert continuous pressure while you tie. In the second method, Fig. 4-10, use forceps in your right hand. The third, Fig. 4-11, is an instrument tie' and is useful if one end of a suture is short, or if the knot is in a deep cavity. The short end can be quite short. First, make a loop with the instrument in front of the long end. Grasp the short end and pull it through this loop. Then pull the first half hitch tight in the plane of the knot. To make the second half hitch, start with the instrument behind the long end.
TO CUT A SUTURE almost close the scissors, slip their open ends over the suture material, and move them gently down towards the knot. Twist the tip to give you the length of tail you want, then cut. Cut the tails of interrupted skin sutures short enough to prevent them tangling in the next suture. Leave buried catgut sutures with 5 mm tails. Cut buried sutures close beside the surgeon's knot.
CAUTION ! Keep the tips of the scissors in view, and don't cut unless you can see what you are cutting.
REMOVING SUTURES. Leave them until the wound has healed properly. Some sutures can be removed on the 4th day, others not until the 14th. Here is a guide:
The tongue 4 days.
Skin sutures on the face and eyelids 4 days.
The scalp 6 to 7 days.
The hand and fingers 7 days.
The scrotum 5 days.
The abdomen: transverse incision 7 to 9 days, vertical incision 9 to 11 days.
The skin of the back over the shoulders 11 to 12 days.
Retention sutures 10 to 14 days (9.13).
When you remove a suture, try not to pull any part of the suture material which has been on the surface through the tissues, or you may contaminate the wound. Clean the skin, cut the suture where it dips under the skin, and pull it in such a way that it brings the edges of the wound together, as in Fig 54- 8.
Using tubes in surgery, especially nasogastric tubes
Tubes lead fluids from somewhere to somewhere else. Inserting one may be the aim of surgery, as when you drain the pleural cavity (65.2), or it may merely be part of an operation, as in decompressing a patient's stomach when his gut is obstructed (10-9). You can also use tubes to drain pus and exudate. The insertion of a tube for gastrostomy (11.8), jejunostomy (9.7), caecostomy (9.6), and cholecystostomy (13.3) are described elsewhere: here we describe the use of nasogastric tubes, which are of great value, even though they are a burden to nurses and an irritation to patients.
TUBE, nasogastric, plastic, Ryle's, with several side holes near the tip, 14 Ch, 16 Ch, 18 Ch, ten only of each size. Transparent plastic tubes are better than rubber ones, because they are less irritant, they don't collapse, and you can see what is inside them. Most tubes have markings, the first at 45 cm showing that the tip is about to enter the stomach, and the second that it is in the antrum.
TUBE, stomach, plastic, adult and child, assorted sizes 8 to 22 Ch, five only of each size. These are critically important for making sure that a patient's stomach is empty before he is anaesthetized (A 16.4), and for washing it out if he has swallowed a corrosive (25.15). Adults need tubes of 16 to 22 Ch, children 10 to 14 Ch, and infants 8 to 10 Ch.
NASOGASTRIC TUBES Here we are concerned with the use of a tube to keep a patient's stomach empty[md]for tube-feeding him, see Sections 9.10 and 58.11.
INDICATIONS. (1) To remove fluid from a patient's stomach before anaesthetizing him, so as to reduce the risk of his inhaling it. The solid food from a recent meal will not come up an ordinary nasogastric tube, so if you want to anaesthetize safely a patient who has recently eaten, you will have to empty his stomach with a larger stomach tube (A 16.1), and then pass a nasogastric tube. (2) To decompress the stomach, particularly during upper abdominal surgery when a distended stomach may get in the way of the operation. (3) To empty the stomach during acute intestinal obstruction. (4) To feed a patient (58.10). (5) To monitor gastric bleeding. (6) To minimize abdominal distension postoperatively, so as to reduce tension on the wound, and hence assist respiration. For all these reasons, it is good practice to pass a tube whenever you do a laparotomy.
PASSING A NASOGASTRIC TUBE. Lubricate the tip of the tube with a water-soluble jelly. Sit the patient up and tell him what you are going to do. Choose the nostril which has the widest channel. Pass the tube horizontally through his nose. When the tube touches his posterior pharyngeal wall, he will gag, so give him a little water to sip, as you slowly advance the tube. The act of swallowing will open his cricopharyngeus and allow the tube to enter his oesophagus. Continue to advance it until its second ring reaches his nose; its tip should now be in his stomach.
CAUTION ! If you are only aspirating a tube, you cannot do much harm, but never start tube feeding until you are sure a tube is in the stomach. You can easily pass a tube into the trachea of an elderly, debilitated, or unconscious patient and drown him with feed. To make sure it is in his stomach: (1) Aspirate greenish-grey stomach secretions. (2) Inject a little air down it and listen over his stomach with a stethoscope for a gurgling sound. (3) Listen to the end of the tube. The sound of moving air confirms that the tube is NOT in his stomach, but is in his trachea or bronchi.
When you are satisfied that the tube is in the right place, secure it with two narrow strips of tape, one on the side and the other on the bridge of his nose, extending downwards on to the tube. In this way you will avoid pressure necrosis of his alae nasae.
Connect the tube to a bedside drainage bottle or plastic bag, to let his stomach contents syphon out. Assist this by aspirating. Suck the contents out every hour, or more frequently if there is much aspirate, to prevent the tube blocking. If you cannot aspirate anything, try irrigating the tube with 5 or 10 ml of water; its terminal holes may be plugged.
If the tube fails to decompress his stomach: (1) Its tip may still be in his oesophagus. (2) It may be kinked or blocked. (3) His stomach may be filled with large food particles. Excessive suction may have sucked food or mucosa into the holes in the tube.
Occasional sips (not gulps) of water will help to ease his misery. Keep a fluid balance chart, and as a general rule replace gastric aspirate by normal saline or Ringer's lactate (A 15.5).
CAUTION ! If you don't care for his mouth adequately, his parotid may become infected. So give him 4-hourly mouth care as a routine after major surgery, especially if he has a nasogastric tube in.
REMOVING A TUBE. As a general rule, leave a tube in place until: (1) There are normal bowel sounds. (2) There is no abdominal distension. (3) His bowel has moved normally or he has passed flatus. (4) There are only about 400 ml of gastric aspirate daily. This is the normal volume; if you aspirate 750 ml or more, suspect ileus or gut obstruction.
If his stomach has a suture line in it, remove the tube at 4 to 5 days.
If you are in doubt as to when to remove a tube, clamp it for 24 hours, and if nausea and distension do not return remove it.
CAUTION ! Don't remove a patient's nasogastric tube if he is nauseated, or distended, or he has passed no flatus, or has more than 500 ml of gastric aspirate. If he has any of these, he probably has paralytic ileus (10.13), or obstruction (10.13), or peritonitis (6.2), or an anastomosis that is too narrow.
DIFFICULTIES [s7]WITH NASOGASTRIC TUBES If he is very WEAK, DEHYDRATED OR SHOCKED, the act of passing a tube may cause him to vomit and inhale his vomit. If so, lie him on his side, with his head tilted down, and pass a large stomach tube (30 Ch). If he vomits he will now do so under controlled conditions. Afterwards, pass a nasogastric tube.
If he develops PULMONARY COMPLICATIONS, these may in part be due to the discomfort of the tube: (1) causing ineffective coughing and (2) drying out his mouth by making nose breathing difficult.
If his NASAL CARTILAGES NECROSE (rare), you applied tape unwisely. Pressure is usually caused by an acute angulation of the tube.
If he develops OESOPHAGEAL EROSIONS, you may have been using too hard a tube. A large one may allow regurgitation through the cardiac sphincter and cause an erosive oesophagitis.
Drains and draining
The purpose of a drain is to let blood, pus, or other fluids escape from a wound while it heals, without letting bacteria get in. Blood or pus will flow through a tubular drain or round a solid one. You will have to use a tube to drain a patient's gut, his bladder, or his pleural cavity (6.1), but when you drain a wound or his peritoneal cavity you have a choice. You can let the exudates flow down a tube, or you can let them seep away round the edge of a corrugated rubber drain. If you have the equipment for suction drainage, you may be able to suck them away. Suction drains are much more effective than corrugated ones, especially if bleeding is expected.
Not all wounds need drains, and drains have their risks: (1) Bacteria may enter from outside, especially if nursing care is poor. The risk of this is small if you use a closed drainage system and your nurses are good. (2) Bacteria may come from inside a patient and infect the tissues through which the drain passes, particularly the abdominal wall. (3) A drain may erode a vessel or a suture line, especially if you leave it in for a week or longer.
If possible, insert a tube drain with a tight seal to the tissues through which it passes, usually the abdominal wall, and lead it into a bag or bottle. There will be less soiling of the dressings and less contamination than with a corrugated rubber drain. Unfortunately, if a tubular drain blocks, it can seal infection in, so that some surgeons prefer corrugated rubber ones.
The modern trend is not to insert a drain unless there is a good reason to do so. So don't drain all wounds routinely[md]insert a drain when the advantages outweigh the risks, and follow the instructions we give for each procedure: (1) Where possible (see above), try to use a tube which will lead the exudate safely into a bottle, rather than a piece of corrugated rubber which will lead it into dressings. (2) Try to place the drain at the bottom of the cavity to be drained, so that exudate can easily flow out downwards. (3) Make it follow a straight path. (4) If a drain is in any danger of falling out, stitch it in as it passes through the skin. (5) Don't try to drain the whole peritoneum in peritonitis[md]it is impossible anyway. Instead, wash out the peritoneal cavity and instil tetracycline (6.2). (6) Finally, be sure to explain to the ward staff why you have inserted a drain, how they are to manage it, and when they are to remove it.
TUBING, red, rubber sterilizable, 2 mm wall, (a) 10 mm bore, (b) 15 mm bore, ten metres only of each size. This is multipurpose tubing, the 10 mm size is for draining air and blood, the 15 mm size is for pus. The firmness of the wall of a drainage tube is important. The tube from a chest drain should be firm enough to ensure an open pathway through the chest wall. The abdominal wall is less likely to pinch a drain closed, so a firm drainage tube is less important. If necessary, use a large bore catheter.
TUBING, drainage, Penrose, assorted sizes, five metres only. A Penrose drain is a soft latex tube 1 to 2 cm in width and of varying length filled with a wick. Being soft it is unlikely to injure neighbouring structures, but because it is soft, it needs an exit opening of adequate size. Cut these drains in suitable lengths and widths as needed. Don't rely on them for draining deep spaces, such as the subhepatic space. Some surgeons think Penrose drains inefficient because they don't keep the wound open.
DRAIN, corrugated red rubber, sheets 1[mu]50[mu]300 mm, ten sheets only. Pus drains between the corrugations. Cut the sheets to make drains of various shapes and sizes. Don't discard used sheet rubber drains[md]wash them, boil them, and store them in antiseptic solution (2.5). For tiny drains, cut up old intravenous sets or gloves.
SUMP DRAIN, rubber or plastic, five only. In an ordinary drain the holes through which fluid is sucked frequently block. A sump drain overcomes this difficulty by having two tubes, an outer one with many holes in it, and an inner one through which fluid is sucked. Fluid trickles into the outer tube and is then sucked away down the inner one. Ideally, suction down the inner tube needs to be applied with a low pressure pump. There should also be a single hole in the inner tube close to the surface to prevent too high a pressure building up in the sump. There are many kinds, and you may be able to improvise one. A sump drain is particularly useful for draining large quantities of fluid from fistulae or a large localized abscesss in the peritoneal cavity. Alternatively, use a folded catheter. Suck through one end and let air enter through the other (E, Fig. 4-12).
DRAINS [s7]AND DRESSINGS See elsewhere for underwater seal drains (65.2), intercostal drains for empyemas (6.1), and also drains for the abdomen (9.8), the urinary bladder (23.5 to 23.7) and the gall bladder.
If dressings are in short supply, wash the patient's wound with unsterilized salt solution (equal to half or full strength saline) 2 to 4-hourly and cover it with a dressing towel. See also 1.12.
LEAVING WOUNDS OPEN POSTOPERATIVELY, where you can, is a useful economy. Do this if a wound is not going to discharge. If it oozes a little, put a thin dressing of gauze or whatever you have on it for 24 hours.
LAYERS OF GAUZE AND COTTON WOOL will collect the discharges from a wound which is too shallow to let you insert a rubber drain, as in A, Fig. 4-12. Change these dressings frequently. If necessary, place a sheet of plastic or waterproof paper between the outermost layer and the patient's clothes.
INDICATIONS FOR DRAINAGE. (1) To allow the escape of blood when the control of bleeding after an operation has been incomplete. (2) To complete the drainage of an abscess cavity. (3) To drain an abscess or a local area of peritonitis (draining generalized peritonitis is impossible, see above). (4) To permit the escape of secretions from a possibly leaky suture line, for example when you have removed a stone from the ureter (23.14) or anastomosed unprepared large gut which cannot be protected by an ostomy, as when ileum is anastomosed to transverse colon.
HOW TO PLACE DRAINS. Where possible, insert a drain through a separate stab wound; if you drain pus through the main wound, it is more likely to become infected. Make sure the drain lies loosely in the cavity to be drained and follows the shortest path from the site to be drained to the exterior.
To avoid cutting blood vessels, cut only the skin with a scalpel, use a haemostat to poke a hole through the abdominal wall and then use the haemostat to push the drain through the hole.
CAUTION ! If you are draining a possibly leaky suture line, place the drain close to it but not actually touching it, or the drain may help to disrupt the sutures. Ideally, there should be no such thing as a leaky suture line'[md]it should not have been made so that it does leak, or if it looks like leaking, it should be made again.
CORRUGATED RUBBER DRAINS are useful for abscesses. Cut more than an adequate hole in the superficial tissues, cut a strip of rubber to fit loosely and push this into the depth of the wound (B, Fig. 4-12). Don't make the hole for the drain so small so that it is tight (C). Use a cutting needle to transfix it with a suture and anchor it to the skin, then tie the ends of the suture several times. When you shorten a drain, you may be able to leave a loop of suture material securing it. A safety pin will prevent it slipping inside the wound, but will not prevent it slipping out.
If there is severe sepsis, as in a septic Caesarean section or a typhoid perforation, make an adequate muscle cutting incision[md]large enough to take three fingers side by side. Using a scalpel, cut all layers of the abdominal wall in the line of the incision. Control bleeding with a gauze pack. If any bleeding vessels remain after 5 minutes, tie them. Even when the corrugated drain is in place you should still be able to get two fingers into the wound.
TUBE DRAINS are useful in large wounds where you expect much exudate, or in areas of infection or oozing (D). They are especially useful in the abdomen (E). Have two or three sizes of drainage tubes ready sterilized with suitable adaptors. Use silicone rubber or polyethylene, rather than red or latex rubber, which is more irritant.
TO INTRODUCE AN ABDOMINAL TUBE DRAIN try to fit a wide bore tube tightly in a small hole. Make a small incision in the skin. Use a 10 mm (30 Ch) tube, and cut side holes in the end. Make a small hole in the tissues and railroad' the drain in as in G, to J, Fig. 4-12. Anchor the drain to the skin with a suture. Insert a skin stitch, tie a second reef knot distal to the first one and then tie the ends of the suture round the drain with a surgeon's knot (L). Finally, tape the drain to the skin. Connect it to a sterile bottle.
CAUTION ! (1) Don't put any drain through the main incision. If it is a tube drain you will not be able to make a good seal round it, and it will make an incisional hernia more likely. (2) A tube drain which blocks is useless.
SUCTION DRAINS are ideal, especially the disposable plastic kind. More practical are the reusable Redivac' suction bottle type, which have disposable drainage tubes.
SUMP DRAINS (see above) are useful if you have a suction pump and you want to drain fluid, such as urine, or pancreatic juice which is welling up from the depths of a wound.
THE TIME TO REMOVE A DRAIN varies with the fluid to be drained. Here are some guidelines:
Draining blood[md]48 to 72 hours.
Draining down to a suture line[md]5 to 7 days.
Draining a septic cavity[md]until pus ceases to flow, usually in 5 to 7 days.
Don't leave a drain in longer than is necessary, because you run the risk that it may erode a vessel. There is seldom any need to leave a drain more than a week at the most, except in a very large deep abscess, as in the subphrenic space, where you may need to leave one in for 10 days. If you remove a drain too early, pus may build up and seek to discharge itself elsewhere.
If a drain is long, shorten it progressively over several days before you remove it. Shorten it by pulling it out, not by cutting it off. Place a safety pin through it and tape this to the patient's skin.
Miscellaneous equipment and materials
Some of the humblest equipment is also the most necessary. Here are many of the things which you should not be without.
TUBE, rectal, rubber, (a) child's size 8 mm (24 Ch), five only; (b) adult's size 10 mm (30 Ch), five only. You can also connect these to a large bore funnel and use them to give an enema. Introduce them carefully: you can easily perforate the sigmoid colon.
CONNECTOR, end-to-end, polypropylene, external diameter (a) 4 mm, (b) 7 mm, (c) 10 mm, (d) 15 mm, (e) 19 mm, ten only of each size. Use these to join short lengths of tubing together for suction or drainage etc.
CONNECTORS, plastic 3 way Y', assorted sizes, 20 only.
CLIP, towel, cross action, 90 mm, 28 only. These are the simplest towel clips.
CLIP, towel, with ratchet, Backhaus, six only. These are more expensive than the towel clips listed above, but they have several other uses, including holding the sucker tube, and the ribs in chest injuries (65.6).
FORCEPS, sponge holding, Rampley, straight, (a) 240 mm, box joint, 22 only. (b) 120 mm, two only. Use these for swabbing, and for swab dissection'.
LOUPE, binocular, Bishop Harman, [mu]2 magnification, one only. Perch its two lenses on the very tip of your nose, or wear it over your spectacles. Curl its ear pieces, so that it fits your face. This is a twentieth the price of a binocular loupe, and is invaluable for fine operations like repairing nerves (55.9), or arteries (55.6), or cut-downs' (A 15.2), or removing splinters. The disadvantage of a loupe is that it focuses close to your nose, so use short-handled instruments.
TROCAR AND CANNULA, straight, with nickel silver or stainless steel cannula and metal handle, (a) 4 mm (12 Ch). (b) 8 mm (24 Ch). (c) 12 mm (36 Ch), one only of each size. The small size is useful for tapping hydroceles, the middle one for suprapubic cystotomy, and the largest one for chest drainage.
CANNULA WITH SIDE ARM, one only. Attach suction to the side arm and use it to aspirate the gall bladder etc. (13-1).
PROBE, malleable, with eye, nickel silver, 150 mm, 3 sizes, one only of each size. Use this to probe perianal fistulae etc.
DIRECTOR, hernia, Key's, one only. Use this for opening the neck of a hernial sac.
DIRECTOR, probe-ended, Brodie, 165 mm, one only. Use this for exploring sinuses.
d RING CUTTER, one only. If you don't have this, you may be able to remove a ring with soap and string (75-5).
NEEDLE, aneurysm, Dupuytren, (a) one needle curving right, (b) one needle curving left, one only of each kind. These are curved needles on the end of a handle. Use them for passing a ligature under something (3-4).
NEEDLE, aneurysm, small, with blunt point, three only. Keep these in your cut down sets' (A 15.2,) and use them to pass ligatures under a vein.
CATHETER, metal female, three only.
BRUSH, for cleaning instrument jaws, ten only. The jaws and joints of surgical instruments need brushing regularly. You can also use suede brushes with bronze bristles.
RAZOR, safety, for preoperative preparation, ten only. Shaving a patient preoperatively is not the essential ritual that it was once assumed to be (9.1). You can also adapt a safety razor for skin grafting (57.7).
BUCKET, stainless steel, with handles, six only.
KIDNEY DISH, stainless steel, with half curled edges, 4 sizes 100 to 300 mm, two dishes of each size only.
GALLIPOT, stainless steel or autoclavable plastic, set of six sizes 40 to 200 mm, two sets only. Use these for lotions, swabs etc.
JAR, stainless steel with dropover lid, 150[mu]150 mm, two only. Use these for spirit swabs.
JUG, plastic, autoclavable, conical, 3 litre, one only. Stainless steel jugs have become standard, but plastic ones are satisfactory.
BIN, soiled, two only.
JELLY, hydroxymethylcellulose, sterile, KY jelly' 1 kg only. This is a sterile non-greasy jelly for catheters etc.
BIPP', bismuth iodoform and paraffin paste BPC, 1 kg only. This is a mildly antiseptic self-sterilizing anaesthetic packing material. You can leave it in the nose for a week without significant infection, or much smell (25.6). If you don't have any, smear gauze or bandage with any non-adherent antiseptic ointment.
CARPENTER'S EQUIPMENT (a) Saw, one only. (b) Twist drill, one only. (c) Hammer, claw head, one only. If you cannot get the surgical equivalent of these, you will find them very useful.
OTHER MATERIALS include gauze, cotton wool, bandages, adhesive tape, and laparotomy pads (1.12).
Instrument sets
For most operations you will need about 50 general purpose instruments called the general set', with a few special ones when necessary. You can handle additions to the general set in three ways: (1) You can keep special instruments in the cupboard, and sterilize them when needed. (2) You can make them up into incomplete special sets, such as a burr hole set or an orthopaedic set, which you use with the general set when necessary. (3) If you have enough instruments, particularly haemostats, you can make complete special sets. This is the best method, and the one which we follow here, but it requires many more instruments.
You can do an occasional emergency operation with only one general set, but when you have a list of patients to operate on, you will need several general sets[md]if you are not to wait too long between operations. Boiling a set takes at least 15 minutes, and autoclaving one at least half an hour. A set costs between $750 and $1000, about a third of which is the cost of the haemostats.
If instruments are limited, start by collecting a general set adapted for Caesarean section and laparotomy, and also the more important special instruments. Once you have all these, try to complete a tracheostomy set, and a chest drainage set, three cut down sets, and a second laparotomy set. When you have these your next objective should probably be a minor set for such operations as wound repairs and circumcisions. If you do many uterine evacuations. two or more sets for these would be useful.
A Caesarean section is only a particular kind of laparotomy. A set for it differs from a laparotomy set mainly in that it includes four Green[nd]Armytage forceps, and that Doyen's retractor, which is specially designed for pelvic operations, replaces Balfour's.
The sets below mostly start with six towel clips and a towel holder, which you can also use to hold the sucker tube. Next come four Rampley's sponge-holders, the first two of which are used for preparing the patient's skin, after which they are discarded. The remaining two are for swabs on sticks', and for swab dissection. Then come toothed and plain dissecting forceps, two scalpel handles, and a heavy and a light needle-holder. There are also four pairs of Allis' tissue forceps, and various retractors, depending on the set. The expensive items, because of the large number you need, are the haemostats, straight, curved, big, and small, clipped together in groups of six on Mayo's pins. The more experienced you are, the fewer of these you will need. We list six of each, which is a generous number for a beginner. Finally, there is the Yankauer sucker and its tube; this is an angled suction tube with a handle.
Keep an inventory of equipment and a check list for each set. Nice instruments tend to disappear. One aid to keeping instruments together is to provide them in pairs, or in even- numbered quantities where possible. For example, the nurses will find it useful to remember that haemostats and towel clips should always be in sixes.
The theatre is the best place in the hospital for sterilizing equipment. So try to develop a simple central sterile supply' service which can prepare sets for the wards.
INSTRUMENT SETS You will want the following sets, some of which are described elsewhere[md]a D and C' set (two if possible), a general purpose set (preferably two sets), a Caesar set, a cut down set (preferably two sets or more), an abscess set, a minor set (for hernias, etc.), an orthopaedic set (for drilling for osteomyelitis, etc.), an intestinal clamp set (for resecting gut), a fine instrument set (for hand surgery), an eye set (24.1), a burr hole set (63.1), a chest drain set (65.2), and a tracheostomy set (52.2). The equipment we have listed in all the various sections of these manuals is summarized in Appendix A and should be enough to make up the following sets.
SHARP EQUIPMENT needs to be kept separately, because it gets blunt if it is autoclaved too often. Keep scissors in dishes of antiseptic fluid (2.5). Keep osteotomes and gouges in a cupboard and put them in sterilizing fluid 30 minutes before you use them. Autoclave the bone saw when you want it. Keep the bone drill and the twist drills to go with it in a special sterile pack.
CAUTION ! Re-autoclave the packs and drums regularly. A pack which has not been resterilized for some time is a risk, especially if it is only covered in towels. You may find termites inside it!
THE CONTENTS [s7]OF PARTICULAR INSTRUMENT SETS THE GENERAL SET (including the instruments for laparotomy $800). Six towel clips. One Backhaus towel forceps. Four Rampley's sponge-holders. One toothed dissecting forceps (Treves). One plain dissecting forceps (Bonney's). One No. 4 and one No. 5 scalpel handle. Two needle-holders, a heavy and a light. Two Allis' tissue forceps. Two Lane's tissue forceps. Six 200 mm curved haemostats (Spencer Wells). Six 200 mm curved haemostats (Spencer Wells). Six 120 or 140 mm straight haemostats (Halstead's or Crile's). Six 120 or 140 mm curved haemostats (Halstead's or Crile's). Two Kocher's artery forceps. Two Czerny's (or Langenbeck's) retractors. Two Morris' retractors. Yankauer's sucker tube. One 20 cm receiver and two gallipots.
Desirable additions include Lahey's curved gallbladder forceps.
CAESAR SET ($950). Six towel clips. One Backhaus' towel forceps. Four Rampley's sponge holders. One 18 cm toothed dissecting forceps. One 18 cm plain dissecting forceps. Two No.4 scalpel handles. Two 180 mm needle-holders. Two Allis' tissue forceps. Six Green[nd]Armytage forceps. Twelve 150 mm straight Spencer Wells haemostats. Six 230 mm curved Spencer Wells haemostats. One Morris' retractor. One Doyen's retractor. Yankauer's sucker and tube. One 300 mm bowl (for blood clot), one 200 mm receiver and two gallipots.
Desirable additions include a tenaculum, and a self- retaining retractor.
MINOR SET ($750). Six towel clips. Two Rampley's sponge holders. Four Backhaus' towel forceps. One No. 4 scalpel handle. One No. 5 scalpel handle. One toothed dissecting forceps (Treves). One plain dissecting forceps (Bonney's). Four Allis' tissue forceps. One West's self-retaining retractor. Two Czerny's retractors (or Langenbeck's). Twelve 125 mm curved haemostats (Spencer Wells). Six 200 mm curved haemostats (Spencer Wells). One 20 cm receiver and two gallipots.
Desirable additions include a dissector and a Volkmann's spoon.
ABSCESS SET. Two Rampley's sponge-holding forceps. Four towel clips. One knife handle. One sinus forceps. One Mayo's scissors. One toothed dissecting forceps. One 150 mm receiver, two gallipots and some gauze swabs. Two towels.
D and C' SET. Four Rampley's sponge-holding forceps. One Sims' vaginal speculum. One Auvard's speculum. Two Teal's vulsellum forceps. One uterine sound. One set of Hegar's dilators. A uterine curette with one sharp and one blunt end. One 200 mm Kocher's forceps. One toothed dissecting forceps.
ORTHOPAEDIC SET. Six towel clips. Four Rampley's sponge holders. Four dissecting forceps (one heavy toothed 180 mm Lane's or Charnley's, one light Adson's 125 mm, one plain 180 mm, one McIndoe's 180 mm). Six curved 150 mm Spencer Wells haemostats. Six curved 200 mm Spencer Wells haemostats. One No. 4 and one No. 5 scalpel handle. Four 220 mm light bone levers, Lane's or Trethowen's. Four 275 mm heavy bone levers. One Faraboef's elevator. One large periosteal elevator (for the femur and humerus) and one small one. One Size C double-ended bone scoop Volkman's. One 350 g mallet. One sequestrum forceps. One 180 mm Read Jensen bone nibbler. One bone file or rasp. One 220 mm Liston's bone cutters. One 200 mm bone hook.
BURR HOLE SET. One Hudson's standard perforator 12 mm. One Hudson's set of conical burrs 13 mm and 16 mm. Hudson's brace. One West's self-retaining retractor. One 60 mm brain sucker. One 14 Ch soft rubber catheter. One 20 ml syringe for washing out with saline.
SMALL (hand) INSTRUMENT SET. Two small sponge holding forceps. One plain 150 mm McIndoe dissecting forceps. One plain 100 mm Silcock's ophthalmic dissecting forceps. One toothed Adson's 120 mm dissecting forceps. Four 165 mm Gilles skin hooks. One light 190 mm McIndoe dissecting scissors. One light 140 mm curved Aufrecht's scissors. Twelve curved Crile's mosquito haemostats. One Bard Parker No. 4 scalpel handle. Two 114 mm Derf needle holders. Two small 178 mm Meydering retractors. Two 114 mm Harlow Wood tendon hooks. One small curette. Two assistant's scissors. One fine probe.
KIRSCHNER WIRE PACK. Six wires of each size 0.75 mm, 1.0 mm, 1.5 mm. One Pulvertaft's Kirschner wire introducer. One pair of Kirschner wire cutters.
