SURGICAL INSTRUMENTATION USE , C ARE AND HANDLING

SURGICAL INSTRUMENTATION: USE, CARE AND HANDLING

1958

1958SURGICAL INSTRUMENTATION: USE, CARE AND HANDLING

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability,negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions,or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independentverification of diagnoses, medication dosages, and individualized care and treatment should be made. The material containedherein is not intended to be a substitute for the exercise of professional medical or nursing judgment.

The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN,INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDINGBUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRDPARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

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Reprinted with permission from The Association of periOperative Registered Nurses, Inc.

Copyright 2012 “Surgical Instrumentation: Use, Care, and Handling.”

All rights reserved by AORN, Inc.2170 South Parker Road, Suite 400,

Denver, CO 80231-5711(800) 755-2676 www.aorn.org

Video produced by Cine-Med, Inc.127 Main Street North, Woodbury, CT 06798

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Surgical Instrumentation: Use, Care and HandlingTABLE OF CONTENTS


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PURPOSE/GOAL/OBJECTIVES.....................................................................................................4INTRODUCTION.............................................................................................................................5MANUFACTURING PROCESSES .................................................................................................5

Stainless Steel ..........................................................................................................................5Titanium...................................................................................................................................5Vitallium ..................................................................................................................................5Other Metals ............................................................................................................................5Instrument names.....................................................................................................................6

TYPES OF SURGICAL INSTRUMENTS.......................................................................................6Cutting and Dissecting Instruments.........................................................................................6Powered Cutting Instruments ..................................................................................................8Clamping and occluding instruments ......................................................................................8Grasping and Holding Instruments........................................................................................10Exposing and Retracting Instruments....................................................................................10Suturing and stapling instruments..........................................................................................11Accessory Instruments...........................................................................................................12

ENDOSCOPIC (MINIMALLY INVASIVE) INSTRUMENTS .....................................................13INSTRUMENT CARE AND HANDLING ON THE STERILE FIELD .......................................14INSTRUMENT CARE AFTER PROCEDURE..............................................................................15

Decontamination....................................................................................................................15Cleaning.................................................................................................................................15Inspecting...............................................................................................................................16Endoscope Cleaning ..............................................................................................................16Laparoscopic Instruments......................................................................................................16Powered Surgical Instruments ...............................................................................................18

SPECIAL PRECAUTIONS ............................................................................................................19Ophthalmic Instruments ............................................................................................................Prion Diseases............................................................................................................................

PERSONAL PROTECTIVE EQUIPMENT (PPE).........................................................................19SUMMARY.....................................................................................................................................19REFERENCES ...............................................................................................................................20POST-TEST ....................................................................................................................................21POST-TEST ANSWERS.................................................................................................................24

PURPOSE/GOALThe purpose of this study guide and accompanying video is to provide information to perioperative staff members on the use,care and handling of all surgical instruments including minimally invasive, powered and endoscopic instruments.

OBJECTIVESAfter viewing the video and completing the study guide, the participant will be able to:

1) State the principles of instrument care.2) Describe the four major categories of surgical instruments.3) Name the basic components of powered instruments.4) Discuss special considerations for endoscopic instruments.5) Discuss intraoperative instrument handling including proper passing techniques.6) Describe the proper cleaning required for each category of instrument.


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INTRODUCTIONSurgical instruments arehigh quality tools that aredesigned for accomplishinga specific desired effectduring invasive procedures.Instruments are integralcomponents of all surgicalprocedures. Perioperative staff members must understand theuse, handling, and care of surgical instruments. Propercleaning and handling minimizes damage, increasesinstrument life expectancy, and protects instruments, whichare a major financial investment for facilities. Carefulplanning, preparation, and use of instruments will contributeto an efficient and effective surgical procedure within a safeenvironment.

Surgical instruments perform basic functions such as holdingor retracting tissue; dissecting, cutting, or incising tissue; andassisting with suturing and or closure of the surgical incision.Most surgical instruments are made of stainless steel or othermetals. The metal selected must be easily cleaned, disinfected,and maintained.

Surgical procedures are becoming more complicated andintricate and as a result surgical instruments are becomingmore complex, more precise in design, and more delicate instructure. With the development of new tools, instrument careand handling becomes more challenging. There are currentlyhundreds of different types of surgical instruments and moreare being developed everyday as surgical procedures changeand evolve.

MANUFACTURING PROCESSES

Surgical instruments are the surgeon’s tools. Each one isdesigned and carefully crafted for an intended surgicalpurpose. They must be durable and not prone to rusting,chipping, or denting with normal handling, which is why mostare made with stainless steel, a combination of carbon,chromium, iron, and a few other alloys (i.e., metals). Withadvances in modern technology, other materials such astitanium and vitallium, and other polymers are also used, butstainless steel continues to account for the majority of

instruments produced. It is important for perioperative staffmembers to know what each instrument is made of. The metalalloys used in surgical instruments must be resistant tocorrosion, which can result from exposure to blood, bodyfluids, cleaning solutions, sterilization, and the atmosphere.

Stainless SteelInstruments made of stainless steel begin the manufacturingprocess with the conversion of raw steel into instrumentblanks. There are more than 80 different types of stainless steeland these are graded based on quality and composition. Themost common grades used for surgical instruments are the 300and 400 series grades and of those, the 400 series is morecommonly used. Instruments such as retractors and speculumsare generally manufactured from the 300 series, while cuttingand non-cutting instruments are made from the 400 series.

TitaniumTitanium has excellent metallurgical properties for use inmicrosurgical instruments. The most notable and usefulproperties of titanium are that it is nonmagnetic and inert. Itis harder, stronger, lighter in weight, and more resistant tocorrosion than stainless steel.1

VitalliumVitallium, the trade name for a cobalt/chromium/molybdenumalloy, is suitable for orthopedic devices and maxillofacialimplants because of its strength and corrosion-resistantproperties. Vitallium instruments must be used with vitalliumimplants to maintain electrolytic compatibility.1

Other MetalsWhile most instruments are made of steel alloys, some aremade from brass, silver, or aluminum. Some cutting blades,tips, and jaws are laminated with tungsten carbide, which isan exceptionally hardened metal.1

The cutting or drilling of instrument blanks is accomplishedby different methods, one of which is the precision blastingof the instrument blank sheath with garnet sand while it issubmerged in a bath of bubbling coolant. The cut needed isprogrammed into a computer that directs the cutting arm ofthe machine. The measurements are precise, sometimes withina fraction of an inch, to make sure the component parts fit andmeet in the exact manner needed. The machines designed toproduce surgical instruments meticulously follow thecomputerized engineering designs and warn the operator iferrors occur during drilling and cutting. When this process iscomplete, the raw steel material has become an instrumentthat is designed to do a particular job and function in aparticular manner.


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The next step in the manufacturing process is providingcorrosion resistance. This is accomplished by the removal ofcarbon steel particles through immersion of the instrument intodiluted nitric acid. The final step is to polish the instrument.

Manufacturers of surgical instruments add one of threefinishes during fabrication: satin (i.e., dull), highly polished,and ebonized.

• A highly-polished finish, increases resistance tocorrosion, but can affect the ability of the surgeon tosee because of light reflection.

• A satin finish is less reflective and reduces glare. • An ebonized finish is black chromium, is

nonreflective, and virtually eliminates glare. For most procedures, either satin or highly-polishedinstruments will be used. Ebonized instruments are typicallyused in laser procedures to prevent laser beam reflection offthe instrument.

Instrument NamesSurgical nomenclature lacks standardization, but willgenerally follow certain patterns. For example, instrumentsmay be named:

• by the action that the instrument is designed toperform (e.g., scissors, knife),

• to recognize the inventor (e.g., Debakey forceps), or • a combination of how the instrument is to perform in

a particular type of surgery and an inventor’s name(e.g., a Lambotte osteotome, a tool that is designed tocut bone, invented by Lambotte).

Names of instruments also vary by the region of the countryin which they are used, the surgeon’s preference for a name,and the facility’s commonly used name.

Because instruments represent a major financial investmentfor a facility, proper care and handling should be a primaryconcern for all personnel who work with instruments. Afterinstruments are received from the supplier, they should becarefully examined, cleaned, decontaminated, and sterilizedaccording to the manufacturer’s instructions before use in thesterile field.

TYPES OF SURGICAL INSTRUMENTSMany different kinds of surgical instruments and tools havebeen invented over the years. Instruments may be designedfor general surgical use or for use during a specific procedure.

Generally, there is a natural progression of instrument useduring a surgical procedure. Paying close attention to what is

happening on the surgical field and knowing this progressionwill help the scrub person to anticipate which instrument willbe needed.

• An incision is made using a cutting instrument, suchas a knife or scissors. Clamps or forceps may be usedto control superficial bleeding at this point.Electrosurgical energy delivered through an activeelectrode may be used to create hemostasis or toextend the excision.

• Cutting of internal tissue layers is accomplished withscissors.

• Exposure of the surgical field is made possible byretractors.

• Suction evacuation is used to eliminate the surgicalsmoke plume created by the electrosurgical unit andto suction fluid or blood from the surgical field.

It is easy to see that surgical instruments can be classified intofour main categories:

• cutting and dissecting,• clamping, • grasping or holding, and • exposing and retracting.

A fifth category exists for other accessory instruments that donot easily fit into these main classifications. These will bediscussed later in this study guide.

Cutting and Dissecting InstrumentsBasic cutting and dissectinginstruments, sometimesreferred to as “sharps,” doexactly what their nameimplies; they cut anddissect tissue or othermaterials. The useable partof the instrument has asharp or cutting edge. Cutting instruments include knives,scalpels, and scissors of all types and shapes.

Knives and scalpelsThe words knife and scalpel are used interchangeably, butgenerally, a scalpel has a detachable, disposable blade andnondisposable handle, while the term knife refers to single-unit cutting device such as an amputation knife. The handlesize and configuration of scalpel handles varies toaccommodate the area of use. Knife blades may have curvededges or sharp, stabbing points. When using a knife, care mustbe taken to avoid injury to self or others.


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Passing Knives and Scalpels

When required to pass a sharp item to the surgeon, AORN’sGuidance Statement: Sharps Injury Prevention in thePerioperative Setting calls for the use of a “neutral or hands-free technique whenever possible or practical instead ofpassing hand to hand.”2A neutral zone is a designated area onthe sterile field where the scrub person and the surgeon placeall sharp instruments (including needles). If it is absolutelynecessary to pass a knife hand-to-hand, it should be heldcarefully between thumb and fingers and presented handlefirst to the surgeon with the cutting edge of the blade pointingdown and away from both of you.

Caution must be taken when loading or removing blades froma knife handle. Typically, an instrument such as a needleholder or clamp is used to hold the blade during removal.Many health care facilities provide disposable scalpels for useas a way to reduce the risk of injury and exposure to blood-borne pathogens.

ScissorsScissors are designed inshort, medium, long, andheavy lengths and may beblunt or sharp with straightor curved tips on theircutting edges. Scissorsconsist of a pair of metal blades connected in such a way thatthe edges of the blades cut materials placed between themwhen the handles are brought together. A conventionalscissors requires one movement to open the jaws and anotherto close them. Some scissors, particularly those used indelicate plastic and eye surgery, have a spring that holds thejaws open. Squeezing the handle together closes the bladesand relaxing of the grip opens them.

When preparing for asurgical procedure, it isimportant to check thealignment of the scissorsblades. For scissors to cutsmoothly, the blades must

meet at the swivel (i.e., the point where the rivet or screwconnects the blades) and the cutting point.

The blades of the scissors also must be sharp. Cutting anythingother than what the scissors were designed to cut (i.e., usingtissue scissors to cut suture) will dull the blades and result intheir misalignment. Routinely check to ensure that the bladesare sharp and that the screw joining them together has notloosened. This can be accomplished by holding the scissorshorizontally by one ring handle. If the blades open freely, thescissors need to be tightened. The two basic types of scissorsare: tissue and suture scissors.

Tissue ScissorsTissue scissors are used for tissue dissection. Most tissuescissors have curved tapered points. Metzenbaum scissors areused to cut medium to delicate tissue while the sturdier Mayoscissors are used to cutheavy or thicker tissue orstructures such as fascia. AMetzenbaum scissors canbe distinguished from theMayo scissors by its narrowshaft and tips.

The curvature on the Metzenbaum and other tissue scissors isdesirable to surgeons because it facilitates the ability to seethe tips of the scissors during dissection and because they canreach around other structures. Small, fine scissors with sharptips (e.g., iris scissors, Castroviejo scissors), are used fordelicate ophthalmic or reconstructive surgery.

Suture ScissorsSuture scissors usually have straight blades and blunt points.Straight Mayo scissors are used primarily to cut suture.Angled bandage scissors can be used to cut bandages anddressings. Wire scissors should be used to cut wire and veryheavy sutures.

Passing scissors

To pass any curved instrument, including scissors, hold theinstrument at the joint and place the handle of the instrumentfirmly in the surgeon’s hand, in its position of use. The tips of


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the instrument should always be visible. Curved tips shouldpoint down. Gently snap or flip the wrist when placing theinstrument in the surgeon’s hand so the surgeon knows wherethe instrument is. This eliminates the need for the surgeon tostop and look for the instrument. Release the instrument assoon as the surgeon has a firm grip on it.

Other Cutting and Dissecting InstrumentsOther specialized cutting instruments include chisels, curettes,osteotomes, rasps, rongeurs, saws, and trephines.

• Chisels are used to sculpt bone and have one bevelededge. A mallet is used in conjunction with a chisel.

• Curettes are used to scrape soft tissue or bone. Theyare manufactured with different size cupped ends andseveral angles and lengths. Uterine curettes are usedto scrape the endometrial lining of the uterus.

• Osteotomes are bone-cutting instruments used forshaping or marking bone. They have a double, bevelededge and come in several widths and are both curvedand straight in design. They may be used to removeperiosteum from bone. A mallet is used in conjunctionwith an osteotome.

• Rasps can be used to smooth rough bone surfaces orto evacuate the medullary canal in preparation forinsertion of an orthopedic prosthesis. They may besingle- or double-ended, with curved or taperedblades. Rasps may be forward- or backward- cutting,with fine or coarse teeth.

• Rongeurs are biting instruments used for cuttingtough tissue or bone. The biting cup comes in varioussizes and angles. When the surgeon squeezes thehandles together, the two sharp, cup-like ends cometogether to bite into the tissue and remove a smallsection. Rongeurs are most commonly used on bonesor heavy ligaments. They may be double- or single-action.

• Saws include any notched blade used for cutting bone. • Trephines are used to cut bone from the skull. A

trephine has a circular, sharpened edge.

Powered Cutting InstrumentsPowered cutting instrumentsare precision devicesdesigned to make workingwith bone and cartilage easierand quicker than working byhand. They are used mostoften for precision drilling,cutting, shaping, and bevelingbone. There are many interchangeable attachments availablefor powered surgical hand pieces, and they are used in a widevariety of procedures. Some uses include:

• Drilling holes for placement of a metal plate to hold afracture together. This requires drill points, screws,and a screwdriver.

• Removing, reshaping, and reaming of bone at the kneeor hip joint for placement of a total joint prosthesis.This requires saw blades and drill bits of various sizesand shapes. Both forward and reverse speeds arenecessary for some of these activities.

The first powered surgical instruments were powered byelectricity, air, or nitrogen under pressure stored in largeportable tanks. The electrically powered instruments weredifficult to maintain because the electrical cords deterioratedrapidly due to processing. For pneumatic instruments, apressure gauge controls the flow at a specified pounds persquare inch (PSI) pressure. Alternatively, compressed gas canbe piped directly into the operating suite. In this type ofsystem, a wall unit acts as the pressure gauge and controls theflow of gas, delivering a specific PSI. Special high-powerhoses connect the gas source to the handpiece of theinstrument. Surgeons found these pneumatic hoses unwieldywhich promoted the development of battery-operated surgicalinstruments, that have now become commonplace. After use,the battery pack is recharged and is sterilized immediatelybefore the powered instrument is used.3

Clamping and Occluding InstrumentsSurgical clamps can be used to either compress or grasp astructure. They can be either occluding or nonoccluding (alsoreferred to as crushing or non-crushing). The types of clampsneeded for a particular procedure will depend on the kind oftissue to be held (i.e., delicate or tough) and the depth of thesurgical procedure (i.e., near the surface or deep). Hemostatsand occluding clamps should never be used to attach items tothe surgical drapes because this could bend their tips and strainthe box lock, making the instrument unsafe to use on tissue.

HemostatsHemostats are the mostcommon of all clampinginstruments. They are usedto grasp bleeding vesselsand prevent blood loss withminimal tissue damage.Hemostats range in sizefrom short to long and fromdelicate to heavier in design. They can be straight or curved.Examples of hemostats are the mosquito, Kelly, and Crile.

• Mosquito clamps are used to control surface bleedersand handle delicate tissue (e.g., plastic surgery handsurgery);

• Kelly clamps are used to control bleeders in muscletissue, to pass drains, and to hold Kitner or peanutsponges; and,

• Crile clamps are used to control bleeders insubcutaneous tissue.

Perhaps the most important design feature of a hemostat is thejaw portion between the box lock and the tip. Some hemostatsare very slender and tapered to a fine point; others are thicker,with more blunt tips. The inside surfaces have deep groovesor serrations, which may go from side to side or runlongitudinally in the same direction as the jaws. Theseserrations allow bleeding vessels to be compressed withsufficient force to stop bleeding. The serrations must becleanly cut and perfectly meshed to prevent the tissue fromslipping free from the ends of the clamp.

Occluding clampsOccluding clamps are usedto occlude or constricttissue and to clamp or graspbowel, ducts, and otherstructures with lumens.These instruments are usedto apply pressure. Theytypically have vertical serrations or special jaws with finelymeshed, multiple rows of longitudinally arranged teeth. Theyfunction to prevent leakage and minimize trauma to vesselsthat are to be reanastomosed. Examples of occluding clampsare Babcock, Allis, and Kocher clamps.

• Babcock clamps have curved fenestrated tips withoutteeth. They are used to grip or enclose delicatestructure such as bowel, appendix, ureters, or fallopiantubes. The smooth edges and bowed shape allowgrasping without penetrating, crushing, ortraumatizing tissue.

• Allis clamps also allow grasping and holding withoutcrushing. They have multiple, tiny, fine teeth thatcurve slightly inward. Allis clamps will hold slightlyheavier tissue than Babcock clamps because they haveserrations along their edges.

• Kocher clamps are easily identified by the transverseserrations and the large teeth at the tips. This enablesthe surgeon to grasp and tightly hold heavy, tough, orslippery tissue such as fascia, bone, and cartilage. TheKocher is also known as an Ochsner clamp.

Other types of clamps include hemostatic clips that may beloaded singly onto an applier or may come as a preloaded,disposable unit. These clips come in multiple sizes and theclip appliers are available in long and short lengths. These willbe covered in more detail under “Suturing and StaplingInstruments.”

A general rule of thumb for selecting a clamp is to use delicateclamps for delicate tissue, heavy clamps for heavier or toughertissue. This concept can also be applied to the depth of thesurgical procedure; shorter clamps for superficial areas, longerclamps when working deep within a cavity. Another conceptto note is that finer clamps should be used on smaller vesselsand heavier clamps on thicker structures.

Anatomy of a clamp

The two parts of a clamp fit together at a box lock which,when closed or clamped together, remains locked until theratchets are released.

The easily identifiable parts of a clamp are:

• The point of the tip which, when closed, should fittightly together unless it is designed to only partiallycompress tissue.

• The jaws of the instrument are either smooth or areserrated to hold tissue securely.

• The box lock is the hinge point of the instrument tipand handle.


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• The shank is the area between the box lock and thefinger rings.

• The ratchet is part of the finger ring handle andinterlocks to keep the clamp shut when the instrumentis closed.

Passing clampsRefer to the preceding section on Passing Scissors. Ensure thatthe clamp is closed and locked (if applicable). The tips andcurve of the instrument should always be visible.

GRASPING AND HOLDING INSTRUMENTSGrasping or holding instruments allow the surgeon to dissectand suture tissue without causing injury. Forceps and somevarieties of clamps are referred to as grasping instrumentsbecause of how they perform.

Forceps, or pickups as they aresometimes called, are two-bladed,tweezer-like instruments that aredesigned to pick up, grasp, andhold tissue to facilitate dissectionor suturing. There are manyvarieties of tips available onforceps. The selection of forceps depends on the intended use.

• Smooth forceps have simple serrations andsmooth, tapered points for use on delicate tissue.Examples of smooth forceps include Adsonforceps and Cushing or bayonet forceps.

• Toothed forceps may be either single-toothed orhave multiple teeth that interlock. These areused on dense structures such as tough skin,fascia or cartilage when a firm grip is needed.They will tear or puncture more delicate tissues.

• Atraumatic forceps are used to grasp fine,delicate tissue with minimal trauma. They haveeither straight or angled tips and come invarious lengths and jaw widths. Examples ofatraumatic forceps are DeBakey vascularforceps and bulldog and Cooley forceps.

When checking forceps, the perioperative nurse must ensurethat the tips meet correctly and that there are no barbs on thetips that could cause tissue damage.

Other grasping instrumentsGrasping instruments also may be designed like clamps withring handles. They may have smooth or serrated tips forgrasping tissue.

• Sponge forceps have ring-shaped jaws and are usedto hold gauze sponges which are then used forretraction, blunt dissection, or to absorb blood fromthe surgical field. Sponge forceps may be straight orcurved. Examples of these are Fletcher sponge forcepsand sponge sticks.

• Towel forceps are typically used to attach and securedraping material but also may be used to hold cartilageor scar tissue or to apply traction. They are availablein perforating and nonperforating varieties.

• Tenacula have sharp points that are used to penetrateand grasp tissue firmly. An example is a uterinetenaculum that is used to manipulate the cervix of theuterus.1 Tenacula may be single- or multitoothed.

Other grasping and holding instruments include stone forcepswhich are used to grasp calculi (e.g., kidney or gallstones).

Passing forcepsThe scrub person should grasp the top of the instrument wherethe two arms meet, and with the points down, pass it to thesurgeon allowing the surgeon access to the full length of theinstrument to adjust his or her grasp. Clamp-type forcepsshould be passed as stated above under Passing Clamps

EXPOSING AND RETRACTING INSTRUMENTSThese instruments are used for two major purposes:

• to hold open the incision to provide exposure of thesurgical site, and

• for holding back surrounding organs and tissue tofacilitate the surgeon’s ability to see during theprocedure.

Retractors come in many different sizes and shapes. Retractorsare referred to as either hand-held or self-retaining. Smallertypes can be held by the fingers or hands to retract skin andsubcutaneous tissue in shallow surgical areas while larger,heavier types may be self-retaining and are used to retractmuscle tissue and organs in deeper surgical sites.

Hand-held retractorHand-held retractors consistof a shaft with a curved,hooked, straight, or angledblade on one or both ends.They usually come in pairs.Some examples of hand-held retractors are:

• Army-Navy retractors or USA retractors are used inshallow incisions. These double-ended retractors are


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eight inches long and have a different-sized blade ateach end.

• Senn retractors – used to maintain exposure in smallareas, such as in carpal tunnel surgery. These retractorsare double-ended and have both sharp and bluntprongs.

• Malleable ribbon retractors – flat metal ribbons thatcan be shaped or bent by the surgeon into the neededshape to adequately retract tissue. They can be usedto protect soft tissue during dissection or to provideretraction of bowel and soft tissue. Many sizes andlengths are available.

• Richardson retractors – frequently used in abdominalsurgery to retract subcutaneous tissue. They come inmany sizes and can be used singly or in pairs.

• Volkmann retractors – hand-held rake retractors thatcome with two to six sharp or dull prongs. They mustbe handled very carefully to prevent injury. They areused to retract superficial tissue.

Passing hand-held retractorsRetractors should be handed to the surgeon handle first, inposition for immediate use. Place the retractor handle gently,but firmly, into the surgeon’s hand.

Self-retaining retractorsSelf-retaining retractorshave holding devices,locks, and catches whichkeep the retractor in a presetposition after it is insertedand adjusted. Some may beclamped in situ orsuspended at the end of arobotic arm or attached to the operating room bed and kept inplace by clamps. All pieces of self-retaining retractors withmultiple detachable parts should be checked and accountedfor before and after the surgical procedure4 to reduce the riskof retained surgical items. Examples of self-retainingretractors include the following.

• Jansen retractors – frequently used in biopsies, theyhave two blunt blades held apart by a ratchet witheither 3 or 4 prongs on each side.

• Weitlaner retractors – used to maintain woundexposure during procedures such as inguinal herniarepairs and are similar to a Jansen. Weitlaners mayhave sharp or blunt jaws and either an arrangement ofteeth that is 2 x 3 or 3 x 4.

• Balfour retractor – used to retract the abdominal wallduring abdominal surgery. The blade on a Balfour is aseparate piece of this retractor and is attached andadjusted on the spreader with a wing nut. The spreadercan have shallow or deep blades.

• O’Conner-O’Sullivan retractors – also used inabdominal surgery but more specifically forhysterectomies. This retractor comes in variousconfigurations with both permanently attached andadjustable blades.

• Bookwalter retractors – table mounted and mostfrequently used in hepatic and thoraco-abdominalprocedures.

SUTURING AND STAPLING INSTRUMENTS

Needle holdersNeedle holders may looksomewhat like clamps, butthey are designed specificallyto grasp and firmly holdcurved suture needles, nottissue. Although theyresemble hemostats, theyusually have shorter, stubbier jaws. The jaws may be straight,curved, or angled. Most have many small serrations on theinsides of the jaws that hold the needle in place duringsuturing.

Standard needle holders have a longitudinal groove or pit inthe jaw that releases tension, prevents flattening of the needle,and holds the needle firmly. “Diamond jaw” needle holdershave tungsten carbide inserts that are designed to prevent theneedle from rotating or slipping while passing through tissue.Some needle holders have crosshatched serrations that preventdamage to the needle and some are smooth. The smooth-jawed needle holders are used for small needles (e.g., plastic,eye surgery).

Needle holders may have a ratchet similar to that of ahemostat, or they may use a locking or non-locking springaction. Needle holders come in many shapes and sizes to fitdifferent needles as well as the procedures to be performed.Examples include the following:

• Mayo-Hegar needle holders – long and narrow, usedto hold medium to heavy-gauge needles to applyheavy sutures in deep abdominal areas, such as duringcardiothoracic surgery. They are also widely used ingeneral surgery.


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• Collier needle holders – hold medium-gauge needles.• Brown needle holders – hold small-gauge needles to

apply sutures in superficial tissue (e.g., for plasticsurgery).

Because needle holders must grasp metal rather than softtissues, they are subject to greater damage than otherinstruments. As a result, they must be carefully inspected andrepaired and replaced as needed. They are designed towithstand some amount of tension, but are not intended to beused as pliers. Always select a needle holder that matches thesize needle being used and the depth of the surgical incision.

To load a needle on the needle holder, place the jaws near thesuture end of the needle, allowing about two-thirds of the pointof the needle free for passing through the structures to besewn. Load the needle so that the tip of the needle will pointto the surgeon’s thumb when the needle holder is passed.When the surgeon receives it, the needle should be in positionand, ready to be passed directly into the tissue. If the surgeonis left-handed, load the needle in the needle holder in theopposite direction.

Needles should only be passedhand-to-hand to the surgeonwhen absolutely necessary.AORN’s Guidance Statement:Sharps Injury Prevention in thePerioperative Setting calls forthe use of a “neutral or hands-

free technique whenever possible or practical instead ofpassing hand-to-hand.”2

If it is necessary to pass the needle holder to the surgeon, takecare to prevent the suture from getting tangled or bunching upin the surgeon’s hand. Pass the loaded needle holder into thesurgeon’s hand as you would pass any clamp, payingparticular attention to the direction of the needle.

Staplers and hemostatic clip appliersSurgical stapling instruments are often used to suture tissuequickly. As surgeons have gained experience in the use ofstapling devices, many different types have been developedto suture and resect tissue. They can come as a single-usedevice or a stainless steel instrument with disposable staplecartridges.

Staplers are widely used in a variety of procedures that requireligation and division, anastomosis, resection, and skin andfascia closure. Skin staples have become one of the mostfrequently chosen methods of skin closure.

These tiny surgical staples are made of stainless steel or an

absorbable, non-metallic materialthat minimizes tissue reactionand infection. They may bepreloaded on the stapling device.Staples are packaged in variousassortments of numbers andtypes of staples, depending on thelength of the incision, and the type of tissue to be stapled.Nonreactive metal staples will remain permanently in thetissue. If staples must be removed, as with skin staples, anextractor is required.

Staplers are easy to use. Most employ a similar anvil typemechanism for forming the staple, but they vary in terms ofweight, handling characteristics, ease of application, and viewof the site during application. They may fire individually orlay down multiple rows in a straight or circular pattern.Devices to cut or anastomose bowel and other structures areavailable for open wound use or through endoscopic cannula.

Hemostatic clip appliers are small V-shaped staples that areused to occlude a vessel. These staples are usually placed oneat a time with the use of a stainless steel instrument. Thestaples are hand loaded and passed to the surgeon who placesthem around the vessel and then closes the applier to close thestaple.

Accessory InstrumentsIn addition, there are accessory instruments that do not fit intoany of these categories by nature of their function. Theseinclude items such as suction tips, towel clips, probes, trocars,and ring forceps.

Suction tips are used to remove blood and/or body fluids asthey accumulate to provide better ability to see the surgicalsite. Suction tips are available in different sizes and designsand may be provided as nondisposable or disposable. Ifnondisposable suction tips are used it is very important thatthe lumens are cleared with a stylet and flushed whenprocessing. If the suction tip has multiple parts, the parts must


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be disassembled and sterilized separately and then re-assembled on the sterile field. The diameter of the suctionshaft determines the size. Narrow diameter suction tips areindicated for use in small delicate areas. Examples of suctiontips are Yankauer, Andrews, and Frazier.

Ruler, probes, and grooves are used to measure and to dilateand probe vessel lumens.

Towel clipswith sharp points are sometimes used with sterilecloth towels during the draping process. Once towel clips havebeen placed, they cannot be repositioned. Nonperforatingtowel clips are available that can be used to secure drapes andtubing.

Mallets are hammer-like instruments used for striking objectslike chisels or osteotomes.

Speculums are used to hold open and provide access to anorifice (e.g., vagina, eye, nose).

ENDOSCOPIC (MINIMALLY INVASIVE)INSTRUMENTSWith the development andincrease in endoscopic andminimally invasive surgicalprocedures, laparoscopic andother minimally invasiveinstruments have beendeveloped and are usedroutinely. Their functionswithin a sealed peritoneal cavity are similar to traditionalsurgical instruments, but their care can be much different.Perioperative nurses need to be familiar with the specificcleaning, disinfection, decontamination, and sterilizationmethods used for these types of instruments. Endoscopes areinserted into a body orifice or through a small incision to allowsurgeons to examine and operate in the interior body cavities,hollow organs, or other structures.

All of the instruments used in endoscopic procedures mustfunction through the narrow lumens of scopes and cannulathat are often only 5 mm to 10 mm in diameter. Endoscopicinstruments typically have long shafts, with handles at theproximal end to control the working tip at the distal end.Endoscopic graspers have a locking mechanism to hold thetips firmly in place. Many of these instruments are single-usedevices, but others are reusable and need specific cleaningprotocols.

Endoscopic Electrosurgical InstrumentsEndoscopic electrosurgical instruments require special careand attention. These instruments provide cutting and

coagulating capabilities. Endoscopic spatulas and hooks areroutinely used with monopolar current, but virtually any typeof dissector, blunt grasper, or scissors can be manufacturedwith this option. The shafts of such instruments are insulatedto avoid injury. This insulation must be carefully checkedduring processing and immediately before use to avoid patientinjuries.

As with standard surgical instruments, it is important to befamiliar with the anatomy of these specialized instruments.The identifiable parts are the:

• handle (can come in several different configurations,controls the movement of the instrument),

• locking mechanism (allows the instrument to besecured in position),

• shaft (allows movement and rotation within theendoscopic surgical field), and

• tip (consists of the working end of the instrument andmay include a grasper, scissors, retractor, orelectrosurgical devices).

EndoscopesEndoscopes may be rigid,semirigid, or flexible. Their lensesmay allow various viewing angles.Diagnostic endoscopes are designedfor observation only and have nooperating channels. Operativeendoscopes have a second channelfor irrigation, suction, and insertion and connection of otherinstrumentation. They come in various diameters and lengths,depending on patient and procedural requirements.Endoscopic forceps and grasping instruments enable thesurgeon to manipulate tissues.

Trocars and cannulasWhen no natural orifice exists for insertion of a diagnostic oroperative endoscope, such openings can be created using atrocar and cannula. The cannula is inserted into the operativesite using a sharp trocar as an obturator or by making a smallsurgical incision and inserting the cannula with a blunt-tippedobturator. Once the port of entry has been made, the trocar or


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obturator is removed and the hollow tube cannula is left inplace.

Trocars and cannula may bedisposable or reusable and comein several sizes. Those used forarthroscopy, for example, aremuch smaller than those used inthe chest or abdomen. More than

one size of trocar/cannula system may be required for a givenprocedure. If more than one size instrument will be insertedthrough a given cannula.

INSTRUMENT CARE AND HANDLING ON THESTERILE FIELDEach surgical procedure requires a specific set of instruments.Instrument sets may start with a basic or standard set ofsurgical instruments. Then special instruments are added thatmeet the specialized needs of each procedure.

When setting up the sterile backtable, the scrub person shouldhandle each instrumentseparately to prevent them frominterlocking which can causedamage. The scrub personshould also check eachinstrument for functionalreadiness. Instruments should be laid side by side, avoidingpiling them one on top of another. This prevents denting andnicking. Instruments such as scissors and forceps should bechecked for proper alignment of the tips and working order.Any damaged or defective instruments should be handed offthe sterile field and marked for repair or replacement. Ring-handled instruments should be kept together with the boxlocks closed on the first ratchet. The scrub person should point

the curvatures and angles ofclamps and scissors in the samedirection. Retractors and otherheavy instruments should belaid out flat on the table. Sharpblades, edges, and tips shouldbe protected from touchingother metal surfaces.

It is important that the scrub person know the name and useof each instrument as well as how to handle them. Duringsurgery, the scrub person is responsible for passing the correctinstrument needed, handling instruments individually, keepinginstruments debris-free and clean, flushing suction tips andtubing, and cleaning each instrument after use. To pass the

appropriate instrument, the scrub person must understandwhat is taking place at the surgical site.

Sharp instruments should beplaced in a neutral zone fromwhich the surgeon can pick upthe instrument. Keepinstruments free of gross soil bywiping them with a moistsponge and sterile distilledwater. Instruments no longerneeded for a procedure may becleaned and immersed in abasin of sterile, demineralized,distilled water. Flush anycannulated instruments withsterile water. Also flush suctiontips and tubing with sterilewater.5

For a minimally invasive procedure, the same principles apply.The instrumentation may include a basic open setup as wellas the required endoscopic instruments for the procedure. Thevariety and configuration of the instrument setup will includethe appropriate trocars and specialized instruments needed forthe type of procedure being performed. Additional requiredvideo equipment should be available in the procedure room.

Attachments for powered surgical instruments should beproperly affixed to the units and tested before use. The scrub

person should place triggerhandles in the safety positionwhen changing attachments orpassing to the surgeon. If airpowered equipment is going tobe used, the manufacturer’swritten instructions should befollowed for proper pressuresettings.

Never rest powered surgicalinstruments on the patient. If theinstrument is too large orcumbersome to be placed on theback table when not in use,


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prepare a separate sterile table or Mayo stand to hold it. Thispractice prevents serious injury to the patient from the weightof the instrument or from accidental activation. It also preventsthe instrument from falling off the sterile field and avoidsaccidental contamination from saws and blades tearingthrough draping materials.

INSTRUMENT CARE AFTER PROCEDUREAfter surgery, all instruments (used and unused) areconsidered contaminated. To ensure that no instruments areinadvertently discarded with the draping materials, instrumentcounts must be finished and the sterile field must be checkedbefore removing drapes. Refer to AORN’s RecommendedPractices for Prevention of Retained Surgical Items forcomplete information about surgical counts.4

Guidelines for instrument careand cleaning are essential andare based on manufacturer’srecommendations. When new,the instruments arrive packagedwith written guidelines,booklets, and/or audiovisualssupplied by the manufacturer.These guidelines, when followed, direct perioperative andsterile processing staff members on safe and effective methodsof cleaning, disinfecting, and sterilization and should alwaysbe followed. The proper care and handling of valuable surgicalinstruments will improve their longevity and function.Cleaning protocols should be established and followed. Theperioperative nurse should ensure that instruments are cleaned,sterilized, handled, and used properly.

The process for the care and cleaning of instruments includesseveral steps: decontamination, cleaning, inspecting,lubricating and testing, packaging, and sterilizing.

DecontaminationThe first step is decontamination. Decontamination rendersinstruments safe to handle. The decontamination and cleaningsteps are often combined.

The decontamination processmay begin in the procedureroom with prerinsing andpresoaking. Presoakingprevents blood and debrisfrom drying on theinstrument. Instruments areorganized, contained, and

transported to the central processing area using closed casecarts. The Occupational Safety and Health Administration

requires that items placed on top of a transport cart must becontained (e.g., in a plastic bag). Blades and drill bits shouldbe removed from powered equipment by the scrub person inthe procedure room before sending to the decontaminationarea. Power equipment should not be immersed or placedunder running water unless indicated in the manufacturer’swritten instructions.

Decontamination and cleaning may be done manually orautomatically using detergent, water, and friction. Themanufacturer’s instructions should be followed for mixing ofdetergents as this can affect proper rinsing.

CleaningSeparate from other instruments those instruments that aredelicate, small, or have sharp or semi sharp edges and processthem according to the manufacturer’s directions. Powered andendoscopic instruments also should be handled separately.Instruments with removable parts should be disassembled toexpose all surfaces. Reusable endoscopic or laparoscopicinstruments need to be specially prepared before terminalsterilization and use. Hinged instruments should be opened toexpose box locks and serrations. Instruments of dissimilarmetals should be separated to prevent the electrolyticdeposition of metals.

As noted earlier, many surgical instruments are made ofstainless steel. It should be noted that stainless steel is bynature, stainless, but it is not stain-proof. This is an importantconsideration when subjecting stainless steel instruments tochemicals and detergents.

Instrument washing takes placein the decontamination area ofcentral processing. Proper attireand personal protectiveequipment must be worn by staffmembers in this area. Thepurpose of cleaning is to removeresidual blood and debris before

terminal sterilization. Some instruments require precleaningby hand to remove gross debris before going into the washer,sterilizer, or decontaminator. Other instruments (e.g., delicateor complex ones) requiring disassembly, may need to becleaned and dried by hand.

When washing by hand, keep the instrument submerged toprevent microorganisms from splashing and aerosolizing.Instruments with multiple parts should be disassembled andbox locks opened. Use a clean, warm water solution that isnoncorrosive and low-sudsing, and a prerinsing liquiddetergent. Thoroughly rinse the instruments in deionized water.


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An automated unit also can be used to mechanically clean anddecontaminate instruments. These systems clean with cyclesthat include a cold water prerinse to dissolve blood andprotein, a detergent wash, a rinse, and a final cycle of steamand heat. Instruments should be arranged in perforated trays,placing heavy instruments in separate trays. If heavy andlightweight instruments are combined in one tray, place theheavier ones on the bottom and the smaller, lightweight oneson top. Turn instruments with concave surfaces, such ascurettes, so that the bowl side is down to promote drainage.Open box locks and pivots of hinged instruments to exposethe maximum surface area. Separate instruments of dissimilarmetals to prevent electrolysis, which can cause etching. Donot mix stainless steel instruments with other metals. Placesharp instruments in their own tray. Arrange instrumentsneatly, and do not randomly pile them on top of one another.Avoid placing delicate instruments into the washer becausemechanical agitation may damage them.

Another type of automated method is the ultrasonic cleaner.Ultrasonic energy uses high frequency sound waves tothoroughly clean instruments by a process called cavitation.It removes the tiniest particles of debris from serrations, boxlocks, and crevices of instruments that may be impossible toclean by other methods.

When pneumatic hand pieces are cleaned, the air hoses shouldbe left attached. The outside of the hand piece should be wipedwith a detergent or germicide and dried. Hoses should beinspected for damage or excess wear before and afterdecontamination. Powered equipment and attachments shouldbe lubricated with a manufacturer’s recommended lubricant.

InspectingInspect and test the function of each instrument afterdecontamination. They should all be clean, and those withmoveable parts should be lubricated according to themanufacturer’s directions.

Endoscope cleaningEndoscopes are fragiledevices and require specialhandling and care to preventdamage. To avoid fogging,the proximal end must be freeof moisture. The endoscopeshould be held by its housingbody and/or eyepiece. Do notdrop or shake the endoscope. When processing, endoscopesshould never be placed in an ultrasonic cleaner as this willdamage the optics. Endoscopes should be cleaned and

processed separately from other instruments.

Endoscopes should be inspected before use. Scrub personnelshould look for any scratches or dents, which might indicate adefect in the endoscope. No distortions should appear on theoutside, or in the lens. If there is any moisture present or therod lens is damaged, cloudiness and possibly a loss of imagemay result. Associated light cords and connectors also shouldbe inspected to confirm that damage has not occurred duringprocessing. The light appearing through the cord should beeven, without any darkened areas, which indicate brokenfibers.

Cleaning laparoscopic instrumentsLaparoscopic instruments can be challenging to clean. Theyhave evolved from first generation devices that wereextremely difficult to clean, to second generation devices thatinclude a cleaning port, to modern instrumentation whichallows for complete disassembly for proper cleaning.

After use and before the next surgical procedure, laparoscopicinstruments must undergo several preprocessing steps, beforebeing cleaned, lubricated, and sterilized for reuse.

Preprocessing.The reprocessing of laparoscopic instrumentsbegins at point of use. As with all devices, excess body fluidsand tissues must be removed immediately in the surgical suite.

Several steps are necessary before laparoscopic instruments areprocessed. Devices must be disassembled by carefully followingthe manufacturer’s written instructions because of the variabilityin how these instruments are designed (i.e., some models oflaparoscopic instruments can be completely disassembled, somehave flush ports, some have neither). The required cleaningagents should be prepared according to the manufacturer’s use,dilution, and temperature recommendations.

Instruments should be inspected for any obvious insulationdamage and bent or missing parts. If any insulation damageor missing parts are discovered, this should be reportedimmediately for patient follow-up to assess whether thepatient has been harmed.

Cleaning. Remember these basics when cleaninglaparoscopic instruments:

• Manual cleaning is required for all instruments withlumens and hollow spaces. Automated cleaning witha washer/disinfector alone may not be effective.

• Metal brushes or scratch/scouring pads should not beused on insulation because they damage theinstrument’s surface and finish. Instead, use soft-bristle, nylon brushes and cotton-tip swabs.


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• Use deionized or softened water, especially for thefinal rinse. Note: Water with high mineral content (i.e.,hardness) can leave residues that affect performance.

• Neutral pH enzymatic detergent cleaning agents arerecommended. Alkaline detergents, if used, must becompletely rinsed from the devices. Do not usecorrosive fluids such as bleach-based products toavoid damaging the instrument.

• Cold soak sterilization is not typically recommendedand, as is always necessary for all instrumentation, themanufacturer’s instructions for specific devices shouldconsistently be followed.

• Totally immerse instruments during cleaning toprevent aerosolization. Do not use steel wool, wirebrushes, pipe cleaners, or abrasive detergents.Anything other than high-quality brushes specificallydesigned for instrument cleaning may damage thedevice.

After disassembly, the following manual cleaning steps areimportant:

• All components should be immersed (i.e., soaked) ina blood-dissolving, enzymatic solution preparedaccording to the manufacturer’s instructions for atleast five minutes with gentle agitation. Note: Soaklonger if protein-containing material is present. It isadvisable to soak instruments vertically to reduce thepossibility that air bubbles will form. Vertical soakingalso enables the solution to enter, rise through, and exitthe device if the solution is sufficiently deep.

• Remove the device from the enzyme solution, andrinse it thoroughly under running tap water for at leastthree minutes.

• Immerse all components in a detergent solutionprepared according to the manufacturer’s instructionsand clean all surfaces.

• Use a hand-held, soft bristled brush with a back-and-forth motion to brush all surfaces. Pay specialattention to the cord connector, crevices, grooves,fittings, and joints.

• While still submerged, use a soft-bristled brush witha gauge recommended by the manufacturer to cleaninner lumen surfaces. If a recommendation is notmade, select a brush with soft bristles that are slightlylarger in diameter than the actual lumen. Use completestrokes and ensure that the bristles exit the lumen.Push and pull the brush completely through the lumenseveral times. If necessary, repeat the brushing processby entering the opposite end of the lumen.

• Flush irrigation channels with deionized water and usea stylus, if necessary, to remove clogs. If instrumentshave cleaning ports, a Luer lock syringe filled withenzymatic solution can be attached to the cleaning portto flush the lumen. Note: Keep the distal end of thelumen under water. If there are no cleaning ports, athree-inch piece of tubing can be inserted over thedistal tip, and a syringe can be attached to the tube’sopposite end for flushing. Compressed air can also beused for flushing if a precise nozzle is available and ifthe pressure can be controlled. Ultrasonic irrigatorsalso are a useful way to flush instruments with lumensto remove debris from hard-to-reach areas, and theycan do so more effectively in a shorter time than amanual process.

• Some detergent solutions may leave a residue on thegold electrical post connector surface that can causeoccasional cord alarms. The residue can be removedwith an alcohol-soaked swab rotated completelyaround the gold connector surface.

• Remove the device from the detergent solution andrinse thoroughly under running distilled or de-ionizedwater for at least three minutes.

• Most instruments can be processed through awasher/disinfector after manual cleaning is completeusing the instrument cycle. If this is done, assure thatno residue remains.

Remove excess moisture and allow the instrument to drybefore sterilizing.

Inspection

Laparoscopic instrument insulation is susceptible to pin holes,cracks, tears, and overall loosening. These defects must bediscovered as the instruments are assembled beforesterilization to reduce the risk of electricity escaping throughinsulation failure points and to minimize the risk of


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inadvertent patient burns. Patient infections, extendedrecovery times, and the need for a possible return to surgerymay result from these burns. If defects are observed, a processshould be in place for patient follow-up to determine if theinsulation failure occurred during the last surgical procedureand injured the patient. To inspect the insulation, locate themetal collar at the distal tip. The insulation should fit tightlyagainst the collar with no spaces visible. Next, grip theinsulation, and try to slide it back. If the insulation slides (i.e.,moves), the instrument needs repair. Finally, check theinstrument shaft for insulation cuts, cracks, and nicks andinspect the handle for chips or cracks because these defectsindicate the need for repair or replacement. Some facilitieshave insulation failure testers that are used routinely on allinsulated instruments.

Powered Surgical InstrumentsPowered instruments use nitrogen, compressed air, electricity,or batteries to be operational. Powered instruments areavailable for use in many different surgical specialties. Theiruse enables the surgeon to work more quickly and efficiently,decreases surgical time and causes less trauma to tissues andsurrounding structures. Powered surgical instrument systemsare complex and have varied assemblies of gears, rotatingshafts, seals, and other diverse components. Most, however,have the following basic parts:

• A power source, which may be compressed gas,alternating current (AC), or direct current (DC)

• A hose or cord that connects the power source to thehandpiece (AC and pneumatically poweredinstruments only)

• The handpiece itself• Hand- or foot-operated controls• Accessory attachments

The action of a powered surgical instrument may be facilitatedby attachment of a blade, drill bit, reamer, or bur to achievereshaping, removal, pinning, reaming, or carving of bone.Power saws have either a reciprocating or oscillating action,while power drills operate via rotary action. The rotary actionmay be fast such as when drilling a hole for pin placement, orslower as when used forreaming the shaft of a longbone.

When cleaning poweredinstruments, make sure thatthe cleaning methods chosenfollow the manufacturer’swritten instructions. Many

powered instruments may not be immersed in water.Guidelines for cleaning powered equipment are to:

• leave air hoses attached to the hand pieces• use manufacturer-recommended detergents• rinse all traces of detergent solution• wipe air hoses clean with damp cloths• remove excess water• dry the outside of the equipment with lint-free towels

For battery-operated power tools, the batteries should beremoved and processed according to manufacturer’srecommendations.

PackagingThe next step in preparing surgical instruments for futureprocedures is packaging. Instruments must be thoroughlydried and lubricated as necessary before packaging.Instruments are arranged to prevent air and moisture frombeing trapped and/or retained. Important concepts toremember are to:

• place instruments in a container that is large enoughto evenly distribute metal mass in a single layer

• if steam sterilization is used, instruments with concavesurfaces should be placed on edge to facilitate drying

• hinged instruments should be opened and unlocked• instruments with removable parts should be

disassembled• delicate and sharp instruments should be protected

with loose-fitting tip protectors that have beenvalidated for use with the selected sterilization method

• heavy instruments should be placed on the bottom ofthe tray

• use only validated containment devices to organize orseparate instruments

• flush suction tip lumens and other channeled deviceswith softened or deionized water before steamsterilization

• remove stylets from lumens• line the instrument tray or basket with an absorbent,

lint-free surgical towel as neededPowered equipment should be disassembled before beingpackaged for sterilization. Delicate parts should be protectedand air hoses loosely coiled. Regardless of what sterilizationmethod will be used, instruments must be packaged to allowthe sterilizing agent to directly contact all surfaces. Steamsterilization under pressure is the recommended method for


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all instruments when possible. Steam makes direct contactwith all surfaces, and water condensate revaporizes producinga dry, sterile instrument.

SterilizationThe final step in preparing instruments for future use issterilization. There are multiple methods of sterilization orhigh-level disinfection that can be used. The process chosenmust be compatible with the type of instrument and thepackaging material chosen. Please refer to AORN’srecommended practices for complete information aboutsterilization methods.6 Also available is the video“Sterilization in the Perioperative Setting” from the AORNPerioperative Nursing Library.

SPECIAL PRECAUTIONS

Ophthalmic InstrumentsSpecial precautions must be taken when reprocessingophthalmic surgical instruments to reduce the risk of patientinjury from toxic anterior segment syndrome (TASS). Mostreported cases of TASS appear to be the result of inadequateinstrument cleaning and sterilization.6

Special precautions should also be taken when cleaningrobotic instruments because these instruments have lumenswith complex and difficult-to-clean internal and externalcomponents, both. Lumens and internal components shouldbe flushed with compressed air after cleaning to preventsubsequent microbial growth.

Prion DiseasesSpecial considerations should also be taken to minimize therisk of transmitting prion diseases. Prion diseases are thoughtto be transmitted through direct inoculation (e.g., oralingestion, inoculation of scratched skin) and iatrogenicallytransmitted through transplanted contaminated tissue (e.g.,cornea, dura mater). Prions are resistant to chemicaldisinfection and routine sterilization methods. Patients shouldbe screened for the possibility of exposure to prion diseasesand consideration should be given to what instruments will beused on patients suspected of having prion disease because ofthe extreme difficulty in sterilization of reusable5 instruments.

Personal Protective Equipment (PPE)Personnel handing contaminated instruments and equipmentmust wear appropriate PPE consistent with the anticipatedexposure. Personnel should expect splashes, splatters, and skincontact to occur during the processing of contaminatedinstruments. A fluid-resistant gown, heavy-duty gloves, and amask and face protection are required PPE. Two pairs of

gloves should be worn when cleaning instruments andequipment. Hands should be washed after removing gloves asperforations can occur in gloves and provide an avenue forcontamination. The Occupational Safety and HealthAdministration requires that a hepatitis B vaccination beoffered to all employees at risk for exposure to blood-bornepathogens.

SUMMARYThe perioperative nurse must ensure that surgical instrumentsare selected based on their intended use and that they areinspected, maintained, and sterilized adequately. Properlyfunctioning tools are essential for performing surgicalprocedures and for the safe care and well-being of patients.


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REFERENCES


1. NM Phillips, ed. Berry & Kohn’s Operating Room Technique. 11th ed. St. Louis, MO: Mosby-Elsevier; 2007: 325,328.

2. AORN guidance statement: sharps injury prevention in the perioperative setting. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2012: 711-716.

3. Gruendemann BJ, Fernsebner B, eds. Comprehensive Perioperative Nursing. Volume 2: Practice. Boston, MA:Jones and Bartlett; 1995.

4. Recommended practices for prevention of retained surgical items. In: Perioperative Standards and RecommendedPractices. Denver, CO: AORN, Inc; 2012: 313-332.

5. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: PerioperativeStandards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 513-536.

6. AORN’s recommended practices for sterilization in the perioperative setting. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc;2012. 547-569.

7. AORN. Sterilization in the Perioperative Setting [video]. Woodbury, CT: Cine-Med, Inc; 2010.


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1) Compared to conventional hand-held instruments,powered surgical instruments:a) enable the surgeon to work more quicklyb) cause less trauma to surrounding tissuesc) decrease surgical timed) all of the above

2) Powered surgical instruments are used for all ofthe following except:a) cutting and fixation of boneb) splitting the sternumc) harvesting of skin for graftingd) suturing of tissue

3) All of the following have a rotary action except: a) femoral reamersb) automatic screwdriversc) bone raspsd) k-wire drivers

4) Direct current is the source of power for: a) pneumatic instrumentsb) battery-operated instrumentsc) instruments that plug into wall currentd) all of the above

5) When regulating the gas flow for pneumaticinstruments, the correct pressure (PSI) should beset:a) by the manufacturerb) before the instrument is activatedc) while the instrument is activatedd) before attaching the hose

6) When not in use, powered surgical instrumentsshould be placed:a) on the patientb) on a nonsterile tablec) on a separate sterile table or Mayo standd) any of the above

7) When decontaminating and cleaning apneumatically powered surgical instrument:a) the gas hose should remain attached to the

handpieceb) a detergent/disinfectant solution should be

usedc) the outside should be dried with lint free

towelsd) all of the above

8) When packaging powered surgical instruments forsterilization, small, delicate parts should be:a) protected by placing in appropriate section of

container or packaged separatelyb) left unpackagedc) placed under the instrument to prevent

movement during sterilizationd) placed loosely in the container to prevent

stress and tension on the parts

9) A hemostat is classified as a _________instrument.a) cutting b) clamping c) grasperd) retractor

10) When passing sharps during a surgical procedure,the best way to protect all members of thesurgical team is to usea) extra careb) an assistive devicec) a neutral zoned) a knife handle

11) Curved Mayo scissors are usually used to cuta) delicate tissuesb) heavier tissuesc) sutured) any of the above.


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POST-TEST

SURGICAL INSTRUMENTATION: USE, CARE AND HANDLINGMultiple choice. Please choose the word or phrase that best completes the following statements.

12) A biting instrument used for cutting tough tissue orbone is called a(n)a) rongeurb) raspc) osteotomed) curette

13) The portion of a hemostat that runs from the fingerrings to the box lock is called thea) jawb) ratchetc) jointd) shank

14) A popular type of occluding clamp that has no teethis the a) Babcock clampb) Allis clampc) Kocher clampd) Ochsner clamp

15) Sponge forceps are used fora) retractionb) absorbing blood in the operative fieldc) blunt dissection of soft tissued) all of the above

16) Compared to hemostats, needle holders have a) shorter, stubbier jawsb) longer jawsc) more teethd) no ratchets

17) The depth of the surgical site will help determine a) the number of teeth on the instruments usedb) the length of the instruments usedc) the number of instruments requiredd) all of the above

18) Flat metal retractors that may be shaped or bent bythe surgeon at the field are calleda) Army-Navy retractorsb) Richardson retractorsc) malleable ribbon retractorsd) Volkmann retractors

19) The abdominal wall may be held open by a self-retaining retractor called aa) Balfour retractorb) Weitlaner retractorc) Jansen retractord) Richardson retractor

20) The hemostatic clamp used to control superficialbleeders and to handle delicate tissue in plasticsurgery and hand surgery is called a(n):a) Oschner clampb) Kocher clampc) Mosquito clampd) Peon clamp

21) Which of the following is used to create an openingin an operative site for endoscopy?a) cannulab) trocar and cannulac) scalpel with a #10 blade d) tissue scissors

22) Surgical instruments are crafted for intendedsurgical purposes. Each instrument is designed to doone of the following: cut, grasp, occlude, expose,retract, aspirate, and suture.a) trueb) false

23) The perioperative nurse is precepting a new scrubperson. The scrub person picks up a disposablescalpel blade with gloved fingers and is attemptingto attach it to the reusable scalpel handle. What isthe most important skill the perioperative nurseshould teach the new scrub person?a) Continue to use fingers to attach the blade since

fingers are more dexterousb) Lay the blade on the Mayo stand and slide the

handle onto the bladec) Hold the blade in a clamp or needle holder and

advance it onto the handled) Convince the OR to purchase disposable

scalpels only

24) The most common type of clamping instrument is ahemostat. Non-crushing hemostats are designed toocclude which of the following:a) bronchusb) esophagusc) blood vesselsd) trachea


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25) The surgical team is ready to close the surgicalwound and has requested specific suture material.What instrument will the scrub person use to deliverthe suture to the surgical team?a) needle holderb) hemostatc) Kocherd) thumb forcep

26) The identifiable parts of a clamp or forceps are:a) point and jawsb) box lock and shankc) finger rings and ratchetd) all of the above

27) Surgical instruments must be made of metal alloysthat will resist corrosion. Exposure to which of thefollowing will result in corrosion:a) sterilization methodsb) cleaning solutionsc) blood or body fluidsd) all of the above

28) The scrub person must know the name and intendeduse of each instrument. As part of the surgical teamthe scrub person should:a) keep several clamps in hand at once b) not worry about cleaning since the instruments

will continue to get dirtyc) discard the suctions when they become cloggedd) pass the instrument appropriately and for the

intended use

29) When preparing a tray for the washer, it isacceptable to randomly place instruments andretractors in the tray as long as all areas are exposedto the cleaning process.a) trueb) false

30) The instruments are being assembled forsterilization in their respective trays. Some of theretractors still have visible blood on them. Theseretractors should be:a) wiped off with a wet towel and placed with the

othersb) assembled anyway, the sterilizer will destroy

any bacteriac) left out of the trayd) none of the above


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1d

2d

3c

4b

5c

6c

7d

8a

9b

10c

11b

12a

13d

14a

15d

16a

17b

18c

19a

20c

21b

22a

23c

24c

25a

26d

27d

28d

29b

30d


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POST-TEST ANSWERS


SURGICAL INSTRUMENTATION USE , C ARE AND HANDLING

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