Surgical Instruments according to their purpose, they can be divided into five groups.

Tissue Separation Instruments(fig. 8.1). Scalpels in the shape of the blades are divided into abdominal and pointed. According to the length of the blades, general surgical abdominal scalpels are divided into large (blade length 50 mm), medium (blade length 40 mm) and small (blade length 20-30 mm). Pointed scalpels are only available in medium size. Nowadays, disposable scalpels and scalpels with changing blades are being used more and more.

Surgical scissors in the shape of the cutting surfaces are straight, curved along the plane (Cooper type), curved along the edge (Richter type). There are also pointed scissors, blunt-pointed and with one sharp end, etc.

Vascular scissors have elongated branches and a shortened cutting surface. A distinction is made between straight scissors with rounded ends and two types of angle scissors for dissecting a vessel only in a certain position.

Auxiliary scissors are intended for cutting plaster and soft bandages, etc.

Distinguish resection and a mutational knives. This group also includes saws (arc, sheet, wire), hammer, nippers, drills and cutters, puncture needles, chisels, trocar, osteotome, drill with knitting needles.

The tools are exciting(clamping) (fig. 8.2).

Clamps extremely diverse in shape, length and thickness, due to their different functional purpose. Hemostatic clamps are used to grasp and clamp bleeding vessels or tissues. They differ in the shape of the tip and the thickness of the gripping sponges from the smallest ("mosquito") to powerful and large (clamps Mikulich, Fedorov).

There are many clamps for grasping tissues, dressings, surgical drapes. The working part of the clamp can have a fenestrated structure (Luer clamp), be in the form of sharp-toothed grips (pin, bullet forceps).

Kornzang is one of the common fixing clamps. It can be straight or curved. Kornzang is intended for feeding dressings, instruments, introducing tampons, drains into the wound, removing foreign bodies, creating a swab, etc.

Tweezers used to grip and hold various tissues. Distinguish between surgical, anatomical, gripping

Instruments to protect tissues from damage. This group includes a grooved probe, a Kocher probe, Buyalsky's spatula, Reverden's spatula, a retractor (Fig. 8.3).

Instruments for expanding the wound. This group of instruments includes sharp and blunt hooks, lamellar Farabef hooks, abdominal speculum, liver speculum, various retractors (Mikulich, Gosse, "Mini-assistant" for minimally invasive operations), Trusso's tracheal dilator, mouth dilators, rectal mirrors (Fig. 8.4).

Tools for connecting fabrics. The connection of the dissected tissues is carried out using various instruments and devices. The tissues are connected by suturing them with surgical needles, which can be straight and curved, round and cutting.

To thread the thread into the eye of the needle, which has a slot provided with two springy protrusions, the thread is applied to the eyelet in a taut state and with a certain force is pushed into the working hole. The least traumatic are the so-called atraumatic needles. These are disposable needles, their thread is pressed into the blunt end of the needle.

Passing the needle through the tissue is carried out using needle holders of various designs depending on the type of operation, the nature of the tissues (Fig. 8.5).

To connect fabrics, various stapling devices have been created, connecting fabrics with metal staples.

All surgical instruments are stored in a dry, heated room at a temperature of 15 - 20 ° C. Do not store active chemicals together with tools, the vapors of which are corrosive to metals (iodine, acids, bleach, etc.). During long-term storage and transportation, tools made of carbon steel are thoroughly degreased, washed, dried, lubricated with neutral petroleum jelly or immersed in petroleum jelly at 60 - 70 ° C, then wrapped in waxed paper. De-preservation of instruments is carried out

gloved. New instruments are kept at room temperature for several hours without unpacking. After removing the waxed paper, they are wiped dry with gauze napkins, then washed, immersed in ether for 1 hour, rubbed in and sterilized.

Of all surgical instruments kits can be compiled to perform typical surgical operations.

The operating nurse's instrument table should contain the “connecting instruments” - ie. those that only the operating nurse works with - scissors, anatomical tweezers, small and long, 2 forceps, 4 linen pins for processing and delimiting the operating field.

Basic set - it includes tools general group, which are used in any operations and are included in the elements of the operation.
For specific operations, special tools are added to them.

Basic set of surgical instruments

Figure 12. Basic set of surgical instruments.
1 - clamp of the "Kornzang" type (according to Gross-Mayer) straight; 2 - linen claws; 3 - bulbous probe (Voyacheka); 4 - grooved probe; 5 - a set of surgical needles; 6 - atraumatic needle with suture thread.

1. Kornzang is used to process the operating field. There may be two of them.
2. Linen pins - for holding the dressing material.
3. Scalpel - should be both pointed and abdominal, several pieces, because during the operation, they have to be changed, and after the dirty stage of the operation - thrown away.
4. Hemostatic clamps Billroth, Kocher, "mosquito" - are used in large quantities.
5. Scissors - straight and curved along the edge and plane - several pieces.
6. Tweezers - surgical, anatomical, gripping, they must be small and large.
7. Hooks (retractors) Farabef and toothed blunt - several pairs.
8. Probes - bulbous, grooved, Kocher.
9. Needle holder.
10. Needles are different - a set.

A set of surgical instruments for PCO wounds

(applies to work only on soft tissues)

Removal of microorganisms trapped in the wound by excision of the edges and bottom of the wound or tissue dissection;
- removal of all damaged tissues, blood clots, which are a breeding ground for microorganisms;
- transfer of all types of wounds to cut to speed up the regeneration processes;
- thorough, complete and final hemostasis;
- restoration of the anatomical integrity of damaged tissues by suturing and, if necessary, wound drainage.

Indications: PHO are subject to:

Extensive wounds of soft tissues with loose, torn, uneven edges and heavily contaminated;
- all wounds with damage to large blood vessels, nerves, bones.

PHO is carried out within 24 - 48 hours and should be, as far as possible, one-step and comprehensive. Preparation for PHO consists in cleaning the skin around the wound, processing the operating field according to the method used in this medical institution, and premedication. PHO begins with general or local anesthesia.

Contraindications:

Shock, acute anemia,
- collapse, development of purulent inflammation.

A common set of tools is used for PHO.

Laparotomy Surgical Instrument Set

Figure 13. Set of instruments for laparotomy.
1 - rack retractor according to Gosse; 2 - Collin's retractor; 3 - surgical retractor (mirror) according to Kocher; 4 - Reverden spatula

To perform, an operation on any organ of the abdominal cavity is performed by abdominal surgery or laparotomy.

Indications: it is used for acute and chronic diseases of the abdominal and retroperitoneal organs, injuries and injuries, sometimes for diagnostic purposes.

An extended general set is used - a general set, which is expanded with Gosse and Mikulich retractors, abdominal mirrors - Ru and saddle, hepatic and renal mirrors.

Expand the hemostatic clamps and add clamps Mikulich, Fedorov, fenestrated, hepatic - renal, ligature dissector and Deschamp's needle.
- Tweezers and scissors should be both small and large (cavity).
- Intestinal and gastric pulp,
- Reverden's spatula,
- Hepatic tube and spoon.

Set of surgical instruments for appendectomy and hernia repair

Surgery to remove the appendix and hernia repair.

Indications: acute attack of appendicitis, infringement of hernial contents. The operation should be performed urgently, in the first hours after the onset of the disease. If not strangulated hernia- in the "cold" period, after a complete examination of the patient.

A set of instruments: a general surgical set is used, cavity instruments are added - Mikulich's clamps; abdominal mirrors - saddle and Ru.

Set of surgical instruments for laparocentesis (abdominal puncture)

Figure 14. Trocar set.

It is carried out with ascites, a similar operation can be used to diagnose injuries and diseases of the abdomen.

A common set of tools is being assembled, since patients are obese and in order to insert the trocar, it is necessary to make an incision in the tissues, and then suture. In patients with a small amount of subcutaneous fat, only the trocar can be used.

Do not forget the PVC tubes for the diameter of the trocar!

Cholecystectomy Surgical Instrument Set

Figure 15. Cholecystectomy instrument set.
1 - ligature dissector; 2 - liver mirror; 3 - a spoon for removing gallstones

It is used for diseases of the gallbladder, liver, liver injuries.

Surgical instruments:

1. General set of instruments extended for laparotomy
2. Clamp Fedorov
3. Ligature dissector, Deschamp's needle
4. Liver mirrors,
5. Hepatic tube and hepatic spoon
6. Hepatic - renal clamp
7. A scoop used for liver injury to remove blood from the abdominal cavity.

Set of surgical instruments for gastric resection

Figure 16. Lana's gastric-intestinal forceps, double.

Figure 17. Lever stomach suture.

It is used for perforated and common stomach ulcers and 12 duodenal ulcers, for injuries of the stomach, stomach tumors.

Instruments:

1. Extended general set for laparotomy
2. Bagasse
3. Liver mirrors
4. Fyodorov's forceps, ligature dissector
5. End clamps

Instruments for operations on the chest wall and chest cavity organs

Tools are used for trauma chest wall, with penetrating wounds, with wounds of the organs of the chest cavity, With purulent pathology and specific diseases of the organs.

Instruments:

1. General set of tools,
2. Doyen's Rib Raspatory and Doyen's Rib Cutters,
3. Screw mechanical retractor,
4. End Luer Clamps,
5. Clamp Fedorov,
6. Ligature dissector and Deschamp's needle.
7. Special instruments used in cardiovascular surgery.

Set of surgical instruments for craniotomy

Toolbox - A common toolbox is used, but widening of the wound requires the use of pointed hooks.

Figure 18. Special set of instruments for craniotomy.
1 - brace with a set of cutters
2 - Dahlgren Nippers, Luer Nippers
3, 4 - raspatory - straight and curved
5 - Volkman's bone spoon
6 - saw Jigli with handles and Palenov's guide

1. Rasp
2. Brain spatulas of various widths
3. Rubber balloon "pear"
4. Special neurosurgical hemostatic clamps

Tracheostomy kit

Fig. 20. Tracheostomy kit.
1 - blunt hook for the isthmus of the thyroid gland; 2 - a sharp hook for holding the larynx and trachea; 3 - tracheal dilator; 4,5,6 - tracheostomy cannula, assembled and disassembled.

Opening the windpipe. Emergency tracheostomy is performed with the aim of immediately providing air access to the lungs, in case of blockage of the airways, in patients with tumors of the larynx or vocal cords.

Indications:

Damage to the larynx and trachea;
- stenosis of the larynx and trachea due to inflammatory processes and neoplasms;
- foreign bodies of the trachea and larynx;
- the need for long-term mechanical ventilation.

Tools:

1. Tools general purpose.
2. Special set of tools:
- Single-tooth hook - a small blunt hook
- Trousseau trachea dilator
- Double tracheostomy cannulas different sizes consisting of outer and inner tubes. The outer tube has holes in the side for a strap that ties it around the neck.

Skeletal Traction Surgical Instrument Set

Figure 21. Skeletal traction tool kit.
1 - hand drill; 2 - Kirschner brace with a wire for skeletal traction.

This kit does not need a common set of tools. It is used to stretch the bone in case of fracture.

Instruments:

Drill, hand or electric
- Kirchner bracket
- A set of knitting needles
- Wrench for tightening nuts
- Key for tensioning the spoke
This kit also requires rubber plugs to hold the gauze ball in place.

Limb Amputation Surgical Instrument Set

Figure 22. A set of instruments for limb amputation.
1 - retractor; 2 - Jigli's wire saw; 3 - Palenov handles; 4 - hemostatic tourniquet; 5 - a set of amputation knives.

Removal of the distal part of the limb.

Indications:

Limb injuries;
- malignant tumors;
- tissue necrosis as a result of frostbite, burns, obliterating endarteritis.

Purpose of amputation: saving the patient's life from severe intoxication and infection emanating from the lesion and creating a workable stump suitable for prosthetics.

Set of tools:

General surgical kit

1. Hemostatic tourniquet
2. A set of amputation knives.
3. Raspatory for displacement of the periosteum
4. Arc or sheet saw and Jigli's wire saw
5. Bone clippers Liston or Luer
6. Rasp for smoothing sawdust bones
7. Blade of a safety razor in the Kocher clamp for truncation of nerve trunks
8. Bone holder Olier or Farabef
9. Retractor for protecting soft tissues when sawing bones and for shifting soft tissues before sawing
10. Volkmann spoon

Surgical Instrument Set for Suturing and Removing Sutures

For suturing

1. Surgical forceps.
2. Needle holder.
3. A set of needles.
4. Scissors.

To remove stitches

1. Anatomical forceps.
2. Sharp-pointed scissors.

EAT. Turgunov, A.A. Nurbekov.
Surgical Instruments

Table of contents of the subject "Operative technique. Surgical instruments.":
1. Operational technology. Separation of tissues. Tissue separation techniques. Stopping bleeding. Temporary stop of bleeding. The final stop of bleeding.
2.
3. Instruments for the separation of soft tissues in surgery. Scalpel. Surgical knives.
4. Surgical scissors. Surgical scissors. Types of scissors. How to hold surgical scissors in your hands?
5. Auxiliary tools. Tweezers. Types of tweezers. How to hold tweezers in your hands?
6. Lamellar hooks (Farabefa). Volkmann's serrated hooks (blunt and sharp). How to hold the hooks in your hands?
7. The probe is grooved. Grooved probe. Deschamp ligature needle. How do you hold the grooved probe and Deshan needle in your hands?
8. Kornzang straight. Curved forceps. Hemostatic clamps. How to hold the clamp and the styptic clamps in your hands?
9. Tools for connecting soft tissues. Surgical needles. Surgical needles. Types of needles. Classification of surgical needles.
10. Needle holder. Gegar needle holders. Threading a surgical needle. How to hold a Gegar needle holder in your hands?

Surgical instruments. Classification of surgical instruments. General-purpose instruments in surgery.

Surgical Instruments can be divided into general purpose tools and special tools. Examples of special sets instruments are given in special guides for operative surgery. Instruments a general practitioner should know a doctor of any specialty and be able to use them.

Classification of surgical instruments. General-purpose instruments in surgery.

1. For loosening fabrics: scalpels, knives, scissors, saws, chisels, osteotomes, nippers, etc. Cutting tools also include resection knives used to cut dense tendon tissue near joints, and amputation knives.

2. Supporting tools(expanding, fixing, etc.: anatomical and surgical tweezers; blunt and sharp hooks; probes; large wound dilators (mirrors); forceps, Mikulich clamps, etc.

3. Hemostatic: clamps (such as Kocher, Billroth, Halstead, "Mosquito", etc.) and Deschamp ligature needles.

4. Tissue Joining Tools: needle holders of different systems with piercing and cutting needles.

Used for manipulation surgical instruments must be sterile.

Surgical Instruments are passed from hand to hand with blunt ends towards the recipient, so that the cutting and stabbing parts do not injure the hands and damage your manicure. In this case, the sender must hold the instrument in the middle.

Surgical instruments. Classification of surgical instruments. General-purpose instruments in surgery.

Surgical Instruments can be divided into general purpose tools and special tools. Examples of special sets instruments are given in special guides for operative surgery. Instruments a general practitioner should know a doctor of any specialty and be able to use them.

Classification of surgical instruments. General-purpose instruments in surgery.

1. For loosening fabrics: scalpels, knives, scissors, saws, chisels, osteotomes, nippers, etc. Cutting tools also include resection knives used to cut dense tendon tissue near joints, and amputation knives.

2. Supporting tools(expanding, fixing, etc.: anatomical and surgical tweezers; blunt and sharp hooks; probes; large wound dilators (mirrors); forceps, Mikulich clamps, etc.

3. Hemostatic: clamps (such as Kocher, Billroth, Halstead, "Mosquito", etc.) and Deschamp ligature needles.

4. Tissue Joining Tools: needle holders of different systems with piercing and cutting needles.

Used for manipulation surgical instruments must be sterile.

Surgical Instruments are passed from hand to hand with blunt ends towards the recipient, so that the cutting and stabbing parts do not injure the hands and damage your manicure. In this case, the sender must hold the instrument in the middle.

Majority surgical instruments made of chrome-plated stainless steel. Number of models surgical instruments currently reaches several thousand.

Scalpel appointment: dissection of any soft tissues (skin, subcutaneous fatty tissue, fascia, aponeuroses, intestinal wall, etc.).

Scalpel device: handle, neck, blade (cutting edge) and back. Removable blade for single use is possible.

Fig 2.1.Scalpels ... 1 - pointed; 2 - belly; 3 - with a removable blade.

The shape of the blade distinguishes between pointed and abdominal (with a strongly convex cutting edge) scalpels(fig. 2.1).

Abdominal scalpel used for the production of long linear cuts on the surface of the body, pointed scalpel for deep cuts and punctures.

Rice. 2.2.Scalpel positions in hand : 1 - table knife; 2 - writing pen; 3 - bow.

Position of the scalpel in the hand:
- in the position of a table knife, when the index finger rests on the edge of the scalpel, for dissecting the skin and other dense tissues, for making deep cuts, strictly dosed according to the force of pressure (Fig. 2.2);
- in the position of a writing pen when puncturing tissues, separating (dissecting) tissues, when producing short accurate cuts deep in the wound;
- in the bow position for long superficial, shallow cuts.

It does not follow cut with a scalpel blade directed upward, except when the incision is carried out along the probe.

Purpose of scissors: dissection of small in thickness formations (aponeuroses, fascia, serous leaves, vessel wall, etc.) and suture material.

Rice. 2.3.Surgical scissors ... 1 - pointed straight scissors; 2 - blunt curved scissors.

Scissors crush the tissues between the blades, so they cannot be used when dissecting skin, bulky tissues, such as muscles.

Scissors device: two blades that turn into jaws with rings at the ends, and a screw that connects them. The ends of the blades are sharp or blunt, the blades can be bent along the plane and at an angle to the axis (Fig. 2.3).

Rice. 1-9.Articulated scissors , a - Mayo's standard model, b - Kelly vascular scissors, c - Marbach scissors for zpiziotomy, d - Kaplan scissors for dissecting septa, e - anatomical scissors for zterotomy.

The most commonly used are blunt curved scissors - Cooper's scissors... Their advantage is that they do not injure tissue as they move forward. They can also be used to bluntly sever tissue by spreading the blades. Cooper's scissors are used to cut through fabrics drawn with hooks or tweezers.

How to hold surgical scissors in your hands?

Rice. 2.4.The position of the scissors in the hand .

The position of the scissors in the hand: the nail phalanx of the IV finger of the working hand is in the lower ring, the W finger lies on the ring at its junction with the branches, the II finger rests on the screw. The nail phalanx of the first finger is located in the ring of the upper branch (Fig. 2.4).

Supporting tools are used to expand the surgical wound, fix and pull tissue.

Tweezers. Types of tweezers. How to hold tweezers in your hands?

To capture tissue in a wound, use tweezers consisting of two elastically connected metal plate-branches.

Rice. 2.5.Tweezers a - anatomical; b - surgical.

The purpose of the tweezers: fixation of an organ or tissues when working with them; fixation of the needle at a certain moment of suturing.

Tweezers device: two springy steel plates, diverging at an angle: anatomical - with transverse notches at the ends, surgical - with sharp teeth (Fig. 2.5). The anatomical forceps grabs the tissue more gently, while the surgical forceps are more traumatic, but hold them more reliably.

For operations on soft tissues, blood vessels, intestines use anatomical tweezers, for grasping denser tissues (aponeurosis, tendon, skin edges) - surgical.

Fig 2.6.Tweezers fixation ... a - correct; b - wrong

Position in the hand of tweezers: tweezers are gripped, as a rule, with the left hand in the middle of the plates, where there are grooved platforms to regulate the force of compression of the spring and firmly fix the tissue.

Correct position of the tweezers in the hand- the position of the writing pen (Fig. 2.6).

Plate hooks (Farabefa)

Purpose of Farabef hooks: dilution of the edges of a deep wound near large vessels or abduction of masses (for example, muscle bundles). The size of the hooks selected depends on the length of the incision and the depth of the incision.

Rice. 2.7. Farabef hooks.

Farabef hook device: a plate with smooth obtuse edges and curved in the form of two Russian letters "Г", connected by long parts (Fig. 2.7).

Hand position of Farabef hooks: usually the assistant grasps the hooks by the long crossbar of the letter "G" in his fists, inserts the short crossbars into the wound, placing them opposite each other symmetrically at right angles to the edge of the wound. The traction when separating the edges of the wound should be uniform so as not to shift its direction.

Volkmann serrated hooks (blunt and sharp)

Purpose of Volkmann hooks: sharp hooks are used only for pulling and fixing the skin and subcutaneous tissue; blunt - for retraction of individual anatomical structures in the depth of the wound (vessels, tendons, etc.) (Fig. 2.8).

Rice. 2.8.Volkmann serrated hooks .

The device of Volkmann hooks: a surgical instrument in the form of a fork, the teeth of which (sharp or blunt) are smoothly curved at an angle of more than 90 °, and the handle is equipped with a finger ring.

Hand position of Volkmann hooks: the handle of the hook is gripped into a fist, the second finger is inserted into the ring for a more firm fixation of the instrument in the hand.

The probe is grooved. Grooved probe.

Purpose of the grooved probe: used to protect deeper tissues from damage with a scalpel during dissection of lamellar anatomical structures (fascia, aponeurosis, etc.).

Grooved probe device: a metal strip with a groove and blunt edges, turning into an expanded plate (Fig. 2.9).

Rice. 2.9.Grooved probe .

Position of the grooved probe in the hand: the probe is fixed by the plate between the I and II fingers of the surgeon's auxiliary hand.

Deschamp ligature needle

Purpose of the Deschamp ligature needle: carrying out ligatures under a blood vessel and other anatomical structures. The bend of the needle can be for the right and left hands.

Figure 2.10.Deschamp's needle .

Deschamp ligature needle device: a curved blunt needle with a hole at the end and a long handle (fig. 2.10).

The position of the Deschamp ligature needle in the hand: the handle of the tool is taken into a fist. The ligature is inserted into the hole like a thread in a sewing needle. The disadvantages of the needle are the absence of a mechanical eyelet and the difficulty of threading in the thread, therefore, when working with a Deschamp needle, the ligature must be inserted into the eyelet in advance.

Kornzang straight. Curved forceps.

Appointment of kortsang: the instrument is used to supply sterile items in the operating room and in the dressing room with non-sterile hands (the forceps are placed in the disinfectant solution from the side of the sponges; the jaws and rings remain non-sterile). The forceps can be used during a surgical operation if it is necessary to go through tissues bluntly (for example, when opening phlegmons and abscesses).

Kortsang device: long jaws with rings, wide massive jaws in the form of olive and lock-ratchet (Fig. 2.11). Kornzang can be straight and curved.

Rice. 2.11.Kornzang straight ... 1 - rack-lock; 2 - ring; 3 - branch; 4 - screw; 5 - sponges.

Position of the stretcher in the hand: The position is the same as that of the scissors, except that the curved ends of the tool point downward (when feeding materials).

To open castle-cremalier, you should lightly press the rings, shift the jaws along the plane, and only then spread them apart.

Hemostatic forceps. How to hold the clamp and the styptic clamps in your hands?

Hemostatic clamps are among the most used and necessary tools.

Appointment of a hemostatic forceps: temporary stop of bleeding.

Hemostatic forceps device: a clamp of any kind consists of two jaws connected by a screw that divides the jaws into a working part (jaws) and an annular part. A stepped ratchet lock near the rings fixes the clamp in a certain working position, provides compression of the vessel without the constant involvement of the surgeon's hands and allows you to regulate the force of this compression.

Rice. 2.12.Hemostatic clamps ... 1 - Kocher clamp; 2 - Billroth clamp; 3 - "Mosquito" clamp.

1. Billroth clamps- straight and curved, serrated, but not serrated.
2. Kocher clamps- straight and curved, serrated and serrated at the ends of the jaws.
3. Clips "Mosquito"- straight and curved, with very narrow and short lips (fig. 2.12).

Position of the haemostatic forceps in the hand: The position is the same as when using the scissors and forceps.

Surgical needle device: straight and curved steel rods, pointed at one end, with a specially designed eyelet on the other for quick thread insertion. Currently, the so-called atraumatic disposable needles without an eyelet with a thread welded into the end of the needle are also widely used.

Needles differ in cross-sectional shape round - piercing, and triangular - cutting. Needles are also distinguished by length and degree of bend (Fig. 2.13).

Rice. 2.13.Surgical needles ... 1 - cutting; 2, 3 - stabbing curved and straight; 4 - atraumatic.

Minimum dimensions curved surgical needle- 0.25 mm in diameter and 8 mm in length, maximum - 2 mm in diameter and 90 mm in length.

The needles are classified according to numbers and types, suture material is selected accordingly.

Cutting triangular surgical needles with curvature of different radius of curvature are used for stitching relatively dense tissues (skin, fascia, muscle, aponeurosis); piercing needles, with a round cross-section, - for connecting the walls of hollow organs and parenchymal organs. In the latter case, triangular needles cannot be used, since the sharp lateral edges of such a needle can lead to additional damage to the tissue.
Atraumatic needles used, as a rule, for the imposition of a vascular or intestinal suture.

When working without a needle holder, use long straight needles.

Purpose of the Gegar needle holder: fixation of the needle for easy suturing and avoiding touching the tissues with fingers.

Gegar needle holder device: are similar in design to hemostatic clamps, but have more massive and shorter jaws, on the surface of which small criss-crossing cuts are applied to increase the friction between the needle and the jaws and to firmly fix the needle (Fig. 2.14).

Rice. 2.14.Needle holder Gegara .

Threading on surgical needle.

Preparing the tool for work:

1. Grip the needle with the jaws of the needle holder at a distance of 2-3 mm from its tip - the narrowest part of the jaws (gripping the needle with the wider part of the needle holder, closer to the screw, can lead to needle breakage). In this case, 2/3 of the length of the needle from the point should be free and to the left of the needle holder (for right-handed people), the point of the needle is directed towards the loader.

2. To thread the suture into the needle, grasp the long end of the suture into a fist along with needle holder handles with the working hand, and with the other pull its short end along the tool, wind it behind the needle to the left of it and, using the needle as a stop, pull the thread to the right of the needle holder and bring it to the cut in the middle of the eyelet. With a tightly stretched thread, press on the spring of the eyelet: the thread will spread the walls of the eyelet and pass into it automatically. The ends of the thread are straightened and tied together. One end of the ligature should be 3 times longer than the other (Fig. 2.15).

Rice. 2.15. Suture thread and needle.

How to hold a Gegar needle holder in your hands?

Position of the Gegar needle holder in the hand:

Needle holder grabbed into a fist together with the long end of the ligature (if the surgeon works with an assistant, the assistant grabs the long end of the ligature), the second finger is placed along the branch of the instrument and fixed on the screw or branch. In this case, the I finger is at the top. In the other hand, the surgeon holds tweezers (surgical - for the skin, anatomical - for other tissues), fixing the tissues to be sutured or holding the needle.

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All surgical instruments are divided into general and special ones: general surgical instruments are used for surgical interventions in any anatomical areas. Special surgical instruments, as a rule, are instruments of the same purpose as general surgical instruments, but are designed to perform operations in "narrow" areas of surgery: thoracic, cardiovascular surgery, neurosurgery, gynecology, urology, ENT and maxillofacial surgery, as well as for endoscopy and endovideosurgery.

4.1 Classification of surgical instruments

All surgical instruments are conventionally divided into the following groups:

1) disconnecting;

2) exciting;

3) piercing;

4) expanding and pushing back;

5) probing;

6) auxiliary;

7) mechanized.

The vast majority of instruments are named after their creators.

4.2 Characteristics of their individual types

I. Tissue Release Tools

The main tools for severing tissue are cutting. Instruments for severing tissue include scalpels, amputation and resection knives, scissors, saws, etc.

Scalpel - a sharp-edged surgical instrument (Fig. 1) used to sever soft tissues.

There are general surgical scalpels and special ones (ophthalmic, neurosurgical, etc.). General surgical scalpels can be solid-stamped and with removable blades. The scalpel has a handle and a blade; on the blade, a point, a back and an abdomen are distinguished. General surgical all-stamped scalpels are available in two types: spiky and abdominal(Fig. 1).

Fig. 1 Scalpels: a) pointed, b) abdominal

Surgical knives- Sharp-sharpened instruments designed to separate soft tissues during amputations, operative access to the organs of the chest cavity, etc. An incision made with a sharp knife is less painful and heals better.

Amputation knife intended for dissection of soft tissues during limb amputation. (Fig. 2, a).

Fig. 2 Small amputation knife (a) and resection knife (b)

Resection knife(Fig. 2, b) is intended for dissection of dense tissues (small bones, more often phalanges) during hand and foot amputations, as well as during osteoplastic operations (joint resection, etc.).

Cartilaginous knife intended for separation of costal cartilage and sternum, as well as fibrous tissue.

Surgical scissors refer to cutting tools with a sharp sharpening, having two blades, dissecting tissue in the opposite motion (Fig. 3). Depending on the nature of this movement, distinguish articulated scissors(shearing action - along the blade) and guillotine shears(dissecting from top to bottom). Articulated scissors are used to separate soft tissues and dressings, dressings. Guillotine scissors are used to separate dense tissues (bones, cartilage, etc.).

Like other surgical instruments, scissors can be horizontally curved, i.e. in the plane of the table and vertically curved, which are more common.

Blunt scissors straight (Fig. 3, a) and curved (Fig. 3, c) (Cooper's) are most often used by surgeons to sever tissues, both on the surface and in the depth of the wound. Can be used to cut gauze. Curved scissors are used to sever adhesions in the pleural space or to separate organs from ligaments in the abdomen. They are also used to trim the ends of ligatures when closing a skin wound.

Pointed scissors straight and curved (Fig. 3, b) are used in cases when it is necessary to pierce the tissue before making the incision.

Rice. 3. Surgical scissors

Saws. In surgery, saws are used to intersect bones, which distinguish between three main types (Fig. 4): Charière's sheet saw (Fig. 4, c), Charière's arc saw (Fig. 4, b) and Gigli's saw (Fig. 4, a ), made in the form of a "sharp" wire, twisted into a spiral. In addition, various types of electric saws are used in traumatology.

Fig. 4 Surgical saws: a) Charière sheet saw,

b) Charière's arc saw, c) Gigli's saw

Surgical cutters used for biting bones (Fig. 5). Instruments in this category include Luer, Liston and Dahlgren's bony forceps, Doyen's rib scissors.

Disconnecting instruments (Fig. 6) include raspators (for separating the periosteum from the bone), chisels and osteotomes (for crossing bones - osteotomies), Volkmann's bone trays and others (for scraping the bone), trephins with a set of cutters (for drilling holes in bones).

Fig. 5. Surgical nippers: a) Luer, b) Liston, c) Dahlgren, d) Doyen's rib scissors

Fig. 6. Disconnecting instruments: a) Farabef's raspator, b) chisels, b) bone spoons, c) trepan with a set of cutters

II. Grasping tissue tools

Hemostatic clamps - are used for clamping a bleeding vessel (temporary stop of bleeding), for ligation of a bleeding vessel (final stop of bleeding) (Fig. 7).

Kocher Serrated Hemostat - can be straight or curved, equipped with a lock (ratchet), and at the ends of the jaws there are teeth (two against one), and all of them working surface covered with slanting notches.

Fig. 7. Hemostatic clamps: a) Kocher, b) Billroth,

c) type "miskit"

Purpose:

1. Specially used to hold the contracted ends of the transected vessel in the thickness of the rough fibrous tissue (palmar and plantar aponeuroses, scalp, etc.).

2. To hold the superficial vessels of the thyroid gland (the initial purpose of the instrument).

3. For holding the dissected peritoneum and fibrous tissue (fascia and aponeurosis).

4. To hold the rib during the rib resection operation.

5. For holding and separating tissues during dissection during surgery.

Billroth's haemostatic forceps. It is similar in design to Kocher's hemostatic forceps. Differs in the presence of cross-cut jaws on the working surface. Can be with straight or curved cheeks (lips).

Purpose:

1. For ligation on a bleeding transverse vessel (less traumatic than Kocher's hemostatic forceps).

2. For holding the peritoneum or fixing it during dissection or suturing.

3. To hold the base of the appendix during appendectomy.

4. To perform blunt separation of tissues during surgery.

5. To open the abscess cavity and destroy the septa in the cavity.

Mosquito-type hemostatic forceps - short and light compared to the Billroth and Kocher hemostatic clamps, working jaws are distinguished by pointed ends, can be straight and curved;

Purpose:

1. For ligation of bleeding small vessels during neurosurgical operations.

2. For ligation with bleeding from parenchymal organs (liver, spleen, etc.), as well as in pediatric surgery.

Vascular clips. They are intended for temporary application on the vascular legs of organs in order to stop blood circulation during an operation on the organ or during its removal (kidney, spleen, etc.) or for temporary application to the vessels when restoring their integrity (imposing a vascular suture) or restoring their patency (Fig. eight). Vascular clamps differ from hemostatic clamps in the figured structure of working sponges and a ratchet with a large number of teeth, which allows you to smoothly regulate the force of squeezing the vessel in order to injure the inner shell as little as possible. The configuration of the working jaws can be angular and arcuate (with different radius of curvature of the circle).

Fig. 8. Vascular clamps: 1-straight, 2-angled, 3-Satinsky clamp, 4- curved, 5-6 bulldog-type vascular clamps

Clamp for the renal pedicle of Fedorov- is a large and long clamp, curved along the plane. Used as a pedicle clamp near the hilum during nephrectomy (Fig. 9).

Fig. 9. Clamp for the renal pedicle of Fedorov

Tweezers - An instrument that is widely used in surgical practice and has a spring-loaded design, it is designed to grasp and hold a variety of tissues, materials and small instruments (Fig. 10).

The shape of the tweezers is straight or curved, depending on the functionality. In special surgical instruments, special purpose tweezers are used.

Fig. 10. Tweezers: a) surgical, b) anatomical,

c) serrated-clawed

Anatomical forceps(Fig. 10, a) has a transverse notch on the working surface of the jaws. It is used to hold easily injured organs and tissues of structures (peritoneum, vessel, nerve, intestine, etc.).

Surgical forceps(Fig. 10, b) is used to work with denser tissues (mainly skin, bone, etc.). Inevitably injures tissue.

Serrated tweezers(Fig. 10, c) has an extension in the form of a foot, on which there are notches (teeth). Has a greater fixation ability than surgical forceps, as it has a large gripping area and large quantity cloves. Designed to hold dense tissue (tendon, skin).

Clips for surgical drapes - hoes (Fig. 11, a) are intended for fixing sterile surgical linen (sheet, towel, etc.) to the patient's skin. In this case, only the operating field is opened for the surgeon, and the rest of the body must be covered with sterile linen (sheets, etc.). The slippers can replace other instruments when holding organs and individual anatomical structures (tongue, rib, spermatic cord, etc.).

The working jaws of these instruments are sharpened at the ends for a better grip of the surgical drape.

Clamp for attaching surgical drapes (Mikulich) to the peritoneum (Fig. 11, b) resembles Kocher's hemostatic forceps in design, but apart from the teeth it has an oblique cut on the working jaws.

Fig. 11. Clips for surgical drapes: a) underwear clip,

b) Mikulich clamp

Kornzang- a special clamp designed for the supply of sterile instruments and dressings, for the introduction of tampons and drains. Kornzang has oval sponges, on the working surface of which there is an oval depression and an oblique notch (Fig. 12).

Fig. 12. Kornzang

Tissue holding clamps . In general surgery, tissue fixation clamps are used for a variety of purposes. Most often they are used to hold tissue firmly, but not to separate it from the surrounding tissue: for the purpose of producing traction (traction) or oppositions.

Fig. 13. Clamps for holding tissues: a) tissue clamp,

b) bullet forceps

To achieve the above goals, these tools are designed in such a way that the most important part of them are the ends of the working jaws, which are tightly pressed against each other, and there is a working space between the working jaws. Sometimes there are teeth that fix the instrument well, but they make it traumatic for tissues (Fig. 13, a).

Vaginal cervical forceps (bullet forceps)- the ends of the sponges are pointed (one tooth against the other), there is a ratchet (Fig. 13, b).

Gastric and intestinal pulp (clamps)

Atraumatic intestinal pulp- the ends of the working jaws have the form of transverse stripes, on the inner surfaces of which there are notches (Fig. 14, a). It is used to hold the intestinal wall during colostomy and gastrostomy operations., To stop bleeding when the source is not installed. Can also be used to hold soft and fragile structures ( the fallopian tubes, ureter, appendix, etc.).

Fig. 14. Atraumatic intestinal (a) and hard gastric (b) pulp

Hard (crushing) gastric pulp of Payer's - superimposed on the removed part of the stomach during its resection (Fig. 14, b).

Needle holder - a surgical instrument designed to hold a surgical needle as it passes through tissue when suturing (joining tissue). The design of the needle holder is similar to a hemostatic clamp (Fig. 15).

Fig. 15. Needle holders: a) Gegara, b) Troyanova, c) Mathieu

III. Tissue piercing instruments

Surgical needle is an indispensable tool for suturing and consists of three parts: an ear, a body and a tip (point) (Fig. 16).

Rice. 16. Components of a surgical needle: 1- tip (point),

2 - body, 3 - ear.

Straight needles, ski-shaped needles with a bend near the tip, and arcuate needles are distinguished in shape. Depending on the cross-sectional shape, surgical needles are round (oval), triangular, square, rectangular, trapezoidal (Fig. 17).

The purpose of the needles is different depending on the cross-sectional shape.

1. Round (piercing) needles are also called "intestinal" needles. They are used to pierce the walls of hollow organs: stomach, small and large intestine, biliary tract. These needles can also be used to suture vessels and nerves.

2. Triangular, or "cutting", needles connect the edges of dense organs and tissues - sternum, fascia, tendons, skin. One of the cutting edges of the needle body can be facing outward (curved-cutting needle) or inward (concave-cutting needle) (Fig. 18).

Rice. 17. Features of the shape of the cross-section of the needle body: 1 - round; 2 - oval; 3 - triangular; 4 - square; 5 - rectangular; 6 - trapezoidal.

A curved cutting needle is used to suture especially strong tissues (aponeurosis, tendon, scars, etc.). With this version of the cross-section of the needle body, the destruction of the inner edge of the channel created by the needle is excluded, and thread cutting is prevented. The concave cutting needle is used in many areas of surgery due to its versatility.

Rice. 18. Concave-cutting (1) and concave-cutting (2) needles.

3. Needles with square, rectangular and trapezoidal sections are used for suturing tissues in microsurgery, plastic and eye surgery.

Using needles different shapes depending on the level of actions in the wound, it obeys certain patterns.

1. Tissues located superficially, or organs brought to the surface of the body, can be sutured using straight needles. With such needles, for example, it is possible to suture the skin, the intestine removed from the abdominal cavity, the isolated tendon.

2. The closer the tissue is sutured to the bottom of the narrow wound, the greater the part of the circumference should be the needle.

3. When working in conditions of limited visibility and the need for constant monitoring in the field of view of the position of the needle tip at the most important anatomical elements (vessels and nerves), shortened surgical needles are used.

V modern designs atraumatic needles the thread and the body of the needle are a single whole (Fig. 19), which gives a number of advantages:

Rice. 19. Atraumatic needle

The diameter of the body of the atraumatic needle and the thickness of the thread are the same, minimizing damage to the stitched tissues;

An atraumatic needle is followed by an ordinary thread, as opposed to a double thread with an open or closed eye needle;

Suture material razvlechenie is excluded.

Infusion needle intended for subcutaneous administration of fluid. It has several lateral holes at the end. The needle for blood transfusion (Dufo), in addition to the olive-shaped part, has a corrugated square section on the head for ease of holding and injecting into a vein.

Needle "butterfly"(Strauss "a) short and thick, has a plate near the head, convenient for holding the needle during vein puncture and fixing during prolonged infusion.

Teardrop needle can be straight or curved. It is used to open a vein when a catheter is inserted.

Spinal puncture needle(Bier "a) is distinguished by a massive thick head, easy to hold, as well as a special design of the mandrel, which has its own head. The mandrin fits snugly into the needle channel and its cut coincides with the cut of the needle. Thus, the needle and mandrel make up a single pointed shaft, comparatively easily piercing dense tissue surrounding the spinal canal. Most puncture-biopsy needles are arranged according to the same type. When the end of the needle reaches the required depth, the mandrel is removed and a syringe cone is inserted into the needle head, with which it is removed required amount content.

Fig. 20. Endoscopic trocars

Trocar - a stabbing surgical instrument designed to puncture the walls of human body cavities in order to remove fluids, introduce endoscopic instruments, and also to take material (biopsy) (Fig. 20). The trocar consists of two parts: a rod (stylet) sharpened on one side with a handle on the other, and a tube (cannula). The cannula is shorter than the rod.

The rod, together with the cannula, is inserted through the skin and penetrates into the body cavity (peritoneal or pleural). The stylet is then removed and the tube remains in the cavity. Through it, a catheter is inserted for the outflow of contents (ascites, pleural empyema, etc.), as well as for the introduction of endoscopic devices and instruments.

IV. Expanding and displacing tissue tools

Instruments of this group are used for better exposure of the surgical wound after a skin incision, for pushing back organs and tissues in order to ensure prompt access and the best visibility of the surgical field during the operation.

Retractors (hooks) - are used for superficial retraction: serrated (Volkmann, etc.) and lamellar (Farabef, etc.) or for deep retraction (mirrors), the working part of which is flat or saddle-shaped with a surface polished to a shine that reflects light, which is necessary for additional illumination of the operating room fields (Fig. 21).

Sharp hooks are used to hold the edges of skin wounds, aponeurosis, and other dense structures. Blunt hooks are applied to more delicate tissues (muscles, tendons, etc.).

Fig. 21. Retractors (hooks): a) and b) Volkmann gears,

c) lamellar Farabef, d) sharp single-toothed

Volkmann serrated hook - has an all-metal handle or with a hole for a finger of various configurations; the working surface is represented by multi-toothed sharp or blunt hooks.

Farabef lamellar hook- is a plate with bent ends and a surface treated to a shine, serves to dilute the edges of the wound and soft tissues, to divert large blood vessels and nerves.

Mirrors. Wide and flat plate hooks are called mirrors. Abroad they are called retractors, just like hooks (Fig. 22). It is used for retraction of the abdominal cavity of organs (liver, spleen, etc.) during operations of cholecystectomy, vagotomy, lumbar sympathectomy, etc.

Fig. 22. Mirrors: a) angular and C-shaped, b) hepatic

Retractors - double-sided mirrors that do not require holding during the operation, because they are equipped with a self-locking device and a ratchet (Fig. 23).

Fig. 23. Screw retractor

Shovels, elevators (lifts), spatulas for pushing back and moving apart various organs and tissues.

Fig. 23. Elevator (lift) (a), Buyalsky's spatula (b)

Dissectors - tools for moving tissue apart. These are the main tools for highlighting anatomical features in the area of ​​the lung root.

V. Probing instruments

Probing instruments include probes(Fig. 24) , bougie, guides, catheters, cannulas... The most common probe is the grooved Nelaton probe (Fig. 24, a), which, like the Kocher probe, serves to dissect tissue along the groove or incisions. A bulbous probe is used to probe the cavities and ducts (Fig. 24, b).

Fig. 24. Probes: a) grooved Nelaton, b) Kocher

VI. Auxiliary tools

Ligature needle - it is an instrument with which a surgical thread (ligature) is passed under or through the anatomical structure on which the surgery is performed (Fig. 25). More often, a ligature needle is used to guide the ligature under blood vessels and ducts. The working part of such a needle resembles a curved oval-section surgical needle, the eye of which is located at the beginning of a blunt (Deschamp's needle) (Fig. 25) or pointed end (Cooper's needle). In this case, the bending of the working part can be both to the right and to the left.

Fig. 25. Deschamp ligature needle

Vii. Mechanized tools

TO mechanized tools include automatic tissue staplers, cystourethroscopes, sigmoidoscope, bipolar forceps, fibroesophagogastroduodenoscope.

5. Technique of performing incisions with the SCALPEL.

Performing incisions of various shapes and sizes requires the surgeon different ways holding the scalpel (Fig. 26). The most comfortable position of the scalpel in the hand is provided when holding the instrument with three fingers (like a writing pen). This position allows precise and subtle movements. If it is necessary to carry out figured cuts or fine manipulations with a high degree of accuracy, the scalpel is held like a writing pen using a V finger support. In this case, the brush should rest on the two phalanges of the V finger or on the entire finger (as when writing with a pen), which allows you to more confidently and accurately manipulate the scalpel.

Holding the scalpel like a table knife is used when performing sufficiently deep straight long cuts when a certain pressure on the scalpel is required (for example, various types of midline laparotomy).

The position of the scalpel like a violin bow is used in the production of linear incisions, where there is no need to press on the instrument (dissection of subcutaneous adipose tissue, dissection of fascia, etc.).

Fig. 26. The position of the scalpel in the surgeon's hand a) like a writing pen, b) like a table knife, c) like a bow

One of the main principles of making a skin incision is the same depth throughout its entire length. To achieve this goal, the scalpel at the starting point of the incision is set perpendicular to the plane of the skin and is injected like a spear to the depth of the planned incision. Then, tilting the instrument by about 45-60 °, the incision is continued in one even and smooth movement until the end point, where the scalpel is again brought to a vertical position relative to the skin. This technique also makes it possible to achieve the same length of the wound at the level of all dissected layers and to bring the size of the skin incision as close as possible to the volume of the surgical wound. When dissecting the skin, the scalpel should always be pulled towards oneself, starting from the outermost point of the incision. Sometimes the scalpel is pulled away from itself (for example, when dissecting the fascia with a fluted probe). When making an incision in the skin, it is necessary to ensure that it is perpendicular to its plane. The incision line should always be clearly visible to the surgeon. At complex cuts it is advisable to first outline the line of skin dissection with a dye.

6. Physical methods of tissue separation

6.1 Plasma flow method (plasma scalpel)

To separate tissues in this case, a plasma flow is used, which is formed by passing an electric current through a high-speed jet of an inert gas great strength... The working part of the "plasma" scalpel is a metal cylinder with a pointed part and a nozzle.

The advantages of the plasma flow method are: high cutting speed of tissues due to the significant power of the flow, pronounced analgesic effect of the plasma flow, sterilization of the wound due to ultraviolet radiation and the release of atomic oxygen (ozone), achieving a hemostatic effect when the diameter of blood vessels is not more than 1.5 mm (vessels larger diameter it is necessary to suture or ligate), no damaging effect on the surgeon's eyes, the possibility of achieving the effect of "biological welding".

6.2 Cryosurgical method

The method is based on the possibility of removing a pathological formation after its rapid local freezing with a cryagent either in a spray mode or in a contact mode.

The working part of the cryosurgery devices are quickly cooled handpieces.

Cryagents are liquid nitrogen, freon, carbon dioxide in the form of dry ice, etc.

Local tissue freezing is one of the main methods of destruction in stereotaxic neurosurgery.

The cryosurgical method has found application in oncology, proctology (when removing a malignant tumor of the rectum), urology, etc.

6.3 Electrosurgical method (electric knife)

Disconnection of tissues in this way occurs due to the conversion of electrical energy into thermal energy. An unmodulated electric current is used to dissect tissues. high frequency... Under the action of a high-frequency current, the continuous movement of ions in the tissues leads to the release of a significant amount of heat, which causes the evaporation of cellular elements (transition of liquid into gas) with the destruction of intercellular connections (separation of tissues). The emergence of "lightning" between the electrode and tissues is the main criterion for the correctness of performing electrosurgical cutting. Tissue dissection is more effective when the electrode has a sharp edge, providing maximum energy density.

6.4 Ultrasonic tissue separation

(ultrasonic cutting tools)

In ultrasonic surgery, instruments (knives, saws, drills) are used, the cutting edge of which continuously vibrates with a frequency of 10-100 kHz and an amplitude of 5-50 microns. To achieve these parameters, a magnetostrictive or piezoelectric phenomenon is usually used. High-frequency vibration provides tissue separation due to mechanical destruction of intercellular connections and the development of a cavitation effect (negative pressure formed in tissues due to the development of cavitation leads to boiling of intra- and intercellular fluid at a temperature of 38 ° C. The resulting vapor destroys the cell membranes and, spreading along intercellular spaces, separates tissues). The use of an ultrasonic knife is most advisable for the isolation and excision of scars, removal of tumors, opening of inflammatory foci, allows you to perform a kind of "soft" preparation - tissue stratification and separation of pathologically altered structures from normal ones.

Bone dissection (sternotomy, laminectomy, claviculotomy, etc.) is performed with an ultrasonic saw, on the cutting edge of which teeth are located with a step and a height of 1 mm.

6.5 Laser scalpel

Mechanism of action laser beam on biological tissues is based on the thermal effect on a limited area of ​​the body with the energy of a monochromatic coherent light beam. In the "irradiated" place, the temperature can rise to 400 "C, providing instant combustion and evaporation of the pathologically altered area. The thermal effect on the surrounding tissues extends over a very small distance, since the diameter of the focused beam does not exceed 0.01 mm. Under the influence of laser radiation, occurs not only coagulation of proteins of living tissue, but also its "explosive" destruction during the instantaneous transition of tissue fluid into a gaseous state.

7. RULES FOR USE OF SURGICAL

INSTRUMENTS

All surgical instruments are tools for performing certain actions... To do this, they must be completely controllable, that is, they must be like an extension of the surgeon's hand. This can only be achieved with the correct position of the instrument in the hand. Of course, the “controllability” of most typical surgical instruments is ensured by the observance of the “rule of three fingers”. It is as follows. The instrument is held by I, II and III fingers of the hand: I and III are held with fingers, the branches are brought together and spread (if there are rings in the handle of the instrument, fingers are inserted into them); The second finger is a guide, it is placed over the instrument and guides the instrument to the desired object, in the required direction (Fig. 27). At the same time, as it was said, the surgeon must see his palm.

The tweezers also include the “rule of three fingers”, which is used to hold it like a writing pen (Fig. 28). The force of squeezing the tweezers with your fingers should be minimal, but not excessive, since soft tissue easy to crush, tough to cut through and hard to crush.

Fig. 30 Position of the needle in the needle holder

The needle is grasped with a needle holder, usually at the border of the middle and outer thirds of its length (Fig. 31). Depending on the direction of the puncture of the stitched tissues, the needle is fixed in the needle holder with the tip towards itself or away from itself, or to the left or to the right.

When suturing, measure the thickness of the thread and needle. The thread must be inserted into the second slot (Fig. 29) to ensure that it is firmly secured in the needle. The exception is thick threads, which are left in the first notch of the needle eye.

When sewing the fabric, rotational movements are made with the forearm in the direction of the needle point (Fig. 30). In this case, you should aim the needle in advance, determining the place of both its injection and injection. To ensure the puncture of the needle at the intended point, it is permissible to carefully insert the tissue onto the needle using open tweezers, tightly pressed by the ribs of the jaws on both sides of the intended place of puncture of the needle. This technique is useful when sewing very dense fabrics. If only the end of the needle appears when punching out, then you cannot grip it with the needle holder. It is necessary to intercept the needle closer to the ear and push it further. The withdrawn needle should not be taken with tweezers, but should strive to immediately grasp it with the needle holder. To do this, when applying a suture "on oneself", it is necessary to first pronate the forearm, which is in the supination position at the time of the needle sticking out. When applying a suture "from oneself" at the time of the puncture, the forearm is in the pronation position and, when removing the needle, it must be supined first. If you do not change the position of the forearm when removing the needle, then this will have to be done by rotating the shoulder. Sewing of tissues should be carried out with such pronation and supination movements of the forearm with a motionless hand fixing the needle holder.

8. SUTURE MATERIAL

Currently existing suture materials are classified according to several criteria.

By structure, the following types of threads are distinguished.

1. Monofilament (often incorrectly referred to by the outdated term "monofilament") is a single fiber with a smooth surface. This type of thread includes such widely used materials as prolene, ethylone, dermalon, makson, nylon, surzhilen, surzhipro, miralen, dafilon, coralen (flexamide), maxilen, steel wire, etc. (Fig. 31, a)

2. A complex thread consists of many fibers (often surgeons call a multifilament thread, which is not recommended modern standards). Depending on the method of connecting these fibers, three types of complex threads are distinguished (Fig. 31, b, c, d).

I. Twisted-fibers yarns are twisted along the axis, for example, flax, twisted silk.

2. Wicker - fibers are woven like a rope, for example, lavsan, etibond, mersilei, mersilk, nurolon, dexon II, etc.

3. Coated thread - braided thread impregnated and (or) covered with polymeric materials, for example, vicryl, polysorb, surzhidak, tikron, bralon, supramid, fluorex, fluorlin.

Fig. 31 Types of threads: monofilament (a), complex twisted (b), complex braided (c), complex with a polymer coating (d).

According to the ability to resorb (biodegradation) in the tissues of the body, three types of suture materials are distinguished:

Absorbable (absorbable) - catgut (simple, chrome-plated, with an accelerated resorption period), materials based on polyglycolides (vicryl, polysorb, dexon, makson), materials based on cellulose (occelon, cacelon, rimin), based on polylecaprone 25 (monocryl ), polydioxanone, polyurethane, tendon threads.