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Surgical instruments

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INSTRUMENTS
 I- DISSECTING INSTRUMENTS
1- Scalpel or knife:
PARTS:
 Handle: of different sizes and shapes, with particular
numbers.
 Detachable blade: of different sizes and shapes, with
particular numbers.
USES:
 Sharp dissection.
 Tissue debridement.
 Incising skin.
 Dividing structure that is to be mobilized or removed.

METHOD OF HOLDING:
 Like a pencil in fine cutting.
 Like a broad strokes.
2- Toothed dissecting forceps:
PARTS:
 Handle:
 Joint: spring action.
 Blades: its end has single or multiple teeth.
SIZES:
 Small, medium, and large depending on the size of tissue
and depth of dissection.
USES:
 Holding and retracting the edges of tough structures
during dissection e.g. skin, fascia, aponeurosis, fat and
muscles.
 Catch skin during suturing.
3- Non-toothed dissecting forceps:
PARTS:
 Handle:
 Joint: spring action.
 Blades: its end has no tooth.
SIZES:
 Small, medium and large.
USES:
 Hold delicate structures e.g. blood vessels, small
intestine, and tendons.
 Dissection of delicate structures e.g. dissection of a
hernial sac from the vessels of the spermatic cord, and
exposure of the cystic duct.

METHOD OF HOLDING:
 Like a pencil,
 Use wrist motion to move forceps rather than moving the
forceps with the fingers.
4- Fenestrated Non-toothed dissecting forceps:
PARTS:
 Handle.
 Joint. Spring action.
 Blade: Fenestrated oval termination at the tip, which
allows it to hold delicate, structures better.
USES:
 Hold delicate structures especially intestines.
 Hold the caecum during appendicectomy.
5- Needle holder:
PARTS:
 Handle: long, to provide firm grip on the needle, straight
or curved.
 Joint: screw.
 Ratchet.
 Blade: short (1/5 or 1/3 the blade), with transverse and
vertical serrations to provide a firm grip on the needle.
May be slightly hollowed or split to avoid straightening out
of curved needles.
SIZE:
 Large, medium or small.
 Fine needle holder is used in plastic surgery.
USES:
 Holding needle during sutures.
 May contain scissor.
Method of holding:
 FORCEPS
1- Artery forceps:
PARTS:
 Handle.
 Joint: screw
 Ratchet.
 Blade: with transverse serrations, which fit when, the
handles are closed for good catch and straightening the
blood vessels and tissue.
TYPES:
 Curved: facilitates tying of ligatures especially in deep
wounds.
 Straight.
SIZES:
 Small, medium, and long forceps.
USES:
 Catching a bleeding point by its tip.
 Division ligation of blood vessels by clamping a vessel by
2 forceps and then dividing in between the two.
 Apply traction on the edges of aponeuroses, rectus
sheath, or peritoneum.
 Hold pieces of tissues e.g. piles or omentum.
 The curved artery is useful in tying off bleeding points as
the curve facilitates the tying of the ligature.
 As a dressing forceps
APPLICATION:
 It should be applied by its tip and not by its edge, as the
grasp is strongest at the tip.

Straight artery forceps

 Curved artery forceps

Measure the amount of blood loss:

1- From pulse and blood pressure
Pulse rate Blood pressure Blood loss
90 -100 Over 90 1 liter
100-140 70 -90 1.5 looters
Over 120 Below 70 2 liters
2- Haematocrit value:
3- Observing blood clot:
 A clot the size of a clenched fist corresponds to about 500
ml of blood.
4- Weighting the towels before and after use X (1.5 – 2) + Blood
collected in suction bottle.
5- Presence of Fracture:
 Fracture femur associated with loss of ≥ one liter.
 Fracture pelvis associated with loss of ≥ two liters.
 Multiple fractures associated with loss of 1/3 to ½ of
patient’s blood.
6- Estimation of blood volume by 32P, or 51Cr: Normally = 77ml
blood /kg body weight.
7- CVP:
 Normally = 6 – 12 cm water.
 Below 6 ------ need rapid transfusion.
 Above 12 ---- Stop transfusion.
8- Haemoglobin estimation:
  Normally 6 liters blood contain 12 gm HB, i. e. each liter
blood contain 2 gm HB.
9- Empty veins and cold nose ----- 2 liters loss.

Type of haemorrhage:
1- Traumatic:
A- Primary haemorrhage.
B- Reactionary haemorrhage: within 24 hours after cessation of
primary bleeding.
C- Secondary haemorrhage.
2- Pathological haemorrhage: ulcer or malignancy.
3- Spontaneous haemorrhage: bleed diseases.
2- Mosquito forceps:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: with transverse serrations, which fit when, the
handles are closed for good catch.
TYPES:
 Curved: facilitates tying of ligatures especially in deep
wounds.
 Straight.
USES:
 As artery forceps but for fine and plastic surgery.
 As artery forceps in children.
3- Sinus (dressing) forceps:
PARTS:
 As artery forceps but there is no ratchet on the handles.
 Handle:
= Tapered with pointed tip (sinus forceps).
= Thicker and slightly curved (dressing forceps).
USES:
 Opening abscesses by Hilton’s method.
 Exploring or swabbing out sinuses.
 Wound dressing.
 Hold sutures during their removal.

Criteria of pus formation:

 Hectic fever.
 Thropping pain.
 Oedema of overlying skin
 Fluctuation.
Site requires drainage before fluctuation?
 Ischiorectal fossa.
 Parotid.
 Lobule of ear.
 Breast.
4- Kocher’s forceps:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: longer than artery forceps, its tips provided with a
tooth and a fitting socket, which help to provide good grip
on tissues and avoid slipping.
USES:
 Clamp vascular bands and pedicles or omentum.
 Traction of tough structures as rectus sheath in
paramedian incision.
 Crush the base of the appendix before ligating it.
 Crush the pedicle of the piles before ligating it.
 Crushes for the bowel.
5- Lane’s tissue forceps:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: its tips fenestrated and toothed.
USES:
 Pull upon tough structures as fascia, aponeuroses, or
skin.
 Hold spermatic cord between its two blades during
herniorrhaphy.
 Holding bladder wall.
 Applied around appendix during appendicectomy to
stretch its mesentery.
6- Allis’s forceps:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: flat, long, and its tips provided with fine teeth.
USES:
 Holding tough structures as fascia or skin.
7- Babcock’s forceps:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: its tips fenestrated (to avoid crushing), with no
tooth.
USES:
 Holding delicate structures as intestine, urinary bladder.
 Applied around appendix during appendicectomy to
stretch its mesentery.
 Holding spermatic cord during herniorrhaphy operation.
8- Sponge- holding forceps:
PARTS:
 Handle.
 Joint: screw.
 Ratchet.
 Blade: fenestrated, with transverse serrations.
USES:
 Cleaning the patient’s skin.
 Mopping away blood from the depth of the operative field.
 Hold gallbladder pouch for straight the S-curve of cystic
duct.
 Hold funds of gall bladder.
 Insert gauze packs.
9- Towel forceps and clips:
PARTS:
 Handle.
 Joint: spring action (clip) or screw (forceps).
 Ratchet.
 Blade: curved, with 2 sharp- pointed tips, which overlap
when closed.
 Towel clips are similar but depend on a spring action for
closure.
USES:
 Fix the towel to the skin around the field of operation.
 Stove in chest by traction to elevate the rib.
 Used as tongue forceps to pull out the tongue of the
anaesthetized patient to clear the air passages if any
respiratory obstruction occurs. It pricks the tongue in the
middle line.

Tongue forceps Towel forceps Towel clip

Role of tracheostomy in flail chest:
 Decrease the respiratory effort.
 Decrease paradoxical movement.
 Allow aspiration of secretions.
 Allow positive pressure ventilation through the tube.
First aid management in chest injury:
1- Correct shock and cardio-respiratory embarrassment.
2- Control external haemorrhage, and correction by transfusion.
3- Occlusive dressing of open pneumothorax.
4- Firm strapping of flail chest.
5- Needle and underwater seal for tension pneumothorax.
6- Aspiration of haemothorax.
7- Sedative for pain.
8- Open-air way, bronchial aspiration or tracheostomy.
9- Antibiotics
10- Thoracotomy: in the following cases:
 Extensive wounds with comminuted rib fracture.
 Uncontrollable bleeding.
 Large retained foreign bodies.
 Complicated penetrating wounds.
 Thoraco-abdominal injury.
 Clotted haemothorax.
 Septic complications in the lungs or pleura.
 GASTROINTESTINAL INSTRUMENTS
1- NON-CRUSHING (OCCLUSIVE) CLAMP:
PARTS:
 Handle: short to avoid crushing of the intestine.
 Joint: screw
 Ratchet:
 Blades: light, may be fenestrated, with transverse
serrations (gastric clamp) or longitudinal serrations
(intestinal clamp), and may be covered with rubber tubing.
TYPES:
 Straight or curved.
 Short (non-crushing intestinal clamp) or long (non-
crushing gastric clamp).
USES:
 Occlude intestinal lumen and blood vessels while doing
gastric or intestinal anastomosis.
 Non-crushing gastric clamp steadies the stomach and
control bleeding and prevent escape of its contents during
gastric operations.
 Non-crushing intestinal clamp steadies the intestine and
control bleeding and prevent escape of its contents during
intestinal operations.
APPLICATIONS:
 They are applied on the healthy part of stomach or
intestines to control bleeding and prevent escape of the
contents while doing the intestinal anastomosis.

Non-crushing gastric clamp

Non-crushing intestinal clamp
2- Gastrectomy twin clamp (Lane’s forceps):
PARTS:
= Two occlusive clamps, locked together by two ring forceps.
= Each occlusive clamp formed of:
 Handle: short to avoid crushing of the intestine.
 Joint: screw
 Ratchet:
 Blades: light, fenestrated, with vertical serrations, and
may be covered with rubber tubing.
USES:
 It facilitates the anastomosis of the stomach and
intestines during resection anastomosis of GIT.
 Usually used in gastro-jejunostomy (gastro-
jejunostomy twin clamp).
ADVANTAGES:
 Easy handling.
 Steady the intestine.
 Control bleeding.
 Prevent escape of intestinal contents.

3- Payr’s crushing clamp:

PARTS:
 Handle: Long to crush the intestine.
 Joint: 4 screw
 Blades: heavy, with vertical serrations.
TYPES:
 Crushing intestinal clamp: small
 Crushing gastric clamp: large.
USES:
 Crushing the part of stomach or intestine, which will be
resected during resection anastomosis of the intestine, or
stomach.
APPLICATION:
 Tow crushing clamps are applied to the part of intestines
or stomach, which will be removed.
 In gastrectomy two clamps are applied over the first part
of the duodenum, which is then divided in between the
two. After that the duodenal stump is sutured and
invaginated.

INDICATIONS OF INTESTINAL RESECTION ANASTOMOSIS:

1- Congenital: as duodenal artesian, diverticulum…..
2- Traumatic: multiple intestinal tears, extensive
laceration.
3- Inflammatory: ulcerative colitis.
4- Vascular: as mesenteric vascular occlusion,
strangulation.
5- Neoplastic: as tumour of stomach or intestine.
6- Polyposis.
7- Obesity.
 INSTRUMENTS USED IN BILIARY
SURGERY
1- Cholecystectomy forceps (Moynihan):
PARTS:
 Handle: long
 Joint: screw
 Ratchet:
 Blade: is long and markedly curved at right angle.
USES:
 Pull on Hartmann’s pouch during dissection of cystic duct
and artery.
 Pass a ligature around cystic duct and artery during
cholecystectomy.
 Clamp the cystic duct and cystic artery during
cholecystectomy.
 Pass a ligature around superior thyroid artery during
thyroidectomy.
2- Gall Stone forceps (Desjardin):

PARTS:
 Handle:
 Joint: screw
 No Ratchet:
 Blade: light and fenestrated (for good grip).
USES:
 Remove stones from CBD.
 Remove small renal and ureteric stones.
3- Bile duct dilator (Bakes):
USES:
 Dilatation of CBD.

CAUSES OF CBD STRICTURE:

1- Congenital:
 Choledechal cyst.
 Biliary atresia.
2- Traumatic:
 Post-operative.
 Stone injury.
 Blunt trauma.
3- Inflammatory:
 Cholangitis:
= Pyogenic.
= Sclerosing.
= Parasitic.
 Chronic DU.
 Chronic pancreatitis.
 Chronic cholecystitis.
 Subphrenic abscess.
 Pooling of bile.
 Pooling of blood.
 Lesser sac abscess.
 Granulomatous lymphadenitis.
4- Neoplastic:
 Cholangiocarcinoma.
5- Others:
 Haemobilia.
 Stenosis of papillae.
 Duodenal diverticulum.
COMPLICATIONS OF CBD STRICTURE:
1- Obstructive jaundice.
2- Persistent cholangitis.
3- Multiple intrahepatic abscesses.
4- Septis death.
5- Biliary cirrhosis.
6- Portal hypertension.
7- Eosophageal varices.
 INSTRUMENTS USED IN UROLOGICAL
SURGERY
1- METAL URETHRAL DILATORS:
PARTS:
 Handle:
= Flat.
= It carries two numbers on its handle, which indicate the
caliber at the anterior and the posterior ends. Each unit = ½
mm.
 Blade:
= Curved tip to follow curved urethra.
= It increases in thickness towards the handle, i.e. diameter of
tip is smaller than diameter of stem so it produces gradual
dilatation.
USES:
 Intermittent dilatation of uretheral stricture.
 Dilatation of the ureter.
 Dilatation of bile duct.
 Diagnosis of stone in the urethra or bladder by click.
CAUSES OF URETHRAL STRICTURE:
1- Congenital.
2- Traumatic.
3- Instrumental by catheter.
4- Postoperative as after prostatectomy.
3- Inflammatory: Syphilis, TB, Bilharziasis, and Gonorrhoea.
2- NEPHRO- LITHOTOMY FORCEPS:
PARTS:
 Handle:
 Joint: screw
 No Ratchet:
 Blade: curved, light, and fenestrated.
USES:
 Remove stones from the pelvis and calyces.
 The angled one used to remove stones from the lower
calyx.
 INSTRUMENTS USED IN VASCULAR
SURGERY
1- VEIN STRIPPER:
USES:
 Stripping of the long or short saphenous veins in varicose
veins of the leg.

APPLICATION:
 Expose the vein at the ankle.
 Stripper is introduced until its tip can be
felt at the groin.
 The vein exposed at the saphenous
opening and all the tributaries are ligated
and divided.
 The proximal end of the vein is ligated
and the stripping is carried out by firm
traction on the stripper after tying the
distal end of the vein.
COMPLICATIONS OF VARICOSE VEIN:
1- Thrombophlebitis.
2- Haemorrhage.
3- Oedema.
4- Pigmentation.
5- Ulceration.
6- Squamous cell carcinoma.
2- BULLDOG CLAMP:
PARTS:
 Handle:
 Blade:
 Joint: spring
USES:
 It is an occlusive non-crushing arterial clamp.
 Temporal occlusion of large arteries during direct arterial
surgery e.g. embolectomy, aneurysmorrhaphy, arterial
anastomosis, thromb-endarterectomy, repair of arterial
injury and arterial grafting.
 Its function is to prevent bleeding.
3- SATINSKY’S VENA CAVA CLAMP:
PARTS:
 Handle:
 Joint: screw
 Ratchet:
 Blade: is long and bended.
USES:
 Isolate part of the wall of the inferior vena cava to be
anastomosed to the portal vein in porto-vacal
anastomosis operations.
 Isolate part of the wall of large sized blood vessels for
repair.
 Applied on the renal pedicle to control haemorrhage
during partial nephrectomy.
 Placed over arteries like aorta, iliac ….etc to occlude
their lumen without crushing their walls in operations like
endarterectomy, arterial grafting, and arterial
anastomosis.
 During resection of an aneurysm.
4- Aneurysm Needle:
PARTS:
 Blade: flattened, curved in one plane only, and
completely blunt at the tip with hole for suture.
 Handle.
TYPES:
 Right.
 Left.
USES:
 Pass ligatures around aneurysm and A-V fistula.
 Pass ligatures around superior thyroid artery during
thyroidectomy.
 Pass ligatures around cystic duct and cystic artery during
cholecystectomy.
 Pass ligatures around any deep blood vessels and narrow
pedicles.

Q- Anomalies of cystic artery and duct?

Q- Complications of thyroidectomy?
 INSTRUMENTS USED IN CHEST
SURGERY
1- DOYEN’S RIB RASPATORY:
PARTS:
 Handle.
 Blade: flattened, curved in one plane only, and completely
blunt at the tip.
USES:
 Separate the deep surface of the rib from its periosteum
in operation of rib resection without periosteum.

APPLICATION:
 It is inserted between periosteum and bone from below
upwards to avoid injury of intercostals vessels, which run
along the lower border of the rib, also to avoid injury to
pleura.
TYPES:
 Right or left according to the holding hand.
INDICATIONS OF RIB RESECTION:
A- RIB RESECTION WITH ITS PERIOSTEUM:
 Local disease in the rib e.g.:
1- Osteomyelitis of the rib:
A- Acute:
B- Chronic: TB osteomyelitis, Typhoid osteomyelitis.
2- Tumours in the rib:
A- Benign: chondroma.
B- Malignant: chondrosarcoma.
 Cervical rib.
B- RIB RESECTION WITHOUT ITS PERIOSTEUM:
 In operation of thoracotomy for chest or heart operations.
 Drainage of empyema.
 Exposure of the kidney by high approach.
 Drainage of subphrenic abscess and liver abscess.
2- RIB SHEAR:
PARTS:
 Handle:
 Joint: screw
 Blade:
= Upper is sharp and
= Lower is curved, with blunt tip, groove, and serration.
USES:
 Divide the rib after its periosteum has been separated.
 INSTRUMENTS USED IN NEURO
SURGERY
1- GIGLI’S SAW:
PARTS:
 Serrated wire, each end fitted to a special handle.
 2 hands.
 Gigli’s wire introducer.
USES:
 Elevation of osteoplastic flap from the skull in operations
on the brain.

APPLICATION:
 Burr holes are made at the margins of the flap.
 The durra is separated.
 The guide is introduced between two burr holes.
 The saw threaded over the guide.
 The bridge of bone between the two holes is divided.
2- BONE NIPPLING FORCEPS (SKULL RONGEUR):
PARTS:
 Handle: spring – loaded.
 Joint: screw
 Blade:
= Upper blade: fenestrated to keep bone intact.
= Lower blade: provide with a tooth, which act as a safe gard
against penetration of dura.
USES:
 Widen the trephine or the burr hole by excising its edges.
 Reposition of depressed fracture.
 Remove bony processes.
 Reshape bones.
INDICATIONS OF TREPHINE:
 Compound depressed fracture skull.
 Subdural haemorrhage.
 Drain cerebral haemorrhage.
 Intracranial suppuration.
 Cerebral tumours.
 INSTRUMENTS USED IN ORTHOPEDIC
SURGERY

1- BONE CUTTING FORCEPS:

PARTS:
 Handle: spring – loaded handle
 Joint: one or four joints to increase its strength so that no
great effort is exerted on the handles.
 Blade: straight or curved, sharp upper and lower blades.
USES:
 Divide small bones as phalanges, tarsal bones and
metatarsal bones.
 Divide bony processes (osteophytes).
 Taking bone graft as iliac crest graft.
 Circumcision in infants and children (), its role is:
= Steady the penis in its position during excision of prepuce.
= Protect glans from injury.
= Control bleeding from small blood vessels by crushing it.
2- PERIOSTEAL ELEVATOR:

PARTS:
 Edge: may be sharp or blunt.
 Handle.
 Blade: straight or curved.
USES:
1- Strip the periosteum from the bone.
 TUBES
1- Ryle’s tube: Nasogastric tube:
PARTS:
 It is about 80 cm long.
 Its tip is blind and contains a small lead weight to facilitate its
introduction. It is radioopaque to insure its reach to stomach.
 There are few openings above the tip.
 It is marked at 40 cm (indicate the cardia), then 60 cm (indicate
the pylorus), then 70 cm (indicate the duodenum).
 When the first mark is opposite the teeth the other end is at the
cardia. With the 2nd mark at the teeth it is at the pylorus. With
the 3rd it is in the duodenum.
INDICATIONS = USES:
I- DIAGNOSTIC:
 Gastric function tests.
 Fractional test meal to detect hypo and hyperacidity.
 To detect blood, or bile.
 To apply insulin test to determine whether any secretary fibers
have been left after vagotomy in treatment of peptic ulcer.
 Taking duodenal sample to examine for:
= Bile and pancreatic secretion (obstruction),
= Irregular cholesterol crystal (biliary stone),
= Blood cells and tissue debris (in carcinoma)
= Bacteriological examination of the specimen (infection of
biliary system),
= Trypsin or lipase (pancreatic disease).
II- THERAPEUTIC:
 Aspiration of fluid and gas in the stomach as in:
= Acute gastric dilatation.
= Gastric outlet obstruction.
= Ileus from any cause.
= Intestinal obstruction from any cause.
 Entral feeding as in fractured jaws, trismus, trauma to the
mouth, operation on cardia or esophagus, pharyngeal paralysis,
coma, anorexia nervosa, psychosis.
 In peptic ulceration, a continuous drip of milk through it.
 Internal haemorrhage.
 Upper GIT bleeding.
  Peritonitis.
 Any gastrointestinal surgery.
 Gastric wash in food poisoning.
CONTRAINDICATIONS:
 Recent esophageal or gastric surgery.
 Absence of gag reflex.
 In corrosive poisoning and petroleum poisoning.
 In comatosed patient when the cough reflex is lost, since
regurgitated stomach contents around the tube may drop into
the trachea causing immediate suffocation.
VALUE:
I- BEFORE OPERATION:
 Relieve distension.
 Preserve the vitality of the GIT.
II- DURING OPERATION:
 Prevent aspiration pneumonia.
 Allow easy identification of stomach and duodenum.
III- POST-OPERATIVE:
 Decrease incidence of paralytic ileus.
APPLICATION:
 Sitting or supine position.
 Measure the distance from mouth to earlobe and down to
anterior abdomen below xiphoid process. This marks the
distance of the tube that should be inserted. At least 50: 60 cm
should be introduced from the nose.
 Place tip of tube in cup of ice to stiffen it.
 Apply lubricant to tube.
 Avoid using aerosolized anesthetic for the pharynx as this may
inhibit the gag reflex, which eliminate the airway protective
mechanism.
 Ask patient to flex neck and gently insert tube into a naris
parallel to the hard palate and not in the direction of nose. The
nostril may be anaesthetized with local anaesthetic spray.
  Advance tube into pharynx, asking the patient to swallow if
possible.
 Once the tube has been swallowed, confirm that the
patient can speak clearly and breathe without difficulty.
 Asking the patient to drink water through straws, while the
patient swallows, gently advance the tube to estimated
length.
 Confirm correct placement into stomach by:
A- Inject 20 ml of air while auscultating epigastric area
(bubbling noise).
B- Aspiration of gastric fluid through the tube.
C- Plain X- ray.
 Fix the tube to patient’s nose and gown.
 Irrigate tube with 15 ml of saline every 4 hours.
 Monitor gastric PH every 4-6 hours and correct with antiacids
for pH ( > 4.5 ).
 The ideal length of tube in the stomach is about 10 –15 cm, so
the tube is advanced to midway between the 50 and 60 cm
markers.
 Monitor gastric residuals if tube used for enteral feeding.
 Tube should always be lower than the nose and never taped to
the forehead of the patient.
COMPLICATIONS:
1- Pharyngeal discomfort:
 Due to large caliber tube.
 Treated by: throat lozenges or slips of water or ice.
2- Naris erosion:
 Due to pressure of tube against naris.
 Prevented by: (a) keeping the tube well lubricated, (b) ensuring
that the tube is taped without pressure against naris skin,
mucosa, or cartilage, (c) taped to the forehead of the patient.
3- Sinusitis:
 Due to long-term use of GI tubes.
 Treated by: (a) removal of tube and place in other naris, (b)
antibiotic therapy.
4- Nasotracheal intubations:
 Result in airway obstruction, cough, and inability to speak.
 Avoided by: Confirm correct placement into stomach by….
5- Gastritis:
 Result in mild, self-limited upper GIT bleeding.
  Avoided by: (a) maintaining gastric pH more than 4.5 with
antacids via the tube or IV H2 receptor blockers, (b) Removal
of tubes as soon as possible.
6- Epistaxis:
 Due to trauma to the mucous membrane during passage.
 Usually self-limited.
 If persists, remove the tube and localize the bleed.
7- Eosophageal reflux, esophagitis, esophageal erosion, and
stricture:
 The placement of tube through the gastro-esophageal junction
causes reflux of gastric contents and may induce esophagitis,
which may result in stricture.
 The tube itself may cause erosion of esophageal mucosa,
which may lead to stricture.
8- Mouth breathing:
 Which results in dry mouth and parotitis.
9- Interferes with ventilation and coughing
10- Aspiration pneumonia: so it should not be used with gag reflex
absent.
11- Loss of fluid:
 Nasogastric suction may remove large amounts of fluids from
the upper GIT ----- depletion of chloride, potassium, and
hydrogen ions.
 If the tube passes beyond the pylorus or if there is transpyloric
regurgitation of biliary and pancreatic secretions------ Sodium
depletion.
12- Otitis media, traumatic laryngitis, and hoarseness.
13- Pressure necrosis of the pharynx or the upper esophagus
opposite the cricoid cartilage.
14- Retropharyngeal or laryngeal abscesses.
2- Sengstaken – Blakemore Oesophageal compression tube:
PARTS: it has 2 balloons and 3 lumens:
 Gastric inflatable balloon: stabilize the
Tube, compress the fundic varices and
make porto-azygos disconnection.
 Oesophageal inflatable balloon: compress
the eosophageal varices.
 Port for gastric balloon:
 Port for Esophageal balloon.
 Port for Gastric aspiration: aspiration of
gastric contents including blood clots,
Gastric wash, and for feeding.
INDICATIONS = USES:
 Control haemorrhage from bleeding esophageal varices,
especially in:
1- Excessive bleeding.
2- Recurrent bleeding.
3- Bleeding with no available blood.
CONTRAINDICATIONS:
 Comatosed patient.
VALUE:
= Diagnostic:
 Differentiate bleeding esophageal varices from other causes
of upper GIT bleeding.
= Therapeutic:
 It is only a temporal procedure before definitive operative or
endoscopic therapy.
APPLICATION:
 Monitors the patient in ICU, in supine or lateral decubitus.
 Sedate the patient.
 The balloons of the tube are checked to make sure that they
inflate properly by inflating both esophageal and gastric balloons
with air (till 40 mm Hg and 300 CC respectively) and examine the
tube under water to test for leaks.
 After boiling in water, the tube is lubricated liberally.
 Ask the patient to flex his neck and gently insert tube into a naris.
 Advance tube into pharynx, asking the patient to swallow if
possible.
 Once the tube has been swallowed, confirm that the patient can
speak clearly and breathe without difficulty and gently advance
 tube to stomach to approximately 55 cm (15 cm beyond the mark
noted at the nose).
 Confirm correct placement into stomach by:
A- Inject 20 ml of air while auscultating epigastric area.
B- Return of gastric fluid through the tube.
C-Plain X- rays chest and upper abdomen.
 At first inflate the gastric balloon with 250: 275 ml saline, and
then clamped.
 Then pull the tube until the balloon impinges against the cardia
and the diaphragm.
 Stop inflating the balloon immediately if the patient complains of
pain because this indicate that the balloon is in the esophagus,
deflate the gastric balloon and advance the tube an additional 10
cm and repeat injection of saline.
 Anchor the tube to the patient’s nose under minimal tension with
padding.
 Irrigate the gastric port with 50 cc saline hourly. If no further
gastric bleeding is found, leave the esophageal balloon deflated.
 Insert another nasogastric tube in the upper part of esophagus
and connect this tube to low intermittent suction, or the pharynx
must be aspirated frequently by a mechanical sucker because
the patient is unable to swallow.
 If bleeding persists, inflate the esophageal balloon to a
pressure of 30: 45 mm Hg by connecting the esophageal balloon
port to Y- shaped tube connected to a blood pressure
manometer. This pressure is just necessary to overcome the
portal blood pressure in varices.
 Deflate the esophageal balloon every 6 hours for 5- 10 minutes
to prevent ischemic necrosis of esophageal mucosa and check
for further bleeding by aspirating through the gastric port.
 After 24 hours without evidence of bleeding, deflate the
eosophageal balloon but the gastric balloon should remain
inflated for another 24 hours. After this, the gastric balloon is
deflated and leaves the tube deflated for additional 24 hours.
 After 24 hours without evidence of bleeding the tube can be
removed. If bleeding recurs, reinflate the balloons.
COMPLICATIONS AND MANAGEMENT:
1- Suffocation:
 Occurs if the gastric balloon ruptures.
 Immediate deflation of both gastric and esophageal balloon.
2- Esophageal rupture:
 Due to intraesophageal inflation of gastric balloon.
 Deflate the gastric balloon and remove the SB tube.
 Emergent surgical treatment.
3- Pressure necrosis of lower end esophagus.
4- Stricture esophagus.
5- Aspiration (spillover) pneumonia:
 Prevented by endotracheal intubations, or use of Menithotta 4
luminal tube.
 Treated by: oxygen and antibiotics.
6- Rebleeding following tube removal:
 Reinsert SB tube.
 Endoscopy or definitive surgery.
7- Uncomfortable for the patient.
8- Air embolism.
3- Minnesota Esophageal compression tube:
PARTS:
 Gastric inflatable balloon: stabilize the balloon and make porto-
azygos disconnection.
 Oesophageal inflatable balloon.
 Gastric aspiration port.
 Eosophageal aspiration port: allow aspiration of saliva from the
esophagus above the esophageal balloon.
4- URINARY CATHETERS:
Types of catheter:
1- Nylaton’s catheter.
2- Foley’s catheter
3- Metal catheter:
4- Malcot self-retaining catheter:
5- De Pezzer self-retaining catheter:
6- Gum elastic catheters:
7- Red rubber catheters:
8- Plastic catheters:
1- NYLATON’S CATHETER.
IDENTIFICATION:
 Non-self retaining catheter.
USES:
I- Diagnostic:
 Collection of urine sample for studies (culture, cytology, and
tumour marker).
 Retrograde instillation of contrast agents during ascending
cystourethrography.
 Urodynamic studies.
 Differentiate true anuria from urine retention.
 Diagnosis of urethral stricture.
II- THERAPEUTIC:
 Acute urine retention.
 Urinary output monitoring.
 Irrigation of blood clots.
 Intravesicl chemotherapy.
 Post-operative urethral stinting.
 After prostatectomy: the balloon fills the prostatic bed producing
a haemostatic effect.
 Bladder irrigation because of haematuria.
 Tube caecostomy.
 As an intercostals tube.
 Drainage of:
= Empyema thoracis.
= Subphrenic collection.
= Amoebic liver abscess.
= Peritoneal cavity.
 To assist fluid balance needed in patient with:
 = Surgical operations.
= Coma.
= Shock.
 After rectal enema for evacuation of rectum.
2- FOLEY’S CATHETER:
PARTS:
 Catheter: made of latex rubber or plastic.
 Balloon: below its tip which is inflated with water for fixation.
 Extra channel to allow washing of the bladder may be present
(Foley’s irrigating haemostatic catheter).

INDICATIONS = USES:
I- DIAGNOSTIC: As Nylaton’s catheter +
 Diagnosis or rupture urethra and rupture bladder.
 Diagnosis of renal trauma.
 Monitoring of renal function.
II- THERAPEUTIC: As Nylaton’s catheter +
 During operation: to prevent urine retention and estimate
fluid balance.
 Chronic urine retention.
 As a stent in rupture urethra.
 Support the prostate during bladder wash.
 Compression of prostatic bed after prostatectomy.
CONTRAINDICATIONS:
 Acute prostatitis.
 Suspected urethral disruption associated with trauma:
A- Blood at urethral meatus.
B- Hemoscroyum (blood- filled scrotum).
C- Perineal ecchymoses.
D- Nonpalpable prostate.
E- Inability to void.
 Severe urethral stricture.
APPLICATION:
I- CATHETERIZATION OF MEN:
 Supine position in men and frog- leg in women.
 Place sterile towels around the penis.
 Retract the prepuce if present.
  Grasp the penis laterally with the nondominant hand and place
it on maximum stretch perpendicular to the body to straighten
the anterior urethra.
 Swab the glans with povidone- iodine with the dominant hand.
 Lubricate the catheter with lubricating jelly and grasp with the
dominant hand. Inject 10 ml water-soluble jelly into the urethra
prior to passing the catheter.
 Advance the catheter into the urethra until both hub of the
catheter is reached and urine is returned.
 Inflate the balloon with 10 ml saline.
 If urine is not returned, irrigate the catheter to confirm correct
placement prior to inflating the balloon.
 Replace the foreskin.
 Connect the catheter to a urinary drainage bag.
II- CATHETERIZATION OF DIFFICULT CASES:
 Manual palpates the catheter tip to define the point of
obstruction along the urethra.
A- Penile urethral stricture:
 Use 16 Fr or smaller straight tip Foley.
B- Bulbar urethral stricture:
 Use 16 Fr or smaller curved tip Foley.
C- Spasm of external urinary sphincter (anxiety or pain):
 Inject 10 ml of lubricant.
 After reaching the sphincter, pull the catheter back a few cm.
 Distract the patient with conversation and by having him
breathe deeply.
 Advance the catheter steadily when the patient is relaxed.
D- Benign prostatic hyperplasia and cancer prostate:
 A large catheter 18 –20 Fr provides the additional stiffness
needed to overcome the obstruction.
 Use two person technique: while catheter placement is
attempted in the usual fashion, the assistant places a lubricated
index finger in the rectum and palpates the apex of the
prostate. The tip of the catheter can usually be felt just distal to
the apex.
E- Bladder neck contracture:
 Use 16 Fr caude catheters.
III- CATHETERIZATION OF WOMEN:
 Lithotomy position.
 Place sterile towel around the introitus.
 Spread apart labia minora by nondominant hand.
 Swab the urethral meatus with sterile solution.
  Grasp the lubricated 16 Fr catheter with the dominant hand and
advance it 10 cm through the urethral meatus or until urine is
returned.
 Inflate the balloon with 10 cc saline.
 Attach the catheter to the urinary bag.
COMPLICATIONS AND MANAGEMENT:
1- False passage:
2- Relief of acute retention led to post-obstructive diuresis.
3- Hypotension:
 Early hypotension caused by vasovagal response to the acute
relief of a distended bladder.
 Late hypotension caused by excessive post- obstructive
diuresis.
4- Haematuria:
 Caused by traumatic catheter placement or small mucosal
disruptions following acute relief of a distended bladder.
 Treated with fluids, catheter irrigation and monitoring.
5- Paraphimosis:
CARE OF FOLEY’S CATHETER:
 Change the catheter every 5 days.
 Urinary antiseptic.
 Deflate the balloon before removal.
3- METAL CATHETER:
TYPES:
 Male metal catheter.
 Female variant (curved and S- shaped).
USES:
A- Used during labour to empty bladder.
DISADVANTAGES:
A- Liable to damage the urethera.
B- Produce false passages.

Male metal catheter

Female metal catheter

4- MALCOT SELF-RETAINING CATHETER:
 Self-retaining catheter.
 Made of rubber.

USES:
A- Supra-pubic drainage of the urinary bladder.
B- Drainage of the pleural cavity as in empyema.
C- Drainage of Amoebic liver abscess.
D- Drainage of peritoneal cavity.
D- Stamm’s Gastrostomy.
E- Nephrostomy.
F- Cholecystostomy.
G- Caecostomy.

APPLICATION:
= For insertion and removal, the catheter is stretched over a
special wire called wire stretcher or introducer.

5- DE PEZZER SELF-RETAINING CATHETER:

 Self-retaining catheter.
 Made of rubber.
USES: As Malcot
APPLICATION: As Malcot

6- GUM ELASTIC CATHETERS:

 Made of woven silk and linen covered with gums and oils.
TYPES:
 Coude, bicoude or olive tip.
DISADVANTAGES:
  Cannot be retained in the urethra for more than two days
because gum elastic may fragment.
 Sterilized with formalin vapor.

7- RED RUBBER CATHETERS:

A- Jacque’s catheter:
 Have a solid tip and one lateral eye.

 Disadvantages: (1) Cannot be retained in the urethra for more

than two days because red rubber is very irritant to the urethra.
(2) Sterilized by boiling.
B- Harris catheter:
 Have a hollow tip (permits the use of a metal introducer) and
two lateral eyes.
C- Whistle tip catheter:
 Has on oblique opening at the tip and one lateral eye.
 Made of firm plastic, which will not collapse when suction is
applied.
 Uses:
1- After retropubic prostatectomy
2- Bladder irrigation because of haematuria.
8- PLASTIC CATHETERS:
A- Gibbon’s catheter:
 Long and narrow about 1.5 meters.
 Retained for a long time without producing urethritis, because
its narrow caliber (4, 6,8,10 F) will not obstruct the mouths of
the urethral glands and allow their secretions to pass along the
sides of the catheter.
 Used in cases of retention of urine following traumatic
paraplegia.
 Have fingers for fixation, 30 cm from the tip in the male, and 15
cm from the tip in the females.

B- Tiemann’s catheter:
 Coude catheter.
 Has olivary tip.
 Its bend facilitates its passage with prostatic enlargement.
 Made of hard rubber or plastic.
5- Mausseau – Barbin plastic tube:

USES:
= Provide palliation in patients with esophageal carcinoma.
= Patients with malignant tracheoesophageal fistulas, in whom the
tube is used to occlude the esophageal side of the fistula while
allowing oral alimentation.
= Patients with unresectable esophageal carcinoma.
TYPE OF ENDOESOPHAGEAL TUBES:
1-Celestin:
 Made of polythene.
 25 cm long, 9-14 mm internal diameter.
 Its upper 5 cm forming funnel.
 Inserted through the tumour by pulsion.
 Allow the passage of fluids and saliva.
2- Souttar:
 Made of German spiral silver wire.
 Inserted through the tumour.
 Allow the passage of fluids and saliva.
 Its introduction does not require laparotomy.
3- Mousseau-Barbin.
4- Wilson-Cook.
5- Fell.
6- Mackler.
APPLICATIONS:
I- Pulsion tubes: which are pushed through the tumor with the aid
of an esophagoscope, as Celestin and Souttar tubes.
2- Traction or pull-through tubes, which are pulled into place by
downward traction through a gastrotomy as Mousseau-Barbin.
COMPLICATIONS:
1- Perforation of the esophagus,
2- Migration of the tubes, or
3- Obstruction of the tubes by food or tumor overgrowth.
4- Oral intake must be restricted to a semiliquid diet, and palliation
is far from optimum.
6- T- SHAPED TUBE:
IDENTIFICATION:
 T- Shaped tube made of rubber latex, which is inert to prevent
rejection.
 Has short transverse limb and long vertical limb.
TYPES:
 Common T-tube
 Maingot’s split tube type.
 Fenestrated T-tube

USES:
 Drain the CBD after its exploration and choledocholithotomy.
 Drain the CBD in cholangitis.
 As a splint for repair of a CBD stricture.
 Treatment of missed stone in CBD by irrigation, dissolution by
bile acids infused through the T-tube, or infusion of saline
solution through the T- tube, or removal of the stone by
inserting a dormia basket through T- tube tract under
fluoroscopic observation.
 External biliary drainage in CBD obstruction not amenable to
internal bypass.
 T- tube cholangiogram.
INDICATION OF CBD EXPLORATION :
I- PREOPERATIVE INDICATIONS:
A- Patient with jaundice or history of jaundice.
B- Patient with pancreatitis.
 C- Palin x-ray of gallbladder reveals uneven number of mixed
stones.
D- Intravenous cholangiogram with evidence of obstruction
(dilated CBD, filling defect, no passage of dye to small
intestine).
E- Abdominal US with dilated CBD.
F- Cholangitis.
II- OPERATIVE INDICATIONS:
A- Uneven number of mixed stone.
B- Dilated CBD more than 1 cm.
C- Palpable stone in CBD.
D- Aspiration of CBD reveals biliary mud.
E- Intraoperative cholangiogram with evidence of obstruction.
III- POSTOPERATIVE INDICATIONS:
A- Persistent jaundice after the operation
B- Finding missed stone.
C- Postoperative cholangiogram reveal obstruction.
APPLICATION:
 Take 2 stay sutures in the CBD.
 Longitudinal incision of CBD between the two stays.
 Introduce CBD dilator till reaching the duodenum, if stopped
with click it indicates stone.
 Introduce stone forceps to extract stone.
 Dilator introduced again.
 T-tube introduced with the short limb is placed in the duct and
the long limb comes out through the wound.
 Close the incision in CBD transversely.
CARE OF T-TUBE:
 T- tube connected to receptacle at bed.
 Daily bacteriological examination of biliary secretion.
 Biliary antiseptic must be given.
 Free flow detected by T-tube cholangiogram.
 Prophylactic antibiotic covering is recommended before T- tube
cholangiogram.
 After the cholangiogram the tube is connected to closed gravity
drainage for several hours. If the cholangiogram is normal, the
tube is clamped for 24 hours, if no symptoms develop, the tube
removed.
 Remove it after 10-15 days postoperative if:
= Clamping the T- tube for 48 hour produces no jaundice, pain,
or fever ----- free passage.
 = T- tube cholangiogram shows free passage of day to
duodenum, no residual stone, no dilatation of CBD.
= Bacteriological examination of bile is free.
COMPLICATIONS OF T-TUBE:
1- Cholangitis and cholangiohepatitis: long arm T- tube allows
reflux of duodenal contents into the CBD ---- cholangitis.
2- Pancreatitis: long arm T-tube that enters the duodenum through
the ampulla of Vater may obstruct the orifice of pancreatic duct
------ pancreatitis.
3- CBD stricture.
4- Biliary fistula.
5- CBD obstruction: due to deposit of biliary mud or blood clots
inside T-tube. Treated by irrigation with saline or water, if failed
--- remove the T-tube
6- Slipping during removal of dressing: Avoided by suturing the
tube to the skin and leave long segment of tube intraabdominal.
7- T- tube dislocation: if still allow escape of bile through it to
outsite ---- not remove it. If distal obstruction with bile escapes
around it and peritonitis --- replace the T-tube operatively.
7- Blood transfusion seat:
PARTS:
 Filter
 Plastic tube.
 Needle.
USES:
 Administration of blood, plasma, or fluids.
 Administration of drugs by intravenous drip infusion method.
 Tension pneumothorax.
 Taping.
CAUSES OF FAILURE OF DRIP:
1- Air inlet block.
2- Filter block by clot.
3- Kinked tube.
4- Clot in needle.
5- Venous spasm.
6- Tight bandage.
7- Point of canula against side of vein.
COMPLICATIONS OF BLOOD TRANSFUSION:
1- Disease transmission:
= Hepatitis B and C.
= AIDS.
= Syphilis.
= Brucellosis.
= Malaria.
= Cytomegalovirus.
2- Immediate transfusion reactions:
= Allergic reactions:
 Fever, chills, urticaria, itching, wheezing or stridor in severe
cases.
 Stop transfusion, antihistaminic, epinephrine and steroids.
= Febrile reactions:
 Caused by antigens on WBCs or platelets.
 Fever + chills.
 Antipyretics.
= Haemolytic reactions:
 Caused by crossmatch incompatible blood transfusion.
 Fever, chills, chest, back or flank pain, dyspnea, hypotension
and shock.
 Unexplained generalized bleeding in anesthetized patients.
  Stop transfusion, diuresis by manitol, lactate ringer, Na
bicarbonate.
3- Complications of massive blood transfusion:
= Decreased oxygen- carrying capacity.
= Coagulation defect.
= Hypothermia.
= Metabolic effects:
 Hyperkalemia.
 Acidosis and citrate toxicity.
 Hypocalcaemia.
= Respiratory insufficiency.
8- FLUID TRANSFUSION SEAT:
PARTS:
 No Filter
 Plastic tube.
 Needle.
USES:
 Administration of drugs by intravenous drip infusion method.
 Administration of fluids.
 Tension pneumothorax.
 Taping.
INDICATIONS OF INFUSION THERAPY:
1- To provide normal requirements when oral intake is impossible.
2- Correct deficits: dehydration, hyponatraemia, hypokalaemia,
bicarbonate, low PH.
3- Replace losses.
4- To maintain life in anuria:
CAUSES OF FAILURE OF DRIP:
1- Air inlet block.
2- Filter block by clot.
3- Kinked tube.
4- Clot in needle.
5- Venous spasm.
6- Tight bandage.
7- Point of canula against side of vein.
COMPLICATIONS OF FLUID TRANSFUSION:
 Circulatory overloading.
 Biochemical disturbance.
 Hypoproteinaemia.
 Pyogenic reaction.
 Thrombophlebitis.
 Air embolism.
 Chemical abscess: if irritant.
 Skin sloughing: if potent vasoconstriction.
DISTRIBUTION OF BODY WATER:
1- Intracellular:
 Constitutes about 40% of the body weight.
 Isotonic with ECF.
 Predominant cations are K and Mg.
 Predominant anions are P and proteins.
2- Interstitial:
 Constitutes about 15% of the body weight.
3- Transcellular fluid (third space):
  Includes CSF, serous and synovial fluids, and GIT secretions.
 Normally this non-functioning compartment represents only
about 10% of the interstitial fluids.
 In conditions as intestinal obstruction and peritonitis, it may be
greatly enlarged leading to depletion of the active ECF.
4- Intravascular (blood plasma):
 Constitutes about 5% of the body weight.
 NEEDLES
I- Traumatic needle:
= Have an eye.
= Classified according to cross section into:
1- Cutting: Used for skin suture.
i- Triangular : triangular cross section. Classified according to
their shape into:
A- Straight:
B- Curved: either 3/8, ½, or 5/8 a circle.
C- Half- curved
ii- Flat from side to side: Used for skin suture
2- Rounded: rounded cross section. Used for suturing
Peritoneum, fascia, muscles, or intestine (intestinal needle).
A- Straight:
B- Curved: either 3/8, ½, or 5/8 a circle.
C- Half- curved
II- Atraumatic or eyeless needle: with thread fixed to it, already
sterilized,
A- Straight:
B- Curved: either 3/8, ½, or 5/8 a circle.
C- Half- curved:
 SUTURES
I- ABSORBABLE SUTURES:
1- Catgut:
 Prepared from the collagenous submucosa of the intestines of
sheep.
 There are 2 types:
(1) Plain catgut: absorbed after one week. Used for ligation of
small subcutaneous vessels, suture of subcutaneous fat,
kidney, ureter, and bladder.
(2) Chromicized catgut: prepared by heating plain catgut in a
solution of chromic salts. It is absorbed after 20 - 30 days. Used
for ligation of vessels, and suture of tissues as deep fascia,
muscle, bowel, bladder, and peritoneum.
2- Dixon: synthetic.
3- Vicryl: synthetic.
II- NON-ABSORBABLE SUTURES:
A- Mono-filament: e.g.
1- Nylon.
2- Polyethylene.
3- Dacron.
4- Stainless steel or tantalum or silver wire.
5- Proline.
B- Multi-filament: e.g.
1- Silk:
= Forms:
 Twisted.
 Braided.
 Floss.
= Size:
 Medium size: 0
 Thicker: 1, 2, 3, and 4.
 Finer: 2/0, 3/0, 4/0, and 5/0.
2- Linen:
3- Cotton threads:
 NEEDLE BIOPSIE
INDICATIONS:
1- Differentiate benign and malignant lesions.
2- Evaluation of both palpable and nonpalpable lesions.
3- Evaluation of lesions of the head and neck, thyroid, breast,
liver, kidney, and soft tissue.
ADVANTAGES:
1- Efficient, simple, and safe technique for obtaining a tissue
diagnosis in the outpatient setting or at the bedside.
TYPES: can be subdivided into two types:
(1) Fine needle aspiration (FNC) cytology, in which a small gauge
needl is used to obtain a sample of cells for cytologic
evaluation and
(2) Needle cutting biopsy (LNCB), in which a trocar and large
bore needle are used to obtain a cylinder of tissue for histologic
evaluation.
I. FINE NEEDLE ASPIRATION (FNC)
INDICATIONS;
a. Evaluation of palpable masses.
b. Differentiation of benign from malignant lesions.
b. Aspiration of cysts.
TECHNIQUE:
 If needed, a small amount of 1% lidocaine infiltrated locally.
 Prep the area for aspiration with alcohol.
 Palpate the lesion and immobilize the mass between the
fingertips of the nondommant hand.
 Using the dominant hand, advance a 25-gauge needle with an
attached 10 ml syringe into the lesion.
 Note the consistency of the mass upon entering it with the
needle (firm, soft, rubbery/ doughy, gritty).
 Once the lesion is entered, a full 10 ml of suction is applied to
the syringe.
 While maintaining suction, move the needle back and forth
through the lesion several times in different directions.
 Release the syringe plunger and allow it to return to a neutral
position prior to removing the needle from the lesion. At this
point the specimen is within the needle and should not be in
the syringe.
 Remove the needle from the patient and have the patient
apply pressure to the puncture site with a gauze pad.
 Detach the needle from the syringe.
 Fill the syringe with air.

 Reattach the needle into the syringe.

 Touch the needle tip to a glass microscope slide with the bevel
at a 45-90° angle to the slide surface.
 Expel material within the needle into the slide.
 Make a smear by using a second glass slide to gently press
down and draw out the material to a feathered edge. If the
material is more liquid, it is pulled in the same fashion as a
blood smear, except that before the feathering process is
completed, the spreading slide is raised leaving a line of
particles across the slide.
 The spreading slide is then turned and again pressed down
against the line of particles and, drawn out into a feathered
edge.
 Air dry or apply cytological fixative to the slide.
 Most cytopathologists require 3-6 needles passes (samples) for
an adequate pathologic diagnosis.
  If a cyst is aspirated, the cyst fluid should be sent for cytology.
The region of the cyst should then be reexamined; if a residual
mass is felt, it should then undergo FNA.
COMPLICATIONS AND MANAGEMENT:
a. Bleeding and hematomas
• Thyroid or breast punctures may produce significant
hematomas and ecchymoses. Apply firm direct pressure to
puncture sites immediately follow aspiration.
b. Tracheal puncture
• If the trachea is entered, the suction in the syringe will be lost,
and the aspiration will need to be repeated.
• Puncture is usually of no consequence due to small gauge of
the needle.
c. Infection
• Extremely rare in FNA
• Antibiotics as appropriate
• Incision and drainage as necessary
d. Pneumothorax
• More likely in thin patients and deep lesions
• If tension pneumothorax suspected, decompression with 16
gauges IV into second intercostals space and then tube
thoracostomy.
• If 10 to 20% pneumothorax, observation and serial chest X-
rays.
• If >20% pneumothorax, tube thoracostomy.
 II. LARGE NEEDLE CUTTING BIOPSIES

A. SILVERMAN NEEDLE BIOPSY:

PARTS:
 Outer sheath
 Obturator.
 Cutting insert
INDICATIONS:
 To differentiate benign and malignant lesions
CONTRAINDICATIONS:
 Coagulopathy (PT or PTT >1.3 ratio, or platelets <20,000).
TECHNIQUE
 Sterile prep and drape the lesion to be biopsied.
 Infiltrate the skin overlying by 1% lidocaine using a 25-gauge
needle.
 Make a 5 mm incision in the skin and subcutaneous tissue with
a scalpel.
 Insert the Silverman needle with the obturator in place into the
skin incision to the edge of the mass.
 Remove the obtrurator and place cutting insert into the outer
sheath and advance into the mass.
 Advance the outer sheath by rotation over the cutting insert to
the tip. This maneuver severs the specimen within the blades
of the cutting insert
 Remove the needle with the outer sheath advanced over the
cutting insert.
 Retrieve the specimen and send to pathology for processing.

 Apply a clean sterile dressing to wound and apply pressure for

20-30 minutes.
COMPLICATIONS AND MANAGEMENT:
a. Bleeding and hematomas
• Apply firm direct pressure to puncture sites immediately
following aspiration.
• Correct coagulation abnormalities.
b. Infection
• Antibiotics as appropriate
• Incision and drainage as necessary

B. TRU-CUT NEEDLE BIOPSY :

INDICATIONS:
 To differentiate benign and malignant lesions.
 Evaluation of both palpable and nonpalpable breast lesions.
 Diagnosis of primary liver disease .
 Assessment of the progression of chronic liver disease.
 Detection of liver malignant primary or metastatic disease.
 Documentation of rejection in liver transplant patients.
 Diagnosis of primary renal disease.
 Assessment of the progression of chronic renal disease.
 Documentation of rejection in renal transplant patients.
CONTRAINDICATIONS:
 Coagulopathy (PT or PTT >1.3 rafcio, or platelets <20/000).
 Uncooperative patient.
 Local infection.
 Massive tense ascites is contraindicate liver biopsy.
 Severe uncontrolled hypertension is contraindicate renal
biopsy.
 Known or suspected renal parenchymal infection is
contraindicate renal biopsy.
 Solitary ectopic or horseshoe kidney is contraindicate renal
biopsy (except renal transplant).
TECHNIQUE:
a. Sterile prep and drape the lesion to be biopsied.
b. Infiltrate the skin overlying the 1% lidocaine using a 25-gauge
needle.
c. Using the 22-gauge needle/ infiltrates the subcutaneous tissue
down to the mass with anesthetic.
d. Make a 5 mm incision in the skin and subcutaneous tissue
with a scalpel.
e. Fully retract the obturator of the Tru-Cut needle so that the
specimen notch is covered.

f. Insert the needle into the lesion so that the specimen notch is
within the lesion to be biopsied.
g. Hold the obturator in place and pull outward on the T-shaped
cannula handle to expose the specimen notch.
h. Quickly but carefully advance the T-shaped cannula handle
over the obturator to sever the tissue that had prolapsed into
the open specimen notch.

i. Remove the Tru-Cut needle with the cannula in the advanced

position over the obturator.
j. Advance the obturator to expose the specimen notch and
remove the tissue for pathology.
k. Apply a clean sterile dressing to wound and apply pressure
for 20-30 minutes.
LIVER BIOPSY:
 Map the liver by percussion (or ultrasound).
 Mark the biopsy site on the skin 2-3 cm above the lower margin
of the liver in the midaxillary line.
 Sterile prep and drape the right upper quadrant of the
abdomen.
 Infiltrate the skin with 1% lidocaine over the biopsy site.
 Using a 22-gauge needle, infiltrate the subcutaneous tissue
with local anesthetic. With a scalpel blade, make a 5 mm skin
incision.
 Fully retract the obturator of the Tru-Cut needle so that the
specimen notch is covered.
 Ask the patient to take a deep breath and hold it.
 Insert the needle into the liver so that the specimen notch is
within the lesion to be biopsied. The needle should only need to
be inserted 2-4 cm.
 Ask the patient to exhale and hold their breath.
 Hold the obturator in place and pull outward on the T-shaped
cannula handle to expose the specimen notch.
 Quickly but carefully advance the T-shaped cannula handle
over the obturator to sever the tissue that had prolapsed into
the open specimen notch.
 Remove the Tru-Cut needle with the cannula in the advanced
position over the obturator.
 Advance the obturator to expose the spedmen notch and
remove the tissue for pathology.
 Apply a dean sterile dressing to wound and apply pressure for
20-30 minutes.
 Patient should lie on the right side for at least two hours.
KIDNEY BIOPSY:
 Percutaneous renal biopsy is performed with the patient in the
prone position with a roll placed under the patient between the
rib cage and the pelvis.
 Transplant biopsies are perforrned with the patient in a supine
position.
 Sterile prep and drape the appropriate flank area.
 Confirm the position of the kidney by ultrasound. Using a 25-
gauge needle, infiltrate the skin with 1% lidocaine over the
biopsy site (lower pole of kidney).
 Using a 22-gauge needle/ infiltrates the subcutaneous tissue
with local anesthetic.
 Make a 5 mm incision through the skin and subcutaneous
tissue with a scalpel blade.
  Ask the patient to hold his or her breath in inspiration and
advance the locating needle is under ultrasound guidance into
the kidney.
 Release the needle and ask the patient to breathe in and out
normally. If the needle is in proper position, the end of the
needle will move in a cephalic direction on inspiration and in a
caudal direction on expiration.
 Determine the depth of the kidney by measuring the distance
from the needle tip to where it exits the skin.
 Remove the locating needle and advance the Silverman or Tru-
cut needle into the kidney at the same angle and depth as the
locating needle.
COMPLICATIONS AND MANAGEMENT:
a. Bleeding and haematomas
• Apply firm direct pressure to puncture sites immediately
following aspiration.
• Correct coagulation abnormalities.
• Surgical exploration if necessary
b. Infection
• Antibiotics as appropriate
• Incision and drainage as necessary
• Operative drainage as necessary
c. Pneumothorax
• During liver or renal biopsy in thin patients and deep lesions
• If tension pneumothorax suspected, decompression with 16
gauges IV into second intercostals space and then tube
thoracostomy.
• If 10-20% pneumothorax, observation and serial chest X-rays.
• If >20% pneumothorax, tube thoracostomy .
 DRAINS
INDICATIONS:
1. Pneumothorax (simple, tension).
2. Nonfunctioning gastrointestinal tract for a period more than1 or
2 days : requires nasogastric drainage.
= Decrease abdominal distention, intestinal dilation, nausea,
and vomiting.
= Allows a determination of the amount and type of fluid loss
so that appropriate replacement can be made.
3. Areas where extensive dissection has been performed in a
closed space, for example, (1) surgical procedures performed
on solid organs, such as the liver or kidney, (2) where
haemostasis is difficult and a postoperative haematoma is
likely, (3) procedures, such as mastectomies or skin flaps,
where there is a large raw area and little surrounding tissue to
tamponade the bleeding.
4. Abscesses that do not communicate with the skin and, thus, do
not provide direct access for local wound management requires
drainage. This usually involves a deep but well-walled-off
abscess cavity, such as a subphrenic, subhepatic, or
periappendiceal abscess. Drains should not be used to control
a generalized infection, such as cellulites or suppurative
peritonitis.
5. Surgical procedures as:
= Colecystectomy ------ drain put in Gallbladder bed.
= Pancreatic surgery ----- drain put in pancreatic region
= Gastrectomy with Biliroth Il reconstruction ---- drain put
Adjacent to or in the duodenal stump.
= Low anterior resection of the colon ---- drain put in the pelvis
= Splenectomy ----- drain put in splenic bed.
= Thoracotomy (except for pneumonectomy) ------ drain put in
the pleural space.
6. To empty existing fluids and those that might collect later.
7. To drains, blood, body secretions, or air.
8. To prevent the formation of spaces which prevent tissue
surfaces from coming into comact and healing.
9.To avoids ischaemia, infection, and tension to sutures.
10. To removes a potential nidus for infection, so drains protect
against future fluid collection, and infection.
11. Leaking wound.
12. Infected wound.
13. Peritonitis.
PRINCIPLES
 Drain by formation of stoma into the surface: The simplest and
most effective method of drainage is to bring the structure or
cavity to be drained to the surface by forming a stoma (Greck =
mouth) into the surface, for example bowel that is obstructed
distally may be brought to the surface as an enterostomy or
colostomy.
 Drain by gravity, or by suction: an artificial drain pass down to
the source of fluid, which flows from a cavity by gravity, or by
suction.
 Drain by force of capillarity: fluid move along fine tubes, or
between the fibers of gauze packs and wicks, which soak up
fluids by this action.
IDEAL DRAIN SHOULD BE:
 Soft.
 Least irritant materials.
 Does not press upon damaged or delicate structures or suture
lines.
 Its path away from important structures, which might be
damaged, or nerves that, might be caught up in the scar and
cause discomfort or pain.
 Its presence does not delay the healing of the main wound: on
occasion it can be sited at one end of the main wound but as a
rule plan to pass thin drains down separate tracks.
 Dependent: a gravity drain passes inwards and upwards,
(suction drain passes inwards and downwards) so that its tip
lies in the most dependent part where fluid will collect.
 To avoid the possibility of infection tracking down the drain; try
to use a closed system if possible.
TYPES:
I- Packs and Wicks.
2- Corrugated Sheet drains:
 Rubber or plastic.
3- Tube Drains
I- PACKS AND WICKS
 Gauze packs: folded sheets of sterile cotton gauze placed on
the raw surface, such as an abscess cavity, or as initial
treatment of an infected wound.
 The gauze will soak up fluid most effectively if it is dry.
 Gauze left in contact with raw tissues soon becomes adherent
to them by the deposition of fibrin threads, so that when it is
removed the raw area may be damaged.
 To prevent the gauze becoming adherent: soak the pack in
sterile liquid paraffin with an antiseptic; however, this destroys
the ability of the gauze to soak up fluid, which must now track
between the raw surface and the paraffin-soaked gauze.

The pack should be large enough to absorb the expected discharge. It is

covered with a folded sheet of dry gauze
 Or a thin non-adherent layer (paraffin jelly) can first be laid on
the raw surface through which fluid may pass to reach dry
gauze laid on the non-adherent layer.
 If cotton wool becomes wet it forms a hard cake and the
purpose of applying it is lost.
 Packs should be changed before they become completely
soaked through; otherwise they provide a moist channel from
the exterior for the penetration of organisms to the raw surface.
 As a rule, infected wound dressings are changed at least once
daily until the discharge has ceased and the surrounding skin is
no longer red and oedematous, usually after 3-7 days.
 The wound may then be closed by delayed primary closure, by
bringing in skin flaps or by skin grafts.
WICKS:
 Folded gauze sheet or ribbon passed down a track to the site
of the discharge.
 Where the source of drainage cannot be left fully exposed, or
brought to the surface,
 This is a much less satisfactory method because the wick
rapidly becomes soaked by the ooze from the track prepared
for it.
 If it is made of folded gauze it swells when it becomes soaked
and this occludes the track along which the fluid should
discharge.
 Folded gauze sheet or ribbon is passed down a track
to the site of the discharge
 Such wicks should be changed frequently and sometimes the
removal of the wick is followed by a gush of retained fluid.
 Because wicks become adherent to the tissues through which
they pass, they may be threaded through flexible thin-walled
rubber tubing, which keeps the gauze out of contact with the
tissues along the track but allows the gauze to absorb a limited
amount of fluid from the depths of the track. Such a drain is
called a 'cigarette' drain.
 If the amount of discharge is expected to be minimal, a wick
can be constructed from threads of ligature or suture material
twisted together or bound loosely.

A cigarene drain. Folded gauze sheet or ribbon gauze

is passcd through a thin-walled rubber tube and acts as a wick
2- SHEET DRAINS:
 A sheet of latex rubber or plastic material often corrugated so
that fluid can track to the surface in the gutters.
 The Yeates drain is a sheet formed from parallel plastic tubes
but very little fluid passes through the tubes once they have
filled it tends to track alongside the drain.

A corrugated sheet drain of latex rubber or plastic maierial.

Notc that it is sutured in place and a safety pin transfixes ihe projecting
portion

Ycatcs drain, a sheet formed of parallel tube of plastic material

 With both these drains, fluid reaches the surface by gravity or

vis a tergo and it must then be soaked up by gauze packs
covering the projecting part of the drains.
 Sheet drains must be firmly anchored to the skin for fear that
they might slip into the wound and be lost. A sterile safety pin is
usually inserted through the projecting part as an extra
precaution.
  Although these drains are not very efficient, they are popular
for draining abscesses and as a temporary means of providing
a track to the surface where the volume of discharge is likely to
be small.
3- TUBE DRAINS:
 Various types of tubes are used to drain either normal body
fluid that cannot be handled by the body or abnormal material,
such as pus.
 A tube can be mandatory, such as a chest tube for a tension
pneumothorax, or optional.
Types of tube drains:
A- Closed drains: tubes connecting a body cavity to a sealed
reservoir.
(1) Gravity drainage: allows material that collects to drain
through the tube into a reservoir at a lower level.
(2) Underwater-seal drainage systems: prevent air and fluid
from reentering the body. The end of the drainage tube is
under water in a sealed drainage bottle at floor level. The
water prevents air from reentering the tube, and the low
level prevents fluid from siphoning back. This system is used
for tubes in the pleural space.
(3) Suction drainage: applies a low level of suction to the
drainage tube and can drain large volumes of fluid, such as
the fluid that collects in the gastrointestinal tract. It also
promotes closure of dead space allowing a better
approximation of tissue surfaces.
B- Open drains: are not sealed at either end. They allow bacteria
and other materials access to the drained area and, as a
result, carry a high risk has deep wound infection. Open
drains have been used for many years, however, still part of
the surgical routine in some centers.
C. Sump drains: are double-lumen catheters that allow air or
irrigation fluid to enter through one lumen while suction is
applied to the other lumen. When air is allowed to enter, a
filter should be used to prevent the entrance of
microorganisms. Sump drains are used to evacuate
particulate matter, such as debris from an abscess or as
continuous irrigation catheters for closed spaces that are not
otherwise accessible, such as deep abdominal abscesses.
Advantage:
 Once fluid has entered the tube it can be led away into a bag or
other reservoir, thus forming a closed system so that infection
cannot track inwards to the raw tissues.
 If the tube is inserted pointing upwards, then fluid tends to drain
by gravity and a column of fluid within the tubing exerts a
gravitational suction action, as it tends to run downwards into
the collecting bags.
 Fluid is forced out by intraabdominal pressure, which rises
intermittently above, atmospheric and fluid may then be forced
out through the drain.

Tube drain with multiple side holes, made of latex rubber or plastic matenal,
it is secured by a stitch through the skin that is loosely ded and the ends are
taken back and forth round the tube and finally tied.
Disadvantages:
 When fluid has entered the tube, it may stagnate and not be
discharged.
 Fluid will flow only if it is not viscous and if the tube is
sufficiently wide so that air can get in to displace it.
 If the tube is too thin the force of capillarity tends to retard the
free flow of fluid through it.
 A limb may be compressed with bandages so that any fluid,
which collects, is forced out along a drain.
Suction drainage:
 The most effective method of removing fluid is to suck it out.
 In this case the tube is inserted downwards where possible so
that the tip lies at the bottom of any pooled fluid.
 A simple method is to attach the drain tube to a syringe fitted
with an elastic bulb that tends to reexpand when it is
compressed.
 After squeezing the bulb, the syringe is attached to the drain
tube and exerts suction on it.
 When the syringe fills with fluid and the bulb re-expands, it is
detached from the drain, emptied of fluid and air, and
reattached to the drain tube. Such a system works only if there
is no air leak, which would allow the bulb of the syringe to fill
rapidly.
 A proprietary system uses a bottle, which can be evacuated
with a vacuum pump and is then attached to the drain and acts
as a suction reservoir.
 The bottle cap incorporates an indicator to signal when the
pressure has risen to atmospheric; the bottle must then be
reevaluated.
 The most versatile method of applying suction to a drain tube is
to use a small electrically driven vacuum pump incorporating a
reservoir to collect any discharge from the drain.
 The methods of applying suction to be tube drain suffer from
the defect that tissue lining the tube track tends to be drawn
into the tube holes, blocking them, and rendering the system
completely ineffective.
 This can be partially overcome by using a pump that
automatically and intermittently breaks the vacuum, allowing
the pressure to rise to atmospheric — even so; the tissue may
remain trapped in the tube holes.
 Suction drainage using apparatus that allows air to leak into the
depths of the wound prevents tissues from being drawn into the
tube holes, and the Shirley drain incorporates a side tube
carrying air to the end of the main tube; the side tube is
protected with a bacterial filter.

Shirley wound drain. This incorporates a side tube guarded by a bacterial

filter so that sterile air can be dravvn down to the drain tip. When suction is
applied, the air leak prevents tissues being sucked into the holes of the drain
and blocking them.
Sump drains:
 A sump drain achieves the same end in a different manner.

Sump drain: The large outer tube creates a cavity in which fluid collects. A
smaller tube attached to a source of suction so that the accumulated fluid is
removed.
 A large-bore outer tube lies against the tissues and allows fluid
to pass through its holes to collect at the bottom by gravity.
Lying within this outer tube is a smaller, inner tube to which
suction is applied; thus the sucking action is limited to the
contents of the large, outer sump and docs not impinge upon
the tissues.
SITES OF DRAINS:
1- Subcutaneous:
 Subcutaneous tissues vary in depth and vascularity in different
parts of the body and in different individuals.
 Blood and reaction fluid collect especially when the skin has
been extensively undermined.
 Small collections can be drained using gauze wicks and
corrugated sheet drains or the fingers out from sterile operating
gloves.
 As an alternative, soft tube drains with multiple side holes may
be laid under the skin and these can be attached to a source of
gentle suction.
 In many sites such suction drains have replaced former
attempts to apply even pressure by means of cotton wool and
crepe bandages in the hope of preventing fluid from collecting.
 In the presence of severe contamination or infection do not
attempt to close the skin, hoping that one or more drains will
provide adequate means of channeling any discharge to the
surface.
  The only safe method of treating such a wound is to leave it
completely open and pack it with sterile gauze changed daily.
 When the discharge has ceased and provided the skin edges
are no longer red and oedematous, it is safe to close the skin.
2- Subfascial and intramuscular :
 Do not trust drains in the presence of damaged muscle trapped
beneath strong fascial coverings, since fluid collecting here
raises the pressure and causes ischaemia with risk of infection
from anaerobic organisms.
 Leave the fascia open, or even slit it further, to ensure
adequate drainage .
3- Extraperitoneal:
 As a rulc, after removing a source of intraperitoneal infection
the peritoneum can deal with the infection.
 However, the extraperitoneal tissues in the operation frequently
become infected and discharge after being closed. Therefore a
drain may be placed down to the closed peritoneum through
one end of the wound or through a separate stab wound, in the
hope of guiding any fluid collection to the surface.
 An alternative is to leave the contaminated skin wound open
and perform delayed primary closure when the surfaces are
clean and have ceased to discharge.
4- Intraperitoneal:
 This form of drainage is the subject of bkter controversy. It was
shown at the turn of this century that a drain is usually sealed
off within 6 hours.
 It is likely that the drain acts as a foreign body and that the
discharging fluid is reaction fluid to its presence.
 However, in some circumstances mtrapen-toneal drains work
for prolonged periods if so much fluid is generated that the
peritoneal surfaces cannot come into opposition and seal off,
as in ascites.
 Although drains will discharge at kast some of the fluid already
present, the fiercest arguments centre around their ability to
channel subsequent fluid collections to the surface and so
signal a haemorrhagc or the breakdown of smure lines with
consequent leakage into the peritoneal cavity. It is likely that all
the criticisms and claims may be correct in some
circumstances. Therefore, until you acquire firm views use
drains where orthodox practice favours them.
 It is usual to insert a drain following the removal of a gall-
bladder , and the drain often discharges a little bile-stained
 iluid.
 Insert a drain, if it gives you comfort, after completing a difficult
anastomosis, but make sure the drain is soft and so placed that
it will not delay healing of the tissues, or iniure them.
 Even more important, make sure that the insertion of a drain is
not replacing more effective safeguards, such as the selection
of another procedure, manoeuvres to defunction the
anastomotic site, bringing the anastomotic site itself to the
surface, mobilization and further resection to allow a better
anastomosis to be fashioned and perfection of the technique of
anastomotic suture.
 Having inserted a drain, do not rely upon it to warn of a leak but
determine to act if other features point to a leak, even though
no discharge has appeared from the drain.
 Intraperitoneal drains are usually made of soft latex or plastic
material and may be corrugated sheets or tubular drains.
 As a rule, insert them through a small stab wound separatc
from the main entry wound.
 Make surc the sitc is clear of major nerves and blood vessels in
the abdominal wall. Make sure that the track is straight to do
this, grasp the peritoneum and posterior rectus sheath of the
main wound on the side of thc drain site with strong artery
forceps and draw the retracted peritoneum and sheath towards
the opposite side of the wound.
 Now lift the whole abdominal wall upwards and clear of the
underlying viscera while cutting straight through the full
thickness of the abdominal wall with a scalpel, taking care to
cut the peritoneum under vision, thus avoiding damage to intra-
abdominal contents.
 Push a long straight artery forceps from skin into the
peritoneum and grasp what will be the external end of the drain
and draw it out through the stab wound.
 Carefully place the inner end of the drain in the most
dependent part where fluid is likely to accumulate but make
sure there are no sharp ends pressing upon delicate structures.
 Now insert a stitch through the skin and drain, and tie it, leaving
the ends long. Place a large safety pin through a sheet drain as
an extra precaution against it dropping into the wound.
 If you are using a closed tube drainage system, insert the skin
stitch, tie it loosely, then take a number of turns round the drain
tubc, back and forth, tying the ligature to fix the tube.
 It is sometimes permissible to insert a drain into the peritoneal
 cavity at one end of the main wound. In this case, make sure
not to include the drain in the suture of the main wound,
otherwise the drain cannot be removed without prejudicing the
main wound closure.
 If any infected material is likely to discharge, always eschew
this method, for fear of infecting the whole wound.
 Whenever possible, drains that rely upon gravity should reach
the body surface at a dependent part but this is not easy to
arrange.
 Conversely, drains that will rely upon suction for removal of the
fluid, such as sump drains, shouid be placed with their tips at
the most dependent part within the peritoneal cavity.
 Sheet drains are covered with a gauze pad to soak up any
dischargc and this is added to or replaced as necessary.
 Tube drains may be connected via sterile tubing to a
disposabie collection bag.
 Plan to remove intraperitoneal drains after 48 hours as a
routine, by which time they have usually ceased to discharge
fluid. However, if fluid is still escaping, retam the drain until it
ccases.
 When a drain has been placed very deeply it is sometimes
removed in stages, being "shortened" cach day unril it is finally
withdrawn.
5- Pleural cavity:
 This type of drain requires special mendon because although
liquid may be drained, the main function of intra-pleural drains
is usually to remove air that has leaked into the pieural cavity
from outside or as a result of lung mjury or operation. If the
pleural cavity becomes filled with air, the lung coilapses.
 A tube is imroduced through the chest wall just above the
upper border of a rib, usuaily in the posterior axillary line in the
seventh or eighth intercostal space, or in the second intercostal
space anteriorly, 3-5 cm from the lateral edgc of the stcrnum.
 Intrapleural drain with under-vvater seal. The tubular chest drain emerges
through the chest wall wliere it is secured by an encircling stitch to the chest
wall. From the drain a tube connects it to the vertical transparent plastic tube
which passes through ihe bung of a large bottle. The tip of the transparent
tube is submerged beneath the surface of the sterile water in the bottom of
the bottle. The angled tube allows air to escape from the bottle. It can be
attached to a source of gentle suction

 When the chest is opened at operation, a stab is made with a

pointed scalpel and the tips of long-bladed forceps are inserted
from externally into the pleura space, grasping what will be the
ouier end of the non-collapsible tubing and drawing it through
the chest wall.
 If the chest wall is not opcn, thc tubc can be inserted as a
sterile procedure under local anaesthesia.
 After cleaning the skin and injecting local anacsthetic
subcutaneously and decply, a nick is made in the skin with the
tip of a sharp scalpel.
 The drain tube is now inserted, mounted on a pointed trocar.
 Firmly grasp the tube and contained trocar with one gloved
hand, at a distance from the tip of the trocar that will prevent
penetration beyond the chest wall, while exerting pressure with
the other hand.
 This prevents the pointed trocar from being thrust deeply into
the thorax. When resistance is ovcrcome, signalling that the
pleural cavity is reached, keep the trocar still and advanec the
tube over it. Now withdraw the trocar, and temporarily clamp
the tube to prevent air entering.
 A proprietary prepacked trocar and cannula set is available.
 Insert a stitch through the skin near the tube, but not through
 the tube. Tie the stitch loosely, leaving the ends long and take
them round the tube, back and forth, tying the threads round
the tube to fix it.
 Insert a separate stitch across the wound, again avoiding the
tube.
 Leave the ends untied but fixed with adhesive plaster; this
suture can be tied to close the hole wheo the tube is withdrawn.
 Attach the outer end of the chest drain to sterik tubing which
leads to an underwater seal bottle.
 The tubing is attached to a venical transparent tube, preferably
of plastic material rather than glass, which may break and
cause injury if the tube needs to be changed.
 This pierces the bung of a large bottle and descends almost to
the base of the bottle, which contams sterile water, covermg
the lower end of the tube.
 The bottle is kept on the floor. A short angled tube pierces the
bung and allows the escape of air from the bottie. Ifthe chest
drain was temporarily ciamped, remove the clamp when the
underwater sealed drain is correctiy connected.
 If the intrapleural pressure rises above atmospheric, air is
expelled down the drain tube and bubbles up through the water
in the bottle to escape through the short angied tube.
 When intrapleural pressure falls beiow atmospheric water is
sucked a few centimetres up the vertical limb of the under-
water tube.
 Thus during normal breathing the water level in the vertical
glass tubing oscillates as intrapleural pressure varics vvith
inspiration and expiration, signalimg that the systems
functioning correctly and is not blocked.
 If liquid drains out of the chest it may be trapped in a loop of
dependem rubber tube, or coilect in the vertical limb of
transparont tube, so that oscijllation i§ damped.
 To empty thd tubing, first doubly clamp the emerging chest
drain. Disconnect the attached tubing and eievatc thc end,
allowing all the liquid to run into the bottle.
 Now firmly reconnect the tubing to thc chest drain and removc
the two clamps.
 The water level in the vertica! limb of transparent tubing is now
at approximately the same level as the water in tlic bottle and
once again oscillates with respiration.
 If the water level in the bottle was markcd, a rise in the level
indicates the volume of liquid drained from the chest.If air leaks
 rapidly into the pleural cavity, the lung may be kept efliciently
expandcd by attaching a gently acting electric suction pump 10
thc short limb of tubmg emerging from the bottie, thus
maintaining the prcssure in the bottle at slighdy below
atmosphcric.
 This will result in a temporary incrcase in the rate of bubbling
from thc vertical transparent tube as air is withdrawn from the
pleural cavity.
 As the lung expands and the leak is scalcd, the rate of bubbling
falls.Intrapleural drains are usually scaled off and fail lo func-
tion within 48 hours, as signalled by cessalion of oscillation.
 If suction has becn applied to the bottle, no osciUation is seen
but sealing is signalled by the ccssatibn of bubbling for at least
24 hours.
 The chest drain can now be removed, after cutting the retalning
stitch. It is usually vvorth attaching the bottle to a source of
suction while removing the drain, so that any Huid along the
drain track is removed.
 The untied stitch is now ticd to seal the drnin holc. Allernativcly,
ihc drain hole is covcred with an impermeable adhesive plaster.
6- Abscesses and cysts:
 These are eminently suitable for drainage. After thc initial
cvacuation of contents, the discharge is usually small but
drainage is maintained to allow the cavity to shrink and become
partiaily or completely obliterated.
 They may be draincd by open or ciosed methods.
7- Fistulas:
 Some fistulas do not produce a large volume of discharge and
arc unsuitablc for trearmcnt by drainage.
 Other fistulas are unsuitabie tor conscrvalivc managcmcni and
are ircaied surgically, including laying open the track, excising it
and drainmg the raw surface by applying packs.
 Some fistulas, especially those from the gastrointesrinal iract,
produce voluminous discharge and this may be irritant to the
skin if it contains digestive juices.
 If they are managed conservatively they may demand
considerabie ingcnuity to prevent severe excoriation and
breakdown of the tissues along the track.
 Drainage can sometimes be achieved by applying a collection
bag.
 The commonly used bags are disposable and have an
adhesive backing.
  A hole is cut to fit accurately over the fistula, and after cleaning
and drying the surrounding skin, the adhesive bag is fitted over
the hole.
 The bag can be replaced when it is full but repeated removal
and replacement of the bag damages the skin. Consequently, it
may be best to drain the bag through a tap or by cutting off a
dcpendent corner, emptying the bag, then folding over the
corner and sealing it with a simple paper clip until it refilis.
 Stoma bags are available that fit over a flange on a ring that is
fitted and secured round the hole. The adherent ring is left in
place and the bag is removed, discarded and replaced withont
disturbing it.
 With both types of apparatus, the hole in the adhesive backing
should be accurately cut so that skin is not exposed to irritant
discharge.
 Also, the skin must be carefully deaned and dried beforehand,
and the contact must be perfect between skin and adhesive, or
fluid will track under the backing.
 Some forms of fistula can be covered with a closely fitting box
which is connected to a source of suction.
 Any fluid entering the box is promptly removed. However, it is
difficult to obtain a perfcct fit that prcvents ieakage.
 When an external collecrion apparatus cannot be fitted, a
catheter can be passed down the fistulous track and this may
also be attached to a source of gentle suction.
 Such a fistula is most easily managed if the drainage is onto a
superior surface, so that Huid remains in thc depths as a sump
that can bc sucked out. If such a fistula drains onto a
depcndent surface, then ieakage occurs around the catheter as
fluid escapes by gravity.
 A Foley self-retaining catheter sometimes provides an excellent
means of emptying a fistulous track.
 The catheter is passed into the track and thc retaining bag is
then filled with sufficient fluid to retain the catheter and seal off
the mouth of the track.
 Suction is now applied to the main catheter tube to empty the
discharge.
COMPLICATIONS:
1. The presence of a drain does not guarantee that an abscess
or other collection will not reform. The foreign body reaction
can isolate a drain from adjacent tissues, preventing blood,
pus, or other fluid from having access to the lumen.
 2. Drains and the tissues that they traverse can be colonized by
microorganisms from exogenous sources. Drains, particularly
open drains, increase the risk of infection. Avoiding bacterial
colonization requires careful wound care at the drains exit site.
3. A drain should not be regarded as a substitute for hemostasis.
Haematomas are likely to develop despite drainage if
hemostasis is not adequate.
4. A rigid drain may erode through the wall of a blood vessel or a
hollow intestinal structure. This complication can be minimized
by using soft drains and removing drains early.
5. Excessive suction on a tube can also cause necrosis of
nearby structures. Intermittent low-level suction is safer.
6. A drain in direct contact with a fistula may perpetuate the
fistula and delay it’s healing. The drain must be advanced
beyond the fistula now and then if further healing is to occur.
7. Drains may become detached from the skin and retract into
the body, especially into the peritoneal cavity. Thus, they
should always be firmly attached to the skin and should be
marked with a radiopaque marker. A safety pin can also be
used to keep drains outside the body.
8. The free peritoneal space cannot be drained as tubes are
quickly walled off Thus, diffuse peritonitis cannot be drained.
Localized collections can be drained.
9. After drains have been removed they may still leave a track
along which fluid can reach the surface.
10. Opponents claim that the presence of drains increases
susceptibility to contamination and that mechanical pressure
from drains damages delicate tissues, delays healing and may
even cause breakdown of suture lines.
11. They point out that most or all of the fluid discharge is reaction
fluid from the tissues in contact with the foreign body. They
produce good evidence that in many tissues and especially in
mesothelia lined cavities such as the peritoneum and pleura;
the drain is usually sealed off within 6 hours.
12. A drain cannot be expected to channel future collections of
fluid, or act as a monitor to detect complications.
13. When dissection has left large raw areas in the tissues,
healing takes place by the opposition of the raw surfaces,
which fuse. Bleeding and exudation are reduced if this fusion
can take place rapidly, but a collection of fluid prevents the
surfaces from coming into contact.
REMOVAL.
 Drains should be removed when they have fulfilled their
purpose.
I. When the main risk of leakage has passed, the drain is
removed.
(1) After a cholecystectomy, if a leak from a bile duct injury is
present, it should be evident in 1 or 2 days. Thus, drains are
normally removed by the second day.
(2) After urinary bladder procedures, a urinary leak will occur
when the bladder catheter is removed. Thus, drains are
removed a day after the catheter is removed.
II. When a drain is used for postoperative fluid collections (i.e.,
blood, serum, or lymph), it is removed when no further drainage
occurs.
III. When the drain is used in a reconstructive procedure, it is
removed once the repair is safe.
(1) Following common duct exploration, a T tube is used to
drain the bile duct until spasm of the sphincter of Oddi has
resolved. The T tube is removed after a cholangiogram
documents free flow of bile into the duodenum.
(2) Following total gastrectomy or esophagectomy, the
esophageal anastomosis is drained internally with a
nasygastric tube. If an anastomotic leak is going to occur, it
usually does so within the first week. Therefore, a "barium
swallow" around the tube is performed to document that the
anastomosis is intact and does not leak. The tube is
removed if the anastomosis is intact.
(3) Following gastrectomy and Billroth II reconstruction, a
potential complication is disruption of the duodenal stump
with formation of a duodenal fistula.
(a) A tube may be placed within the duodenal lumen
(duodenostomy) to prevent over distention of the repaired
duodenum, since this reduces the risk of disruption.
(b) Once the patient has recovered from the surgical
procedure, and if no signs of duodenal leakage have
developed, the tube can be removed 2-4 weeks after
surgery.
 LAPAROSCOPIC INSTRUMENTS
INDICATIONS OF LAPAROSCOPY:
1- DIAGNOSTIC LAPAROSCOPY:
1- Evaluate abdominal pathology: as Ascites of unknown origin,
liver disorders of unknown aetiology.
2- Evaluation of unexplained acute and chronic abdominal pain.
3- Evaluation of intraabdominal malignancies.
4- Evaluation of Abdominal trauma.
5- Biopsy of intra-abdominal structures.
11- THERAPEUTIC LAPAROSCOPY:
1- Laparoscopic Cholecystectomy.
2- Laparoscopic Common bile duct exploration.
3- Laparoscopic appendectomy.
4- Laparoscopic Antireflux procedures.
5- Laparoscopic treatment of peptic ulcer.
6- Laparoscopic feeding tubes insertion.
7- Laparoscopic colon resection.
8- Laparoscopic Hepatic and pancreatic procedures.
 Partial hepatectomy.
 Unroofing of hepatic cyst.
 Cholecysto-jejunostomy as palliative bypass for
unresected pancreatic cancer.
 Gastro-jejunostomy.
 Laparoscopic pancreatic resection.
 Laparoscopic Whipple.
10- Laparoscopic splenectomy.
11- Laparoscopic hernial repair.
12- Laparoscopic adrenalectomy.
13- Laparoscopic assisted abdomino-perineal resection.
14- Laparoscopic assisted cystectomy.
14- Laparoscopic pelvic lymph adenectomy.
15- Laparoscopic nephrectomy.
16- Laparoscopic varirocelectomy.
17- Laparoscopic incisional hernial repair.
18- Laparoscopic sympathectomy.
CONTRAINDICATIONS TO LAPAROSCOPIC SURGERY:
1- Absolute:
1- Uncorrectable coagulopathy,
2- Frozen abdomen from adhesion,
3- Intestinal obstruction with massive abdominal distension,
4- Hemorrhagic shock,
5- Severe cardiac dysfunction.
6- Concomitant disease requiring laparotomy.
II- Relative:
1- Inability to tolerate general anaesthesia,
2- Abdominal sepsis.
3- Peritonitis,
4- Intraabdominal malignancy.
5- Pregnancy.
6- Morbid obesity.
7- Multiple previous abdominal operations.
8- Severe Chronic obstructive pulmonary diseases.
9- Diaphragmatic hernia.
EQUIPMENT:
1-LAPAROSCOPE:
= Types of laparoscopes:
A- Rigid laparoscopes:
 It contains the rod lens system of optics.
 Size: 3, 5, 7, and 10 mm in diameter.
 Viewing angle:
 0 º or end / forward viewing
Laparoscope (least image distortion,
and brightest image, but less field of
view 76º).
 Angled (30 º, 45º) scope (allowing
better viewing from angles, allow
exploration of less accessible areas,
but difficult to operate).
 Disadvantages:
 Limited field of view (76º for 10 mm laparoscope).
 Less illumination of the target area.
B- Flexible laparoscope:
 Use fiberoptic bundles for visualization,
 Advantages:
 Provide greater flexibility in the viewing angle.
 Disadvantages:
 The field of view is smaller than a laparoscope of
comparable diameter.
 Limited resolution of image.
  2-mm fiber optic scope allows inspection of the
peritoneal cavity through the small bore of insufflations
needle.
2-VIDEO IMAGING SYSTEM:
= It is formed of:
 Light source:

 Video camera:
 Separate or attached to the Laparoscope.
 Camera control unit:
 Reconstruct the image on the video monitor
 Video monitor:
 Conventional horizontal screen with high resolution.
3- INSUFFLATORS:
 Deliver C02 gas for establishing and maintaining
pneumopertonium (to create working space),
 It has the ability to control the maximal flow rate of gas
and the pressure within the abdomen (12-15 mmHg).
 It has an inlet valve for connection to a gas tank and
an outlet port from which plastic tube is passes to the
patient.
 Flow rate my be low (1L/min), medium (2-3L/min), or
high (4-10 L/min).
 C02 is the agent of choice because of low risk of gas
embolism, lack toxicity to peritoneal tissues, rapid
reabsorption, low cost, suppresses combustion; allow
use of electrocautery or LASER and ease of use.
INSTRUMENT:
I- INSUFFLATIONS NEEDLE ( Veress needle):
IT CONSISTS OF:
 An outer sharp cutting needle
and
 An inner blunt spring- loaded,
hollow obturator, with a side
hole at its tip to allow instillation
of liquid or gas. It retracts on
contact with solid tissue to
reveal a cutting tip, with a hand
piece marker moves upwards.
USES:
 Allow instillation of liquid or gas.
APPLICATION:
= As the Veress needle is inserted into the peritoneal cavity,
resistance at the muscle fascia causes the blunt tip to retract
backwards.
= Once the cutting needle has penetrated freely into the peritoneal
cavity, the blunt stylet springs forward beyond the cutting
needle, so reduce the risk of injury to intraperitoneal structures.
= Once the peritoneal cavity is entered, gas may be instilled
through the hollow shaft of the needle.
= The needle is then removed and a trocar / cannula are inserted
through the same site.

II- TROCAR - CANULA APPARATUS (Laparoscopic port):

PARTS:
= Trocar is a cutting obturator within a cannula,
= It consists of:
 A cutting obturator (trocar): inner removable trocar fit
through the outer sheath, used only while inserting the
port through the abdominal wall. and
 A working cannula (3 – 33 mm in diameter): outer
hollow sheath.
TYPES:
  Multiple channels cannula: for insertion of laparoscope
and instruments through the same cannula.
 Single channel cannula: for laparoscope or
instruments. It may be:
 Disposable cannula: Equipped with:
= Plastic sleeve: automatically
covers the cutting obturator
once it has pierced the
abdominal wall. Or
= Automatic retraction of the
sharp trocar into the shaft of
the cannula after the trocar
has pierced the abdominal wall.
= Contain valve to prevent loss
of pneumopertonium when no
instruments is in place (it had
open during removal of
Specimens or suture needle by handle).
= O- ring fit around an instrument to prevent gas leakage.
= Reducer: simple piece of rubber with a hole, allow use of
small instruments without leakage.
 Reusable:
= Do not have plastic sleeve & automatic reduction.
= Have a spring – loaded trumpet valve to prevent air loss
when no instruments are in place.
= Cannula secured to the
abdominal wall with a fascial
thread, or adhesive patch.
= It is radioopaque, (in contrast
to the disposable).
= Disadvantages:
-- The trocar may dull with
repeated use.
-- Trumpet valve is less
convenient to use than
flap valve of disposable.
= Advantages:
-- Lower costs.
APPLICATION:
= Once the pneumoperitonium is established, a cannula must be
inserted through the abdominal wall into the peritoneum, to
allow the passage of the laparoscope and instruments into the
abdomen.
= Once the trocar – cannula apparatus is successfully inserted into
the abdominal cavity the trocar is removed to leave the cannula
in situ.
III- ANTERIOR ABDOMINAL WALL RETRACTION SYSTEM:
Parts:
= Formed of:
 Metallic arm, circular device,
T- bar or
 Wire holder that is attached to
the inner abdominal wall or just
to the skin,
 Second metallic arm is
attached to the operating table.
= The device may be operated by simple traction or by a hydraulic
or motorized lifting system.
Uses:
 Mechanical retraction of the anterior abdominal wall
(as
alternative to gas insufflations).
Advantages:
 Avoid complications of pneumoperitonium,
Disadvantages:
 It produce tent-like space make the device difficult to
use.
 Working space is smaller than gase methods.
VI- LAPAROSCOPIC INSTRUMENTS:
= General features:
 May be disposable or reusable. Or combination of
disposable and reusable components.
 Disposable instruments are made of plastics that cannot
be sterilized after a single use, Costs less than reusable
but the overall cost is higher, allow the surgeon to use
modern version of the instruments available, and always
sharp.
 Reusable instruments can be repeatedly sterilized, dull
with repeated use, and more expensive.
= Typical instruments: a typical instrument consists of:
 A Handle: with or without locking
Ratched, or spring – loaded
Handle, It may allow 360º
Rotation in the Surgeon’s hand,
it may be detachable.
 Locking mechanism: keep the
Jaws closed for tissue grasping.
 Rotating mechanism: allow 360º
rotation of the jaws of the instruments,
 Shaft: 30 cm long,
 Jaws: which determine its function:
Grasper, dissector, or scissor.
 Metal connector: allow electro surgical procedures.
 Lack of tactile sensation.
 Less able to gauge the force exerted on the tissue.
1- Dissectors:
 Used for dissecting tissue,
 Slightly curved slender jaws
with sharp tips.
 Shape: curved, straight or
right angled.
2- Babcock:
3- Grasper:
 Used for grasping tissue,
 Wide, dull tips jaw,

4- Scissors:
= According to the tips:
 Blunt tips (Metzenbaum) scissors: used for dissection.
 Sharp tips scissors: used for
piercing tissue.
= According to the blade:
 Hook scissors: cut tissue or
suture precisely.
 Curved blade (facilitate
precise cutting).
 Straight blades
= According to action:
 Single action scissors.
 Double action scissors.
= According to the size:
 Micro scissors: used for microscopic procedure.
 Brood jaw.
5- Clip Appliers:
PARTS:
 Trigger handle: to load
the clip before firing.
 Rotating device,
 Spring-loaded piston to
advance the clips into
the firing position.
 Jaws: straight or at 15
to 20 º to the shaft, or
right – angle .It may be
rotated to provide the
optimal approach to the
structure being ligated.
 Clips are: medium sized (6 mm), medium/large (9
mm), & large (10-11 mm).
 Clips formed from Titanium (radioopaque, not
magnetic), or Polyglyconate (absorbable, need
locking).
TYPES:
= Reusable: loaded with only one clip at a time.
= Disposable: provide with a rack of 20 clips.
USES:
= Used to apply clips to permanently close small structure as
BLood vessels, and cystic duct.
6- Suction – irrigation device:
PARTS:
 Suction channel: connecting to the vacuum system.
 Irrigation channel: connected to a bag of irrigating fluid.
SIZE:
 Size: 5 and 10 mm in diameter.
USES:
 Suction of blood.
 Suction of vapor resulting from dissecting and haemostatic
tools as elecrocautery Units.
7- Tissue retrieval:
= To remove tissue from abdomen.

LAPAROSCOPY COMPLICATIONS:
1- Related to insertion:
 Major vascular injury
 GIT injury
 Bladder injury
 C02 embolism
 Abdominal wall haemorrhage.
2- Related to pneumoperitonium:
 Hypercarbia: due to peritoneal C02 absorption
 Acidosis,
 Ventillation / perfusion mismatching: due to cephalic
displacement of the diaphragm.
 Hypertension: as hypercarbia stimulate sympathetic
discharge, which increase systemic vascular
resistance and mean arterial pressure.
 Brady arrhythmias.
 Ventricular arrhythmias
 Gas embolism.
 Pneumothorax.
 Pneumo-mediastinum.
 Subcutaneous emphysema.
 Phlebothrombosis.
 Pulmonary embolism.
 Precipitation of sickle cell crisis in patient with sickle
cell disease: due to acidosis,
3- Related to position:
 Neuropathy:
 Brachial plexus injury from abducted arm
 Femoral nerve neuropathy in-patient placed in
lithotomy position.
 Hypotension.
4- Related to instrumentations:
  Trocar and Veress needle injuries of the intestine or
major blood vessels.
 Abdominal wall bleeding
 Trocar site hernia
 Electrocautery or LASER burns
 Wound infections
 Retractor injury
 Trocar site recurrence.
5- Complications of specific operations:
A- Laparoscopic cholecystectomy:
 Bile duct injury
 Bile fistula
 Haemorrhage
 Intraperitoneal gallstones
 Retained common duct stones
B- Laparoscopic appendicectomy:
 Abdominal abscess
 Wound infection
 Appendiceal rupture
C- Laparoscopic colectomy:
 Trocar site recurrence
 Bowel injury
 Urethral injury
 Duodenal injury
D- Laparoscopic herniorrhaphy:
 Recurrence
 Bowel erosion
 Mesh infection
 Nerve entrapment
E- Laparoscopic antireflux procedures:
 Perforated esophagus
 Vagal nerve injury
 Pneumothorax
 Dysphagia
 Gas bloat
 Paraesophageal hernia.
ADVANTAGES OF LAPAROSCOPE:
1- Reduction of postoperative pain,
2- Diminished postoperative hospitalization and disability.
3- Accurate diagnosis.
4- Staging of cancer.
SOME OPERATIONS:
= Lap. Hernial repair:

= Lap. Colectomy:

= Laparoscopic splenectomy

= Lap. Appendectomy
 STAPLER IN SURGERY

TYPES OF STAPLER:
II- STAPLERS OF OPEN SURGERY:
1- LINEAR STAPLER:
A- Thoracic anastomosis (TA) staplers:
 Size: varies from 30mm to 90 mm.
 They place a double line of
Staplers in a linear, everted
fashion.
 Uses:
 Closing various portions of the GIT.
 GIT anastomoses
 Thoracic surgery.
 Advantages:
 Provide a haemostatic, hydrostatic, and air – tight
closure.
 Adapted to laparoscopic usage.

B- Gastro-intestinal anastomosis (GIA) staplers:

 Size: Available in several sizes.
 Place 2 double rows of
Staples and simultaneously
divides the tissue in the jaws of
the stapler, with a knife mounted
within the instruments.
 Uses:
 Divide bowel on the proximal and
distal ends of a resection site.
 Create side- to – side anastomoses between two
segments of
bowel.
 Technique:
 The two limbs of bowel to be anastomosed are brought
together at their anti-mesenteric margin.
 Stay sutures are placed and the GIA stapler is inserted into
each limb via small enterotomy
  The stapler arms are brought tightly together and the bowel is
checked on each side to ensure that no mesentery will be
included in the staple line.
 The stapler is fired, lasting down 6 rows of staples and cutting
between them.
 The arms of the stapler are opened and removed,
 The two opening through which the stapler is applied become a
single orifice that is closed with TA staplers.
 Advantages:
 Adapted to laparoscopic usage.
 Minimally inverted serosa – to-serosa anastomoses
is formed in two layers.
2- CIRCULAR STAPLER:
 Size: ranging from 25 to 33 mm
in diameter.
 Uses:
 A tubular device that is
employed for creating an end-
to- end or end – to side inverting
anastomoses.
 Low pelvic and rectal
anastomoses.
 Advantages:
 It provides an inverting serosa –
to serosa anastomosis.
 It has a detachable anvil that is
inserted into one limb of the
bowel while the shaft and head
of the instrument are inserted
into the other.
 It provides a completely inverting anastomosis.
 Technique:
 The bowel is cleared approximately 1 cm from the cut margin.
 Purse- string on both proximal and distal margins is done to
secure the bowel around the anvil and shaft.
 The purse- string suture should be of sufficiently strong non-
absorbable material to allow a secure closure.
 The anvil is inserted into one limb of the bowel and secured to
the head of the shaft.
 The purse-string sutures are snugged down over the
instruments ends.
  The head and the anvil of the instrument are brought together,
screwed down until the head and the anvil are in close
apposition,
 Then a double layer of staples is fired, creating an inverting
anastomosis.
 After firing the circular stapler, the screw mechanism is undone
for one –half or one-quarter turn by gently twisting the
instrument, it can be removed from the bowel.
 Check 2 complete mucosal rings,
3- SKIN STAPLER:
II- STAPLERS OF LAPAROSCOPIC SURGERY:
= Disposable and reusable.
= Types:
1- LINEAR STAPLER:
A- Thoracic anastomosis (TA) staplers:
 Length: 30 mm, 35 mm, or 60 mm,
 Fire 3 rows of staples without cutting,
 It may be reloaded up to three times before disposal.
 Used for closing intestinal resection, gastric
resection, and appendicectomy or lung resection.
B- ENDOSCOPIC LINEAR STAPLER:
 Deliver 4-6 rows of staples and
divide tissue between the
middle 2 rows of staples.
 Used in intestinal
anastomoses, transect bowel,
and transect large vascular
structures (as mesoappendix)
and blood vessels as renal
vessels.
 It may be reloaded up to three
times before disposal.
 It has:
= Handle to open and close the jaws.
= Safety lever: to prevent accidental firing of the staples.
= Cartridges: 30 and 60 mm length.
= Staple depth varies from 1 to 2 mm.
C- Hernia Stapler:
 Deliver single staples; B – shaped or box
configuration.
 Has fully rotational shaft.
 Used for:
= Laparoscopic hernia repair
(attach mesh to tissue during
inguinal hernia repair).
= Re- approximating the
peritoneum after
retroperitoneal dissection,
= Closure of mesenteric
defects after intestinal
resection, and
= Repair of perforated DU.

2- CIRCULAR STAPLER:
 Size: 21 – 33 mm in diameter,
 Used in anterior resection,
 It has:
= Long curved shaft: inserted rectally,
= Head: one part attached to the shaft and circular blade.
TYPES OF STAPLED ANASTOMOSES:
1- Direct End – to – end anastomosis:
 Created by using circular, intraluminal stapler.
 In low anterior resection of the rectum the stapler is
introduced from the anus or via proximal colostomy.
2- Direct side – to – side anastomoses:
 Creating by using GIA stapler
USES OF STABLER:
1- GIT anastomosis.
2- Liver Biopsy.
 Lesions that are located on the
thin edge of the liver may be
easily
Biopsied using two applications of
the linear stapler to avoid
Destruction of the tissue.
 This method is also useful in
obtaining blind liver biopsies
requiring larger specimens than
 those available with a core biopsy
needle.
3- Division of vascular pedicle as the vascular pedicle of sigmoid
Colon divided using a stapler.
4- Lung surgery.
5- Closure of duodenal stump.
6- Tretment of esophageal varices: transection of lower end
esophagus.
7- Laparoscopic surgery.
8- Haemorrhoidectomy.
ADVANTAGES OF STAPLER:
 The double-staple technique is most commonly used to restore
intestinal continuity after rectal resections in which a short rectal
stump remains.
 Stapler anastomoses produce less degree of ischaemia: It
diminished blood flow by approximately 43%, in contrast the
traditional two- layer anastomosis produce nearly 60%
reduction in blood flow.
 Stapler anastomoses produce less incidence of leakage (2.5%
vs. 5% in hand suture).
 Stapler anastomoses produce less incidence of tumour
recurrence (19% vs. 30% for manual suturing). As micro
metastases are more likely to adhere to a braided material as
opposed to steel or titanium used in the staples.
 Rapid anastomoses.
 COOLINSIDE

USES:
 The COOLINSIDE is an electrosurgical device intended for
haemostatic sealing, coagulation and cut (in the model DUAL)
of soft tissues. Specifically, it is intended for use in liver and
kidney, both in open and laparoscopic procedures.
 Since it allows coagulation and cut of the tissue, the
COOLINSIDE is especially intended for partial or total resection
of these organs, i.e. for radiofrequency-assisted surgical
resection.
DESCRIPTION:
 The COOLINSIDE (COAG and DUAL models) comprises a
metallic electrode that delivers radiofrequency energy to the
tissues.
 This energy induces a rapid heating of the tissues what
provokes the shrinkage of the collagen of the vessels and the
coagulation of the tissue. The collapse of the vessels together
with the coagulation of the blood present in the treated tissue
minimize the bleeding and permit the blade (in DUAL variants)
to perform the mechanical cut of the previously coagulated
tissue without bleeding.
 The electrode of the COOLINSIDE has an internal cooling
system to keep cold the surface of the electrode and thus
prevent the charred tissue sticking to the electrode.
GENERAL PRECAUTIONS:
 The surgical procedure must be performed by personnel with
adequate training and preparation. Personnel should fully
understand the nature and use of RF before performing
electrosurgical procedures to avoid the risk of shock and
burn hazards to both the patient and the operator and
damage to instrumentation.
 DO NOT USE out of the Intended Use.
 The device is provided as a sterile, single-use disposable
device. Do not re-sterilize or reuse this device.
Reprocessing, (re-sterilizing or reusing) of the device does
not guarantee the sterility and can produce the obstruction of
the internal cooling systems.
 Examine the shipping carton, packaging, sterile barrier and
device to confirm expiration date and integrity. If there are
any deficiencies, breakage or apparent damage, do not use
the device. Return the device to Apeiron Medical and use a
new device.
 DO NOT use COOLINSIDE in the presence of flammable
anesthetics or nearby other flammable gases, fluids or
objects or in the presence of oxidizing agents, as fire could
result.
 The cable on the device should be positioned in a way to
avoid contact with the patient or other cables.
 Examine all devices to be connected to the electrosurgical
generator. After connection, ensure that they are functioning
as intended.
 Electrosurgical equipment can affect the functioning of the
monitors used during the procedure. Monitoring electrodes
should be placed as far as possible from the treated area.
 Consult the operating and user manuals of the RF generator,
the peristaltic pump for the saline solution and any other
ancillary devices for operating instructions, warnings and
cautions prior to their use in the same surgical field as
Apeiron Medical’s device.
 Use the device with an appropriate electrosurgical generator.
 Use the device with caution in the presence of pacemakers,
as electrosurgical devices may cause interference with
pacemakers or other active implants.
 Use of two to four patient return electrode pads (PRE) is
required for use of this device. Ensure that all connections
are safe and monitor closely to maintain appropriate contact
between the PRE and patient skin during use. Consult PRE
 manufacturer's Instructions For Use for proper placement
and use
MODELS AND VARIANTS:
 There are two models of COOLINSIDE:
• COAG: Without blade. Coagulation by means of RF.
• DUAL: With blade. Coagulation by means of RF and cut
with the blade.
 Each model has variants in diameter and length of the
electrode.
 First digit indicates diameter of the electrode, (8, 5 or 3 mm).
 Letter ―C‖ indicates ―Short‖, (open surgery) and letter ―L‖
indicates ―Long‖, (laparoscopy)
1- Coolinside DUAL (8C11, 5C11, 3C11)
 Indications for use : The Dual Coolinside device is a sterile,
single use, electrosurgical device intended to be used in
conjunction with an electrosurgical generator of RF energy
and a peristaltic pump that drives the cold saline for
haemostatic sealing, coagulation of soft tissues and
mechanical cutting of the coagulated tissue. It is intended for
hepatic and renal surgery in open procedures (laparotomy)
2- Coolinside COAG (8C01, 5C01, 3C01)
 Indications for use: The COAG Coolinside device is a sterile,
single use, electrosurgical device intended to be used in
conjunction with an electrosurgical generator of RF energy
and a peristaltic pump that drives the cold saline for
haemostatic sealing and coagulation of soft tissues. It is
intended for hepatic and renal surgery in open procedures
(laparotomy)
3- Coolinside DUAL-L (5L11, 3L11)
 Indications for use: The Dual-L Coolinside device is a sterile,
single use, electrosurgical device intended to be used in
conjunction with an electrosurgical generator of RF energy
and a peristaltic pump that drives the cold saline for
haemostatic sealing, coagulation of soft tissues and
mechanical cutting of the coagulated tissue. It is intended for
hepatic and renal surgery in laparoscopic procedures.
4- COAG Coolinside-L (5L01, 3L01)
 Indications for use: The COAG-L Coolinside device is a
sterile, single use, electrosurgical device intended to be used
in conjunction with an electrosurgical generator of RF energy
and a peristaltic pump that drives the cold saline for
haemostatic sealing and coagulation of soft tissues. It is
 intended for hepatic and renal surgery in laparoscopic
procedures.
USE OF THE COOLINSIDE
 System Diagram:
Below is a simple schematic of how the device is connected to the
rest of the elements of the system. Use the device with any CE
mark peristaltic pump that delivers an internal flow of sterile saline
(0.9% NaCl) from 80 to 250 mL/min. Saline storage system may
be a bag of saline that has been previously cooled down to a
temperature between 5 and 15°C.

 Warning!
• Electric Shock Hazard. Ensure that the device plug is correctly
connected and that no metal
pins are exposed.
• Read the instructions, warnings, and precautions provided with
the electrosurgical device
before using.
• Inspect the device and cord for breaks, cracks, nicks, or other
damage before use. Failure to
observe this caution may result in injury or electrical shock to the
patient or surgical team.
Setting up the device:
STEP 1: Place dispersive electrode pads on patient, according to
its manufacturer's instructions, and connect pads to appropriate
generator.
Warning: Patient’s skin must be clean and dry before placing the
PRE.
Ensure that the placement area of the PREs has enough surface,
muscles and vasculature for the estimated power and time of the
procedure. This is important to facilitate the distribution of the
current and avoid current concentrations, for instance,
in the edges of the PRE. Consult the instructions for use of all
devices to be used, including the RF generator PRE and any
associated equipment. Do not place the PRE on an anatomic
structure insufficient to allow a proper return of the current. In
infants, for instance, the safer location of the PRE is in bigger
anatomic structures such as the back. Placing a PRE around the
thigh, calf or arm enhances the possibility that temperature raises
in the PRE area. It is also important not having heating pads or
electric blankets while the device is being used because that could
raise the temperature in the PRE zone. When multiple PREs have
to be used, each one has to be placed on an area with appropriate
muscle and vasculature and at the same distance to the treatment
area. This is especially important in patients who have a smaller
body mass or weight as infants, children and paediatric patients
and weak adult patients. In any case, consult the manufacturer
instructions from the PRE to specific limitations in relation to the
weight and power.
STEP 2: Using aseptic technique, open the package and place its
content on sterile field.Carefully remove the blade guard from the
tip of the electrode (models DUAL and DUAL-L)
STEP 3: Connect the spike of the cooling tube to a bag of cold (5-
15ºC) sterile saline (0.9% NaCl) of appropriate volume (2 - 3 L is
advisable and replace when empty). It is important to stock
additional cold saline bags (5ºC).
STEP 4: Install the silicone tube section inside the peristaltic pump
ensuring the sense of flow is from the bag into the electrode.
STEP 5: Place the cooling output (female Luer connector) so that
the output of the discarded saline is collected in an appropriate
recipient at floor level.
STEP 6: Open the roller clamp and activate the pumping of saline
using the peristaltic pump, allowing it to pass through the tubes
and the device.
STEP 7: Wait until saline fills up the circuit and device and starts to
flow out by the output connector to the floor recipient.
STEP 8: Stop the peristaltic pump until the device is ready for use.
STEP 9: Connect the device cable to the generator (see the
generator manufacturer's instructions).
Adjusting the power of the RF:
STEP 1: Set generator to desired power setting. Start with the
lowest recommended power setting and increase as needed to
achieve the desired effect.In the event that a higher than normal
electrosurgical power setting is required, before changing power
settings, check all instrument connections, cables and patient
contacts. If all connections, cables and patient contacts are fault-
free, then increase power settings in small increments, checking
carefully after each change.
Activation and operation of the COOLINSIDE:
Before using the device, confirm the following:
• The cable from the device is connected to the monopolar output
of the electrosurgical generator.
• All electrical connections are tight, clean and dry.
• Set the RF energy power to the lowest setting for desired tissue
effect.
• All fluid connections are secure.
• The saline delivery tubing and device have been fully primed with
cold (5-15ºC) sterile saline solution (0.9% NaCI).
• The dispersive electrodes return pads are in place (as far as
possible from the treatment area) and appropriately connected,
according to the manufacturer's instructions.
STEP 1: Turn on the flow of saline and verify that is flowing into
the floor recipient.
STEP 2: Place the tip of the device on the tissue to be treated
STEP 3: Activate the device by depressing the foot pedal
(connected to the electrosurgical
generator) continuously during treatment and release the pedal to
stop treatment.
STEP 4: Repeat the previous step as many times as necessary by
placing the device on the next area to be treated.
STEP 5: Make sure the electrode (metal part) is only in contact
with the tissue to be treated.
STEP 6: For optimum performance, the metal tip must be kept free
of debris. Do not manipulate the blade in DUAL and DUAL-L
models.
Caution:
For COAG-L and DUAL-L devices carefully insert and remove the
device from the trocar cannulas to prevent possible damage to the
device and/or injury to the patient.
Warning: If while using the device the blade (in the models DUAL)
becomes bent to one side, stop using the device because there is
a risk that the blade breaks off from the electrode. DO NOT
attempt to straighten or reposition the blade. Discard the device
and use another one.
Warning: Do not use sandpaper or other abrasive objects to try to
clean the area of the electrode and the blade during operation, as
it may cause damage to the device.
If charred tissue adheres to the electrode or the blade, you can try
to remove using wet gauze, but never scratching.
Warning: If the electrode is not cold, it means that saline flow is
interrupted. If this happens during the electrosurgical procedure,
stop using the device and attempt to resume the flow of saline.
Ensure that the source of saline is appropriate and that
the pumping system is working properly. If unable to resume the
saline flow solution,
stop using the device, get a new one and return the used one to
Apeiron Medical.
End of procedure and disposal of the device
STEP 1: Turn off the electrosurgical generator and peristaltic
pump.
STEP 2: Remove the spike from the saline bag.
STEP 3: Connect the peristaltic pump until there is no further
outflow of saline (which means
that STEP the internal cooling circuit is empty of saline).
STEP 4: Remove the bag of saline from the IV pole.
STEP 5: Unplug the device from the RF generator.
STEP 6: Dispose the device and the used saline bag according to
the procedures of your
institution.
TECHNICAL DESCRIPTION
General Description:
 Monopolar electrosurgical device: Uses RF energy and saline
to achieve haemostatic sealing, coagulation and, in models
DUAL and DUAL-L, the precise dissection of soft tissues.RF
power source: external electrosurgical generator, not included.
 General Information
 Sterilized by gamma radiation
 Disposable, Do Not reuse
 Caution: Do not use after expiration date.
 Caution: Sale, distribution and use of this device only under
the prescription of a
 physician.
 Caution: Do not use if package is open or damaged
 Caution: Read the instruction for use (IFU) before using this
device.
Dimensions:
 Electrode width: 3, 5 or 8 mm
 Length (without cables): 202 or 445 cm
 Power Cord Length: Approximately 3 meters
 Length of saline tubes: Inflow: 5 m, Outflow: 3 m
Electrical Characteristics:
 Maximum voltage: 1000 V (pp)
 Maximum current: 2 A
Operating conditions:
 Standard laboratory conditions
 Temperature: 15ºC to 35°C
 Humidity: 45% - 75%, non-condensing
 Pressure this device is designed to be used at altitude
under 2,000 m
Transport conditions:
 Temperature: -10°C to 50°C
 Humidity: 15% - 85%, non-condensing
Storage conditions:
 Temperature: 10ºC to 40°C
 Humidity: 15% - 85%, non-condensing

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