BY lSZCZEPAN BARAN, VMD, ELIZABETH JOHNSON, VMD AND MARCEL PERRET-GENTIL, DVM
Although not always recognized, proper handling of surgical instruments plays a vital role in positive surgical patient outcomes. Correct handling of surgical instruments improves precision and reduces fatigue. There are significant differences between holding standard surgical and microsurgical instruments, but in either case, the main goal is to increase comfort, minimize tremors, limit fatigue, maximize precision, and improve access to the operative field.
Optimizing handling of instruments improves surgical outcomes, as errors due to fatigue are minimized. This article addresses surgical instrument handling ergonomics; the proper handling of various surgical instruments during surgical procedures.
For microsurgical procedures, forearms and hands should be propped and held steady. Microsurgery in rodents is unique in that generally, the fingertips are the part of the hand that controls instrument movement. To facilitate finger movement, hands can be propped on folded pads or manufactured “propping blocks,” adjusting the height for the individual animal, so that the hands are placed slightly higher than the surgical field. This provides better control of the instruments and improves access to the operative field. Freely holding hands in the air leads to fatigue, tremors, and imprecise movements.
When one first begins to perform microsurgeries, even when following correct surgical protocol, the fingers, hands, and forearms will fatigue quickly, leading to tremors. Therefore, initial training periods should last only 20 to 40 minutes. As one continues to practice microsurgery, the surgeon’s muscles will gradually adjust and strengthen, allowing for longer, more complicated procedures.
Holding Needle Drivers and Needles
Standard needle drivers are generally held with the distal phalanges of the thumb and ring finger. This provides the highest degree of instrument control. Using this technique, needle drivers are held by placing the thumb and ring finger into the rings while placing the distal pad of the index finger on top/side of the needle holder. The middle finger supports the instrument laterally. This technique provides multiple points of contact, allowing for better control of the instrument.
The second technique, termed the palmed grip technique, does not have fingers placed into rings. Micro-needle drivers are held with a pencil grip technique, where the index finger and the thumb rest on the body of the instrument and the distal portion of the instrument is supported by the webbing between the index finger and the thumb.
The needle driver should grasp the needle in the “needle holding zone,” which is the middle third of the needle. Holding the needle too close to the point will dull the needle and will restrict how far the needle traverses into tissue. Holding the needle too close to the suture attachment site can bend the needle and/or release the suture.
Loading and Removing the Scalpel Blade
Loading and removing the surgical blade must be performed with caution to prevent injury to the surgeon, patient, and assistants. When placing a scalpel blade on, it should be held by the tip of the blade and loaded onto the handle. It should load smoothly and click when placed properly.
Removing the scalpel blade should be performed by grasping the distal end of the blade, pulling it slightly sideways away from the handle, and pushing it away from the tip of the scalpel handle.
Scalpel
The scalpel handle is held in the palm of the hand by the thumb, middle and ring finger, while the index finger is on the top edge of the scalpel handle or blade. The index finger guides the scalpel. The scalpel should be held at about 30 degrees to the surface of the incision to allow for more contact of the blade with the tissue and make the incision process easier.
Scissors
Scissors are held similar to needle drivers with the ring finger in one loop, the thumb in the other, and the index finger resting near the hinge to provide optimal stability and control of the instrument.
Tissue Forceps
Tissue forceps are used with a modified pencil grip where a thumb is placed on one blade so that the blade becomes an extension of the thumb, and the index finger is placed on the opposite blade. The shank of the instrument is placed on the metacarpal-phalangeal joint. This grip provides the widest range of maneuverability and improves instrument control.
Mental Attitude
Frustration is almost guaranteed for the novice surgeon or the surgeon performing a particular technique for the first time. The anxiety that accompanies this frustration will often lead the surgeon to instrument ‘over gripping’ especially during microsurgery. This over gripping results in hand fatigue and imprecise movements, and a continuous cycle of fatigue and errors. When caught in this cycle, stop immediately. Place the instruments on the table, relax for a moment and let go of your hands tense movements. Following these simple steps, repeated as necessary, will help break this vicious cycle.
Practice
Review photos and videos of proper instrument holds and practice the observed techniques at the same time. When handling microsurgical instruments, you should practice rotating them with your fingertips while keeping the hand in the same steady position. Also try opening and closing the instruments, especially the needle drivers, as this movement can be difficult. Practicing and being able to perform these tasks without thinking about them will allow you to concentrate on the surgical procedure, which will lead to better surgical results.