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THE SURGICAL TRAY
EXCISION AND REPAIR
0733-8635/98 $8.00
+ .OO
THE SURGICAL TRAY L. Arthur Weber, MD
Dermatologic surgeons make clinical decisions based on sound scientific evidence whenever possible. In the case of choosing surgical instruments, no such evidence exists. Experience gained from training programs and discussion with colleagues will enter into the decision process. However, a surgeon needs only to peruse any instrument catalogue to see that the multitude of available instruments can be bewildering. Ultimately, which instrument works best for a given surgeon is largely a matter of personal preference. As such, this article will distill the choices down to the essential tools for the dermatologic surgeon to skillfully perform excisional surgery on the skin. Brand names (such as Bard-Parker and Beaver, Becton Dickinson Acutecare, Franklin Lakes, NJ) that have entered into common parlance will be used for convenience, but do not necessarily imply an endorsement of these products. SCALPELS AND BLADES
The two main types of scalpels are the Bard-Parker (BP) style and the Beaver style. Bard-Parker style blades have a slot that slides over a corresponding raised portion on the scalpel handle to lock the blade in place. The No. 3 handle is the workhorse for most dermatologic surgery. The No. 3 handle may be obtained with a measuring rule inscribed on one side. This ruler is handy for measuring the size of lesions and wounds, as well as planning flaps and grafts. Since it is flat, the
No. 3 handle will not roll around on the surgical tray. Round handles with a knurled surface are also available and some surgeons prefer the pencil-like feel to them.5 Beaver style handles are typically composed of two pieces. The end of the handle is threaded to accept the second piece known as the collet. The blade is placed in a slot in the collet and the two pieces are screwed together to hold the blade securely. Beaver handles may be round with a knurled surface or they may be hexagonal in cross section. Beaver scalpel handles are particularly useful for fine delicate work. Each system of scalpels has its own corresponding set of blades. The Bard-Parker No. 15 blade is the standard blade used for most dermatologic surgery. The surgeon should bear in mind that the belly of the blade is the sharpest part and thus should be used to cut. The No. 10 blade is similar in shape to the No. 15 blade, but is larger. It is useful for operating on areas with thick, tough skin, such as the back or scalp. The No. 11 blade is relatively long and narrow and comes to a sharp point. It is suitable for making the stab incisions used in incision and drainage procedures. The No. 15c blade is smaller than the No. 15 blade and is more ~ u r v e dIt. ~may be advantageous when doing delicate surgery as an alternative to using a Beaver blade. Surgical blades may be made from carbon steel or stainless steel. Carbon steel blades are sharper, but stainless steel blades hold their edge better.16 Blades are also available with
From Private practice, Grand Junction, Colorado
DERMATOLOGIC CLINICS
-
VOLUME 16 NUMBER 1 *JANUARY1998
17
18
WEBER
Figure 1. Surgical scalpel blades (left to right). No. 7515 (Microsharp), Beaver blade No. 64, Beaver blade No. 67, Beaver blade No. 68 (curved), No. 11 blade (for stab or puncture wounds), No. 15 blade (most commonly used), No. 15c blade (smaller, for more delicate surgery), No. 10 (good for thicker dermis), and No. 21 blade.
Teflon coatings that reduce "drag" through tissue. Beaver blades are available in different styles. The No. 67 blade is the most commonly used. Like the BE' No. 15 blade, it has a pointed tip with a sharp belly, but is smaller. The No. 64 blade has a rounded tip with a sharp edge. This blade is useful for procedures such as removing a thin layer of skin from the cartilage of the external ear. The No. 7515 blade differs from the previously described blades in that it is composed of a
tiny yet very sharp pointed blade fixed in plastic. The plastic portion is threaded and screws directly into the end of the scalpel handle without the use of the collet. Cutaneous surgery on the eyelid is a good use for the No. 7515 blade (Fig. 1). SCISSORS The dermatologic surgeon requires a variety of scissors in their armamentarium (Fig. 2). In addition to the use of scissors in cutting
Figure 2. Surgical scissors (left to right). Mayo, short bent suture removal, Gradle, Stevens tenotomy, Castroviejo, and Metzenbaum.
THE SURGICAL TRAY Table 1. SCISSORS AND THEIR USES Scissors Castroviejo Gradle Iris Kaye Lister Mayo Metzenbaum Shortbent Stevens tenotomy
Uses Cutting delicate tissue Cutting tissue, dissection, suture removal Cutting tissue Cutting lax tissue Cutting dressings, bandages Cutting dressings, sutures Cutting tough tissue, blunt dissection Suture removal Cutting tissue, blunt dissection
tissue, scissors will be used for cutting sutures and dressing materials. Different scissors lend themselves to particular tasks (Table 1).Tissue scissors may be used to cut sutures but at the risk of more rapid dulling of the blades. For most excisional skin surgery, the Gradle scissors will work well for both cutting tissue and blunt dis~ection.~ Similar in configuration to Gradle scissors, the Stevens tenotomy scissors have a slightly wider, less delicate tip, which may work better for blunt dissection. Scissors with a serrated edge, such as the Kaye scissors, can be used to cut tissue without slippage on lax areas such as the eyelid.'O Iris scissors are favored by some dermatologic surgeons but because the fulcrum, i.e., the screw, is farther back from the tips, they have less fulcrum power than Gradle or Stevens scissors.2 Iris scissors are also available with a serrated edge, which helps prevent tissue slippage.12Castroviejo or spring scissors are relatively expensive but can be invaluable for making very fine cuts on deli-
19
cate t i s s ~ e .The ' ~ handles on these scissors are squeezed to bring the blades together, and then the blades spring apart when pressure is relieved on the handle (Fig. 3). For wide undermining of the skin edge or for use on tough or fibrotic skin, a larger, longer scissors will provide more leverage. The 7 inch curved Metzenbaum scissors serve this purpose well. Curved scissors offer more mobility and visibility than straight scissors when cutting deep in a wound.' For most skin excisional work, a versatile pair of tissue scissors such as the Stevens tenotomy scissors will be required on the surgical tray. However, in certain circumstances, one might choose one of the other scissors to make the job easier. In addition to tissue scissors, it is necessary to have scissors for more mundane tasks such as cutting sutures and dressings. Mayo scissors in a 5 1/2 inch length or general operating scissors with blunt tips can be used by the surgical assistant to cut sutures during procedures. A larger set of scissors such as the 7 1/2 inch Lister bandage scissors can be useful for cutting through thick gauze dressings or trimming bandages. For suture removal, some find the Gradle scissors ideal." However, there are other scissors specifically designed for this task. The 3 1 / 2 inch shortbent suture removal scissors have one blade that is narrow and more pointed that can be hooked under small sutures to allow cutting of the suture. FORCEPS
The first two sections of this article have addressed instruments for cutting. Next, con-
Figure 3. Castroviejo scissors. Close-up view demonstrating unique handle that requires minimal hand motion and is useful for delicate areas such as the eyelids.
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sideration needs to be given to instruments used for holding. In addition to fingers, forceps are the most commonly used instruments to hold tissue. The Adson 1 x 2 tooth forceps is a versatile instrument for holding tissue while cutting or suturing tissue. The numbers indicate that one tooth on one jaw inserts into two teeth on the opposite jaw. The Brown-Adson 8 X 9 tooth forceps allows an even better grip at the risk of greater crush injury to tissue. For grabbing onto a slippery epidermal cyst, it may be just what the doctor ordered. At the opposite end of the spectrum are the delicate, lightweight Bishop-Harmon forceps, which can be used to gently grasp the smallest piece of tissue.16 They are available with serrated tips or in a 1 x 2 tooth configuration. While they are more expensive and will not be used in every procedure, having a pair of Bishop-Harmon forceps available for fine eyelid work will make for a happier surgeon. For tasks such as grasping sutures for removal, the Adson forceps with serrated tips is preferred. Some surgeons will also use this forceps to grasp tissue during surgery. One should keep in mind that although Adson serrated forceps enable a more firm grasp on tissue, they can also cause more crush injury than a 1 X 2 tooth Adson forceps.s Splinter forceps such as the Carmalt straight splinter forceps have sharp pointed tips of triangular shape with serrations. They can be employed in a variety of tasks such as grasping sutures for removal, grasping blood
vessels to obtain pinpoint hemostasis when used with an electrosurgical device, or placing adhesive wound closure strips.6 (Fig. 4) NEEDLE HOLDERS Like all surgical instruments, needle holders are available in a variety of styles and sizes. The jaws may be smooth or serrated. Serrated jaws tend to fray or break sutures when using them to tie knots. Needle holders are also available with jaws that have alloy inserts made of tungsten carbide. Tungsten carbide inserts are said to be harder, more durable, and allow a better grasp of the needle. Needle holders with this feature usually have gold plated handles and a correspondingly higher price. The gold plated handles look neat on the surgical tray, but it is debatable as to whether the tungsten carbide jaws are worth the additional cost.z*l6 When choosing needle holders, size matters. For the smaller needles and sutures used in most skin surgery, the Webster or Halsey smooth jawed needle holders will be suitable. To handle larger needles, the Baumgartner or Crile-Wood needle holders would be appropriate. Two other specialty needle holders also deserve mention although not everyone will need them. The Castroviejo needle holder is a delicate needle holder that operates on spring action like its similarly named scissors counterpart. It is available with or without a
Figure 4. Tissue forceps (left to right). Adson 1 x 2, Bishop-Harmon 1 x 2, and Adson serrated tissue forceps (front and side view of each).
THE SURGICAL TRAY
catch that locks the jaws together. These needle holders are well suited for use with the small needles used in delicate oculoplastic procedures. The Olsen-Hegar needle holders are unique in that the jaws of the instrument incorporate a scissors proximal to the needle holding platform. These needle holders may be a time saver if one is operating without an assistant but it takes practice to avoid cutting the suture inadvertently.14 SKIN HOOKS
Use of skin hooks is a matter of personal preference more so than for any of the previously described instruments. Those who are facile in their use will be able to handle tissue in a relatively atraumatic manner as compared to using forceps. On the other hand, some dermatologic surgeons have abandoned their use for fear that the sharp skin hooks place them at risk for percutaneous injury and exposure to transmissible disease^.^ The Frazier skin hook is a commonly used model. It is available with a curved hook as well as with a shepherd crook configuration. The shepherd crook style holds snugly but is more difficult to re1ea~e.I~ The Joseph skin hook has two prongs for a better hold on tissue, which allows better eversion of wound edges.13 HEMOSTATS
Hemostats are used to clamp off blood vessels during surgery. While they will not be required for every procedure, hemostats
21
should be placed on the surgical tray for quick access. The curved Halsted model, also known as a mosquito forceps, is well suited to cutaneous surgery. Popular in general surgery, the Kelly clamp is generally too large and heavy for use in skin procedures and may result in excessive crush injury. CURETTES
Curettes are ”rounded blades” that are used to scrape benign and malignant lesions from their underlying attachments. Surgeons will often curette a lesion prior to excising to determine the size of the defect. Tumors such as basal cell carcinomas feel ”softer” than surrounding tissue and are easily scraped with a curette. The Fox curette has a rounded or oval head, which is measured in millimeters (Fig. 5). The Piffard curette has an oval head and has a thick or narrow handle. Having curettes of varying sizes is ideal. Like other surgical instruments, blade sharpness should be maintained. MISCELLANEOUS INSTRUMENTS
In addition to the basic instruments already described, there are several additional items that may be of use in certain procedures. The Desmarres chalazion clamp has two handles joined at one end, while the clamping end consists of a flat oval surface on one side and a ring on the other side. The handles are joined by a threaded rod with a nut that can be tightened down. The chalazion clamp is useful for procedures on the lip and the
Figure 5. Curettes. Fox dermal curettes with round 2 mm head (bottom) and oval 5 mm head (top).
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skin excisional procedures, the surgical tray would include the following: No. 3 scalpel handle with No. 15 blade, Stevens tenotomy scissors, Adson 1 X 2 tooth forceps, Halsey needle holder, Mayo scissors, mosquito clamp, suture, gauze sponges and cotton tipped wooden applicators (Table 2, Fig. 7). Other specialty instruments could be added depending on the procedure. INSTRUMENT CARE
Figure 6. Chalazion clamps. Available in various sizes, they are used for holding tissue such as eyelid or lip margins as well as providing hemostasis.
tongue. The lesion can be positioned in the center of the ring and the clamp tightened. The snugly tightened clamp provides immobility and hemostasis (Fig. 6).3 Another item that should be available is a blade remover to remove scalpel blades from the scalpel handles. The Tiemann model (George Tiemann & Co., Hauppauge, NY) is relatively easy to use although other types are available. Whatever model is chosen, the surgical personnel must feel comfortable using it or else it will not be used. Proper use of a blade remover may reduce the risk of accidental injuries. Although not an instrument, mention should be made of the use of cotton dental rolls in dermatologic surgery. They can be moistened and placed in the nares to provide a firm surface when operating on the nose. Similarly, they can be placed in the mouth when performing lip surgery both to position the lip as well as to absorb blood. Anatomic rubber stamps are an easy way to document the location of lesions and procedures. They can supplement a written description of the location in the medical records.15 THE SURGICAL TRAY
The individual components of the surgical tray have been discussed. For most common
Fine surgical instruments require proper care. If possible, the instruments should be rinsed promptly after surgery or at least placed in a solution of one of the commercially available instrument detergents. The instruments are then scrubbed with a plastic brush to remove tissue and debris. Alternatively, one can employ an ultrasonic cleaner that uses sound waves to produce tiny bubbles that lift debris off the surface of instrum e n t ~ .Ultrasonic '~ cleaners are advantageous in that they are effective in removing debris from the crevices of hinged instruments. A disadvantage of these instruments is that they may produce an aerosol that contaminates the work area.* Regardless of method used, the instruments should be rinsed with water to remove detergent, then allowed to dry before sterilization. Spraying surgical instrument lubricant or instrument milk on hinged instruments, may help to keep them operating smoothly. STERILIZATION OF INSTRUMENTS
Instruments may be sterilized in one of four main ways. Dry heat sterilization offers a non-corrosive method but the high temperatures do not allow the instruments to be packaged in the common paper or plastic packs. Thus, there is the problem of storing
Table 2. THE SURGICAL TRAY FOR BASIC EXCISIONS No. 3 scalpel handle with No. 15 blade Stevens tenotomy scissors Adson 1 x 2 tooth forceps Halsey needle holder Mayo scissors Mosquito clamp@) Gauze sponges, cotton tipped wooden applicators Sutures
THE SURGICAL TRAY
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Figure 7. The basic surgical tray (left to right). Mayo scissors, Adson 1 x 2 tooth forceps, No. 3 scalpel handle with No. 15 blade, Stevens tenotomy scissors, Halsted needle holder, mosquito clamp, and skin hooks.
the instruments in a sterile fashion. Steam autoclaving is the most popular method for sterilization in office based practice. The steam autoclave uses a combination of pressure and temperature to destroy microorganisms. An advantage is that it only requires distilled water to operate. The disadvantage is that the humidity may dull sharp instruments. A similar device is the chemical autoclave, which uses a formaldehyde and alcohol mixture instead of distilled water. Less moisture is used with these devices, which prevents dulling of instruments. The disadvantage is that the chemical solution is not as easily obtained as distilled water. Ethylene oxide gas sterilization is particularly useful on devices that would be destroyed by heat or moisture. It requires complex equipment, which is impractical for the office based surgeon but may be found in hospitals. Proper care and maintenance of quality surgical instruments will provide many years of service to the dermatologic surgeon. SUMMARY
This article provides an overview of the most commonly used instruments for excisional surgery. It has also discussed some of the specialty instruments that may be of
value. It may serve as a starting point for the outfitting of a dermatologic surgery practice. However, it is no substitute for seeing, touching, and handling the instruments. At many of the larger specialty meetings, the instrument vendors will be displaying their wares. These displays offer an excellent opportunity to evaluate the many instruments. All of these fancy shiny instruments are merely tools to be used as an extension of the surgeon’s hand and brain. They should work for the surgeon in a manner that is comfortable and efficient. Only the surgeon can decide what works best. References 1. Anderson RM, Romfh RF: Scissors. In Technique in the Use of Surgical Tools. New York, Appleton-Century-Crofts, 1980, p 38 2. Bennett RG: Instruments and their care. In Fundamentals of Cutaneous Surgery. St. Louis, CV Mosby, 1988, pp 249, 256, 261 3. Ceilley RI, Bodian E L Biopsy of oral lesions. In Robins P (ed): Surgical Gems in Dermatology. New York, Journal Publishing Group, 1988, pp 15-16 4. Chemosky ME, Chernosky DL: Cold steel surgery. Dermatol Clin 10:265-273, 1992 5. Field LM: A new, rounded scalpel handle. J Dermatol Surg Oncol 8:918, 1982 6 . Fish FS, Perez M, Greenway HT: The Carmalt straight splinter forceps. J Dermatol Surg Oncol 17428-430, 1991
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7. Gibbs RC: A love affair with a Gradle scissors. J Dermatol Surg Oncol 7:771, 1981 8. Grande DJ, Neuberg M: Instrumentation for the dermatologic surgeon. J Dermatol Surg Oncol 1528% 297, 1989 9. Kaspar TA, Wagner Jr RF: Percutaneous injury during dermatologic surgery. J Am Acad Dermatol 24:756-759, 1991 10. Kaye B L Useful scissors for fine dissecting. Br J Plast Surg 24319-320, 1971 11. Koranda FC: Fundamentals of cutaneous surgery. In Sauer GC, Hall JC (eds): Manual of Skin Diseases. 7th edition. Philadelphia, Lippincott-Raven, 1996 12. Koranda FC, Luckasen J R Instruments and tips for
13. 14. 15. 16. 17.
dermatologic surgery. J Dermatol Surg Oncol 8:451, 1982 Lynch WS: Surgical equipment and instrumentation. In Wheeland RG (ed): Cutaneous Surgery. Philadelphia, WB Saunders, 1994, pp 96,98 Maloney ME: Instruments. In The Dermatologic Surgery Suite. New York, Churchill Livingstone, 1991, pp 29,31 Mohs FE, Snow S N More about anatomic rubber stamps. J Dermatol Surg Oncol 17:915-916, 1991 Neuberg M Instrumentation in dermatologic surgery. Semin Dermatol 13:lO-19, 1994 Sebben JE: Surgical preparation. In Roenigk RK, Roenigk HH (eds): Dermatologic Surgery Principles and Practice. New York, Marcel Dekker, 1989
Address reprint requests to L. Arthur Weber, MD PO Box 3141 Grand Junction, CO 81502-3141
0733-8635/98 $8.00
+ .OO
THE SURGICAL TRAY L. Arthur Weber, MD
Dermatologic surgeons make clinical decisions based on sound scientific evidence whenever possible. In the case of choosing surgical instruments, no such evidence exists. Experience gained from training programs and discussion with colleagues will enter into the decision process. However, a surgeon needs only to peruse any instrument catalogue to see that the multitude of available instruments can be bewildering. Ultimately, which instrument works best for a given surgeon is largely a matter of personal preference. As such, this article will distill the choices down to the essential tools for the dermatologic surgeon to skillfully perform excisional surgery on the skin. Brand names (such as Bard-Parker and Beaver, Becton Dickinson Acutecare, Franklin Lakes, NJ) that have entered into common parlance will be used for convenience, but do not necessarily imply an endorsement of these products. SCALPELS AND BLADES
The two main types of scalpels are the Bard-Parker (BP) style and the Beaver style. Bard-Parker style blades have a slot that slides over a corresponding raised portion on the scalpel handle to lock the blade in place. The No. 3 handle is the workhorse for most dermatologic surgery. The No. 3 handle may be obtained with a measuring rule inscribed on one side. This ruler is handy for measuring the size of lesions and wounds, as well as planning flaps and grafts. Since it is flat, the
No. 3 handle will not roll around on the surgical tray. Round handles with a knurled surface are also available and some surgeons prefer the pencil-like feel to them.5 Beaver style handles are typically composed of two pieces. The end of the handle is threaded to accept the second piece known as the collet. The blade is placed in a slot in the collet and the two pieces are screwed together to hold the blade securely. Beaver handles may be round with a knurled surface or they may be hexagonal in cross section. Beaver scalpel handles are particularly useful for fine delicate work. Each system of scalpels has its own corresponding set of blades. The Bard-Parker No. 15 blade is the standard blade used for most dermatologic surgery. The surgeon should bear in mind that the belly of the blade is the sharpest part and thus should be used to cut. The No. 10 blade is similar in shape to the No. 15 blade, but is larger. It is useful for operating on areas with thick, tough skin, such as the back or scalp. The No. 11 blade is relatively long and narrow and comes to a sharp point. It is suitable for making the stab incisions used in incision and drainage procedures. The No. 15c blade is smaller than the No. 15 blade and is more ~ u r v e dIt. ~may be advantageous when doing delicate surgery as an alternative to using a Beaver blade. Surgical blades may be made from carbon steel or stainless steel. Carbon steel blades are sharper, but stainless steel blades hold their edge better.16 Blades are also available with
From Private practice, Grand Junction, Colorado
DERMATOLOGIC CLINICS
-
VOLUME 16 NUMBER 1 *JANUARY1998
17
18
WEBER
Figure 1. Surgical scalpel blades (left to right). No. 7515 (Microsharp), Beaver blade No. 64, Beaver blade No. 67, Beaver blade No. 68 (curved), No. 11 blade (for stab or puncture wounds), No. 15 blade (most commonly used), No. 15c blade (smaller, for more delicate surgery), No. 10 (good for thicker dermis), and No. 21 blade.
Teflon coatings that reduce "drag" through tissue. Beaver blades are available in different styles. The No. 67 blade is the most commonly used. Like the BE' No. 15 blade, it has a pointed tip with a sharp belly, but is smaller. The No. 64 blade has a rounded tip with a sharp edge. This blade is useful for procedures such as removing a thin layer of skin from the cartilage of the external ear. The No. 7515 blade differs from the previously described blades in that it is composed of a
tiny yet very sharp pointed blade fixed in plastic. The plastic portion is threaded and screws directly into the end of the scalpel handle without the use of the collet. Cutaneous surgery on the eyelid is a good use for the No. 7515 blade (Fig. 1). SCISSORS The dermatologic surgeon requires a variety of scissors in their armamentarium (Fig. 2). In addition to the use of scissors in cutting
Figure 2. Surgical scissors (left to right). Mayo, short bent suture removal, Gradle, Stevens tenotomy, Castroviejo, and Metzenbaum.
THE SURGICAL TRAY Table 1. SCISSORS AND THEIR USES Scissors Castroviejo Gradle Iris Kaye Lister Mayo Metzenbaum Shortbent Stevens tenotomy
Uses Cutting delicate tissue Cutting tissue, dissection, suture removal Cutting tissue Cutting lax tissue Cutting dressings, bandages Cutting dressings, sutures Cutting tough tissue, blunt dissection Suture removal Cutting tissue, blunt dissection
tissue, scissors will be used for cutting sutures and dressing materials. Different scissors lend themselves to particular tasks (Table 1).Tissue scissors may be used to cut sutures but at the risk of more rapid dulling of the blades. For most excisional skin surgery, the Gradle scissors will work well for both cutting tissue and blunt dis~ection.~ Similar in configuration to Gradle scissors, the Stevens tenotomy scissors have a slightly wider, less delicate tip, which may work better for blunt dissection. Scissors with a serrated edge, such as the Kaye scissors, can be used to cut tissue without slippage on lax areas such as the eyelid.'O Iris scissors are favored by some dermatologic surgeons but because the fulcrum, i.e., the screw, is farther back from the tips, they have less fulcrum power than Gradle or Stevens scissors.2 Iris scissors are also available with a serrated edge, which helps prevent tissue slippage.12Castroviejo or spring scissors are relatively expensive but can be invaluable for making very fine cuts on deli-
19
cate t i s s ~ e .The ' ~ handles on these scissors are squeezed to bring the blades together, and then the blades spring apart when pressure is relieved on the handle (Fig. 3). For wide undermining of the skin edge or for use on tough or fibrotic skin, a larger, longer scissors will provide more leverage. The 7 inch curved Metzenbaum scissors serve this purpose well. Curved scissors offer more mobility and visibility than straight scissors when cutting deep in a wound.' For most skin excisional work, a versatile pair of tissue scissors such as the Stevens tenotomy scissors will be required on the surgical tray. However, in certain circumstances, one might choose one of the other scissors to make the job easier. In addition to tissue scissors, it is necessary to have scissors for more mundane tasks such as cutting sutures and dressings. Mayo scissors in a 5 1/2 inch length or general operating scissors with blunt tips can be used by the surgical assistant to cut sutures during procedures. A larger set of scissors such as the 7 1/2 inch Lister bandage scissors can be useful for cutting through thick gauze dressings or trimming bandages. For suture removal, some find the Gradle scissors ideal." However, there are other scissors specifically designed for this task. The 3 1 / 2 inch shortbent suture removal scissors have one blade that is narrow and more pointed that can be hooked under small sutures to allow cutting of the suture. FORCEPS
The first two sections of this article have addressed instruments for cutting. Next, con-
Figure 3. Castroviejo scissors. Close-up view demonstrating unique handle that requires minimal hand motion and is useful for delicate areas such as the eyelids.
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sideration needs to be given to instruments used for holding. In addition to fingers, forceps are the most commonly used instruments to hold tissue. The Adson 1 x 2 tooth forceps is a versatile instrument for holding tissue while cutting or suturing tissue. The numbers indicate that one tooth on one jaw inserts into two teeth on the opposite jaw. The Brown-Adson 8 X 9 tooth forceps allows an even better grip at the risk of greater crush injury to tissue. For grabbing onto a slippery epidermal cyst, it may be just what the doctor ordered. At the opposite end of the spectrum are the delicate, lightweight Bishop-Harmon forceps, which can be used to gently grasp the smallest piece of tissue.16 They are available with serrated tips or in a 1 x 2 tooth configuration. While they are more expensive and will not be used in every procedure, having a pair of Bishop-Harmon forceps available for fine eyelid work will make for a happier surgeon. For tasks such as grasping sutures for removal, the Adson forceps with serrated tips is preferred. Some surgeons will also use this forceps to grasp tissue during surgery. One should keep in mind that although Adson serrated forceps enable a more firm grasp on tissue, they can also cause more crush injury than a 1 X 2 tooth Adson forceps.s Splinter forceps such as the Carmalt straight splinter forceps have sharp pointed tips of triangular shape with serrations. They can be employed in a variety of tasks such as grasping sutures for removal, grasping blood
vessels to obtain pinpoint hemostasis when used with an electrosurgical device, or placing adhesive wound closure strips.6 (Fig. 4) NEEDLE HOLDERS Like all surgical instruments, needle holders are available in a variety of styles and sizes. The jaws may be smooth or serrated. Serrated jaws tend to fray or break sutures when using them to tie knots. Needle holders are also available with jaws that have alloy inserts made of tungsten carbide. Tungsten carbide inserts are said to be harder, more durable, and allow a better grasp of the needle. Needle holders with this feature usually have gold plated handles and a correspondingly higher price. The gold plated handles look neat on the surgical tray, but it is debatable as to whether the tungsten carbide jaws are worth the additional cost.z*l6 When choosing needle holders, size matters. For the smaller needles and sutures used in most skin surgery, the Webster or Halsey smooth jawed needle holders will be suitable. To handle larger needles, the Baumgartner or Crile-Wood needle holders would be appropriate. Two other specialty needle holders also deserve mention although not everyone will need them. The Castroviejo needle holder is a delicate needle holder that operates on spring action like its similarly named scissors counterpart. It is available with or without a
Figure 4. Tissue forceps (left to right). Adson 1 x 2, Bishop-Harmon 1 x 2, and Adson serrated tissue forceps (front and side view of each).
THE SURGICAL TRAY
catch that locks the jaws together. These needle holders are well suited for use with the small needles used in delicate oculoplastic procedures. The Olsen-Hegar needle holders are unique in that the jaws of the instrument incorporate a scissors proximal to the needle holding platform. These needle holders may be a time saver if one is operating without an assistant but it takes practice to avoid cutting the suture inadvertently.14 SKIN HOOKS
Use of skin hooks is a matter of personal preference more so than for any of the previously described instruments. Those who are facile in their use will be able to handle tissue in a relatively atraumatic manner as compared to using forceps. On the other hand, some dermatologic surgeons have abandoned their use for fear that the sharp skin hooks place them at risk for percutaneous injury and exposure to transmissible disease^.^ The Frazier skin hook is a commonly used model. It is available with a curved hook as well as with a shepherd crook configuration. The shepherd crook style holds snugly but is more difficult to re1ea~e.I~ The Joseph skin hook has two prongs for a better hold on tissue, which allows better eversion of wound edges.13 HEMOSTATS
Hemostats are used to clamp off blood vessels during surgery. While they will not be required for every procedure, hemostats
21
should be placed on the surgical tray for quick access. The curved Halsted model, also known as a mosquito forceps, is well suited to cutaneous surgery. Popular in general surgery, the Kelly clamp is generally too large and heavy for use in skin procedures and may result in excessive crush injury. CURETTES
Curettes are ”rounded blades” that are used to scrape benign and malignant lesions from their underlying attachments. Surgeons will often curette a lesion prior to excising to determine the size of the defect. Tumors such as basal cell carcinomas feel ”softer” than surrounding tissue and are easily scraped with a curette. The Fox curette has a rounded or oval head, which is measured in millimeters (Fig. 5). The Piffard curette has an oval head and has a thick or narrow handle. Having curettes of varying sizes is ideal. Like other surgical instruments, blade sharpness should be maintained. MISCELLANEOUS INSTRUMENTS
In addition to the basic instruments already described, there are several additional items that may be of use in certain procedures. The Desmarres chalazion clamp has two handles joined at one end, while the clamping end consists of a flat oval surface on one side and a ring on the other side. The handles are joined by a threaded rod with a nut that can be tightened down. The chalazion clamp is useful for procedures on the lip and the
Figure 5. Curettes. Fox dermal curettes with round 2 mm head (bottom) and oval 5 mm head (top).
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skin excisional procedures, the surgical tray would include the following: No. 3 scalpel handle with No. 15 blade, Stevens tenotomy scissors, Adson 1 X 2 tooth forceps, Halsey needle holder, Mayo scissors, mosquito clamp, suture, gauze sponges and cotton tipped wooden applicators (Table 2, Fig. 7). Other specialty instruments could be added depending on the procedure. INSTRUMENT CARE
Figure 6. Chalazion clamps. Available in various sizes, they are used for holding tissue such as eyelid or lip margins as well as providing hemostasis.
tongue. The lesion can be positioned in the center of the ring and the clamp tightened. The snugly tightened clamp provides immobility and hemostasis (Fig. 6).3 Another item that should be available is a blade remover to remove scalpel blades from the scalpel handles. The Tiemann model (George Tiemann & Co., Hauppauge, NY) is relatively easy to use although other types are available. Whatever model is chosen, the surgical personnel must feel comfortable using it or else it will not be used. Proper use of a blade remover may reduce the risk of accidental injuries. Although not an instrument, mention should be made of the use of cotton dental rolls in dermatologic surgery. They can be moistened and placed in the nares to provide a firm surface when operating on the nose. Similarly, they can be placed in the mouth when performing lip surgery both to position the lip as well as to absorb blood. Anatomic rubber stamps are an easy way to document the location of lesions and procedures. They can supplement a written description of the location in the medical records.15 THE SURGICAL TRAY
The individual components of the surgical tray have been discussed. For most common
Fine surgical instruments require proper care. If possible, the instruments should be rinsed promptly after surgery or at least placed in a solution of one of the commercially available instrument detergents. The instruments are then scrubbed with a plastic brush to remove tissue and debris. Alternatively, one can employ an ultrasonic cleaner that uses sound waves to produce tiny bubbles that lift debris off the surface of instrum e n t ~ .Ultrasonic '~ cleaners are advantageous in that they are effective in removing debris from the crevices of hinged instruments. A disadvantage of these instruments is that they may produce an aerosol that contaminates the work area.* Regardless of method used, the instruments should be rinsed with water to remove detergent, then allowed to dry before sterilization. Spraying surgical instrument lubricant or instrument milk on hinged instruments, may help to keep them operating smoothly. STERILIZATION OF INSTRUMENTS
Instruments may be sterilized in one of four main ways. Dry heat sterilization offers a non-corrosive method but the high temperatures do not allow the instruments to be packaged in the common paper or plastic packs. Thus, there is the problem of storing
Table 2. THE SURGICAL TRAY FOR BASIC EXCISIONS No. 3 scalpel handle with No. 15 blade Stevens tenotomy scissors Adson 1 x 2 tooth forceps Halsey needle holder Mayo scissors Mosquito clamp@) Gauze sponges, cotton tipped wooden applicators Sutures
THE SURGICAL TRAY
23
Figure 7. The basic surgical tray (left to right). Mayo scissors, Adson 1 x 2 tooth forceps, No. 3 scalpel handle with No. 15 blade, Stevens tenotomy scissors, Halsted needle holder, mosquito clamp, and skin hooks.
the instruments in a sterile fashion. Steam autoclaving is the most popular method for sterilization in office based practice. The steam autoclave uses a combination of pressure and temperature to destroy microorganisms. An advantage is that it only requires distilled water to operate. The disadvantage is that the humidity may dull sharp instruments. A similar device is the chemical autoclave, which uses a formaldehyde and alcohol mixture instead of distilled water. Less moisture is used with these devices, which prevents dulling of instruments. The disadvantage is that the chemical solution is not as easily obtained as distilled water. Ethylene oxide gas sterilization is particularly useful on devices that would be destroyed by heat or moisture. It requires complex equipment, which is impractical for the office based surgeon but may be found in hospitals. Proper care and maintenance of quality surgical instruments will provide many years of service to the dermatologic surgeon. SUMMARY
This article provides an overview of the most commonly used instruments for excisional surgery. It has also discussed some of the specialty instruments that may be of
value. It may serve as a starting point for the outfitting of a dermatologic surgery practice. However, it is no substitute for seeing, touching, and handling the instruments. At many of the larger specialty meetings, the instrument vendors will be displaying their wares. These displays offer an excellent opportunity to evaluate the many instruments. All of these fancy shiny instruments are merely tools to be used as an extension of the surgeon’s hand and brain. They should work for the surgeon in a manner that is comfortable and efficient. Only the surgeon can decide what works best. References 1. Anderson RM, Romfh RF: Scissors. In Technique in the Use of Surgical Tools. New York, Appleton-Century-Crofts, 1980, p 38 2. Bennett RG: Instruments and their care. In Fundamentals of Cutaneous Surgery. St. Louis, CV Mosby, 1988, pp 249, 256, 261 3. Ceilley RI, Bodian E L Biopsy of oral lesions. In Robins P (ed): Surgical Gems in Dermatology. New York, Journal Publishing Group, 1988, pp 15-16 4. Chemosky ME, Chernosky DL: Cold steel surgery. Dermatol Clin 10:265-273, 1992 5. Field LM: A new, rounded scalpel handle. J Dermatol Surg Oncol 8:918, 1982 6 . Fish FS, Perez M, Greenway HT: The Carmalt straight splinter forceps. J Dermatol Surg Oncol 17428-430, 1991
24
WEBER
7. Gibbs RC: A love affair with a Gradle scissors. J Dermatol Surg Oncol 7:771, 1981 8. Grande DJ, Neuberg M: Instrumentation for the dermatologic surgeon. J Dermatol Surg Oncol 1528% 297, 1989 9. Kaspar TA, Wagner Jr RF: Percutaneous injury during dermatologic surgery. J Am Acad Dermatol 24:756-759, 1991 10. Kaye B L Useful scissors for fine dissecting. Br J Plast Surg 24319-320, 1971 11. Koranda FC: Fundamentals of cutaneous surgery. In Sauer GC, Hall JC (eds): Manual of Skin Diseases. 7th edition. Philadelphia, Lippincott-Raven, 1996 12. Koranda FC, Luckasen J R Instruments and tips for
13. 14. 15. 16. 17.
dermatologic surgery. J Dermatol Surg Oncol 8:451, 1982 Lynch WS: Surgical equipment and instrumentation. In Wheeland RG (ed): Cutaneous Surgery. Philadelphia, WB Saunders, 1994, pp 96,98 Maloney ME: Instruments. In The Dermatologic Surgery Suite. New York, Churchill Livingstone, 1991, pp 29,31 Mohs FE, Snow S N More about anatomic rubber stamps. J Dermatol Surg Oncol 17:915-916, 1991 Neuberg M Instrumentation in dermatologic surgery. Semin Dermatol 13:lO-19, 1994 Sebben JE: Surgical preparation. In Roenigk RK, Roenigk HH (eds): Dermatologic Surgery Principles and Practice. New York, Marcel Dekker, 1989
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