1, composition and function: commonly used is a foldable blade and scalpel, which is divided into two parts: blade and handle. When in use, the blade is installed on the knife handle. The commonly used model is 20-24 large blade, which is suitable for cutting large wounds.No. 9- 17 is a small blade with a number engraved at the end of the blade. Handles are classified according to length and size, and numbers are engraved at the end. Several different types of blades can be installed on the handle.

The blade should be clamped and installed with a vascular clamp (or needle clamp) to avoid cutting fingers.

Scalpel is generally used to cut and peel tissue. At present, there are scalpels with hemostasis function, which are used in the operation of liver and spleen and other substantive organs or large surgical wounds that need repeated hemostasis (such as radical mastectomy). Such as various electric knives, laser knives, microwave knives, plasma scalpels, high-pressure water knives, etc. But these tools need a whole set of equipment and professional operation. And disposable scalpels and handles. It is convenient to operate and can prevent nosocomial infection. Here, an ordinary scalpel is taken as an example to illustrate the use method.

2. Holding method: There are four correct holding methods:

1) Bow-holding style: It is a common way to hold a knife, with thumb under the handle, forefinger and middle finger on the handle, and wrist force. Used for skin long incision and rectus abdominis anterior sheath incision.

2) Pen-holding type: the main force of action lies in the fingers, which is a fine change in short distance, and is used to dissect blood vessels, nerves, peritoneal incisions and short incisions.

3) grip type: the grip of the knife is relatively stable. Wide cutting range. Cut with great force. Such as amputation, tendon incision, longer skin incision, etc.

4) Anti-pick type: it is forced to open by fingertips, which is mostly used for abscess incision to prevent damage to deep tissues.

No matter which way you hold the knife, the protruding surface of the blade should be perpendicular to the tissue, and the tissue should be cut layer by layer. Don't use the tip of the knife to operate hard. The knife will be unstable if it is too high, and it will hinder the line of sight if it is too low. Should be moderate.

Second, scissors (scissors, straight, curved)

According to its structural characteristics, there are sharp, blunt, straight, curved, long and short types. According to the purpose, it can be divided into tissue scissors, suture scissors and ligation scissors. Tissue scissors are mostly bending scissors, sharp and fine, and are used to dissect, cut or separate cut tissues. Usually, direct scissors are used for superficial surgery and bending scissors are used for deep surgery. Most of the thread scissors are direct scissors, which are used to cut suture, dressing, drainage and so on. The difference between thread scissors and tissue scissors is that the blade of tissue scissors is sharp and thin, while the blade of thread scissors is dull and thick. Therefore, we must not be greedy for convenience and use tissue scissors instead of thread scissors, which will damage the blade and cause waste. Thread-taking scissors are direct scissors with blunt pages and sharp pages, which are used to take out stitches. The correct way to hold and cut is to insert the thumb and ring finger into the two rings of the cutting handle, with the middle finger placed on the cutting handle of the ring finger ring and the index finger pressed on the shaft joint, which plays a stabilizing and guiding role and is beneficial to the operation.

Three, vascular forceps (hemostatic forceps or forceps, straight, curved)

Vascular clamp is mainly used to clamp blood vessels or bleeding spots, also known as hemostatic forceps. The main structural difference of vascular forceps is alveolar bed, which can be divided into straight, arc, right angle and arc (such as renal pedicle forceps) due to surgical needs. Vascular forceps used in vascular surgery are called non-invasive vascular forceps because of their thin and shallow teeth, good elasticity, little squeezing effect on tissue and little damage to vascular wall and intima. Because the front end of tweezers is smooth, it is easy to insert into fascia and not easy to puncture vein. It is also used to separate anatomical tissues. It can also be used to pull suture, pull out suture needle, or replace tweezers, but it is not suitable for clamping skin, organs and fragile tissues. When used to stop bleeding, the tip should be perpendicular to the tissue, and the broken end of the bleeding blood vessel should be clamped, and the nearby tissue should be clamped as little as possible. Hemostatic forceps has various shapes and lengths to meet the needs of different operations and sites. In addition to the common straight bending type, there are toothed vascular forceps (full-tooth groove) and mosquito straight bending vascular forceps.

A. Kelly clamp (large, medium. , small): used to clamp deep tissue or visceral vascular bleeding, there are two kinds.

B. Straight clamp: used to clamp superficial tissue bleeding and assist needle extraction.

Large medical Kirchl forceps. , small, small): used to clamp thick tissue and easy-to-slip tissue of vascular bleeding, such as mesentery, omentum, etc. The front teeth can prevent slippage, but they can't be used for subcutaneous hemostasis. D Mosquito vascular clamp (Mosquito C 1amp): It is a small and exquisite vascular clamp, with straight and curved types. It is used to stop bleeding in organs, face and plastic surgery, and is not suitable for clamping large tissues.

The use of vascular forceps is basically the same as that of surgical scissors, but when it is released, hold one ring opening of vascular forceps with thumb and forefinger, block the other ring opening with middle finger and ring finger, and gently press the thumb and ring finger against the top.

It should be noted that vascular forceps should not clamp the skin, intestines, etc. To avoid tissue necrosis. You can only buckle one or two teeth when stopping bleeding. It is necessary to check whether the buckle lock is out of order, and sometimes the grip will automatically loosen, resulting in bleeding, so be vigilant. Before use, check whether the two pages of the front transverse alveolar are consistent. If they are inconsistent, do not use them to prevent the tissue clamped by the hemostatic tube from slipping off.

Four, surgical forceps (forceps)

Surgical forceps are used to clamp and lift tissues, which is convenient for dissection and suture, and can also clamp sewing needles and dressings. There are different lengths, including toothed pliers and toothless pliers:

1. Tooth forceps: also known as tissue forceps, the forceps tip has teeth, which are divided into coarse teeth and fine teeth. Coarse-toothed pliers are used to clamp hard tissue, which is more harmful, while fine-toothed pliers are used for fine surgery, such as tendon suture and plastic surgery. Because the tip has hook teeth, it is clamped firmly, but it does some damage to the tissue.

2. Toothless pliers: also called smooth pliers or dressing pliers. Its tip has no hook teeth and is used to clamp fragile tissues, organs and dressings. Short forceps for superficial surgery, long forceps for deep surgery and pointed flat forceps have less damage to tissues, and are used for vascular and nerve surgery.

The correct way to hold the forceps is to hold the middle and upper parts of the two forceps feet with your thumb against the index finger and middle finger.

Verb (abbreviation for verb) needle holder

Needle holder is also called needle holder. Mainly used for sewing needles and sewing various tissues. Sometimes it is also used for knotting tools. It is appropriate to clamp the middle and rear 1/3 joint of sewing needle with the tip of needle holder. In most cases, the clamped needle tip should be on the left, and in special cases it can be on the right. The stitches should overlap 1/3, and the overlapping part of the winding should also be placed at the needle mouth. So that the operation is convenient, and if the needle is clamped in the middle of the needle seat, the needle is easily broken. The method of holding the needle clamp is as follows:

1. grasping method: also called one-handed grasping or one-handed grasping, that is, one-handed grasping needle pliers. The clamping ring clings to thenar muscle, and the thumb, middle finger, ring finger and little finger are pressed on the clamping handle respectively, and the last three fingers are fixed together, and the index finger is pressed on the proximal joint of the needle holder. Use thumb, thenar muscle and metacarpophalangeal joint to expand the toothed buckle on the handle ring of the needle holder, loosen the toothed buckle, and control the opening size of the needle holder to hold the needle. When closed, the thumb and thenar muscles will lock with the rest of the palm and fingers. This method is stable, easy to change the direction of sewing needle, stable and convenient to operate.

2. Finger cuff method: traditional law enforcement. The thumb and the ring finger are sleeved in the clamping ring, and the opening and closing of the needle holder is controlled by the movement force of the fingers, so that the action range of the needle holder during opening and closing is controlled. The method of middle finger holding the clamp in the clamp ring is a wrong law enforcement because it is far from the fulcrum and the clamp is unstable.

3. Palm-finger method: put the thumb into the clamp ring, the index finger presses the front half of the clamp ring to support and guide, and the other three fingers press the clamp ring in the palm. The thumb can be opened and closed up and down to control the opening and closing of the needle holder.

Six, commonly used pliers

1. Ring pliers: also known as holding pliers. There are two kinds: toothed and toothless. Toothed ones are mainly used to clamp and transfer disinfection instruments, sutures, sutures, dressings, drainage tubes, etc. It is also used to clamp gauze dipped in disinfectant to disinfect the skin in the operation field, or to wipe the deep blood in the operation field, and to clamp organs without tooth marks for auxiliary exposure. In dressing rooms and operating rooms, sterile holding forceps are usually placed in sterilized beakers or flasks with knives and scissors in them. Attention: (1) Don't put the head end (that is, the end immersed in the disinfectant) upward, so that the disinfectant will flow to the bacteria-carrying area at the handle end, and the head end will be polluted if it is put back. The normal grip head should always face down. (2) It is specially used for gripping sterile articles and cannot be used for dressing change. (3) When it is taken out or put back, the head end should be closed, and the container mouth and the instrument table should not contact. (4) The container mouth of the vice should be covered with a plastic sleeve.

2. Tissue forceps: also known as Allis. The compression of tissue is lighter than that of vascular forceps, so it is generally used to clamp soft tissue and is not easy to slip off. For example, the excised focus is clamped and pulled, which is convenient for operation, and the gauze pad is clamped with the subcutaneous tissue at the edge of the incision to avoid the tissue in the incision from being polluted.

3. Towel clip: used to fix the surgical towel around the surgical incision. As shown in figure 1-2 1.

4. Angular clamp: used to free and bypass the back wall of major blood vessels, biliary tract and other tissues, such as left gastric artery and cystic duct.

5. Intestinal clamp: used to clamp the intestinal tube, with thin tooth slot, good elasticity and little damage to tissue. When in use, the latex tube can be put on to reduce the damage to the intestinal wall. 6. Payr's clamp: it is used to clamp the stomach and facilitate gastrointestinal anastomosis, with multiple joint axes.

Seven, traction hook (tractor)

Traction hook, also known as retractor or retractor, is a necessary instrument to expose the operating field. Several commonly used retractor are introduced as follows:

1. Skin retractor: It is a rake retractor, which is used to retract the skin in superficial surgery.

2. Thyroid retractor: It is a kind of flat hook, which is often used for pulling and exposing the thyroid gland, and also for pulling the skin and muscles during abdominal incision.

3. Appendiceal retractor: It is also a hook retractor, used for appendectomy, hernia and other operations, and also used for abdominal wall traction.

4. Abdominal retractor: it is a wide and smooth hook, which is used for large abdominal surgery.

5.S-shaped deep retractor: It is an S-shaped deep abdominal retractor. When using the retractor, use a gauze pad to separate the retractor from the tissue, and the pulling force should be uniform. Don't force it suddenly or excessively, so as not to damage the tissue. The correct way to hold the retractor is to hold the palm up.

6. Self-fixed retractor: Self-fixed retractor can be used for abdominal, pelvic and thoracic surgery.

Eight, suction (suction)

It is used to aspirate bleeding, exudate, pus, hollow organs and other contents in the operation field, so as to make the operation field clear and reduce the chance of pollution. The suction device consists of a suction head, a rubber tube, a glass joint, a suction bottle and a power part. Power is divided into motor power and pedal straw: the latter is used in areas without power. There are many kinds of structures and shapes of suction head, mainly single tube and sleeve type, and the tail is connected to the suction bottle with rubber tube for standby. Single-tube suction head is used to suck the blood in the operation field and the liquid in the chest and abdomen. The cannula suction head is mainly used to suck the liquid in the abdominal cavity, and its shell has many side holes and air inlets, which can prevent the omentum and intestinal wall from being sucked and blocking the suction head.

Nine, needle (needle)

Suture needle is an instrument for suturing various tissues, which consists of three basic parts: needle tip, needle body and needle eye. According to the shape, the needle tip can be divided into three types: round head, triangular head and shovel head: the needle body has three types: near round head, triangular head and shovel head. Needle eye is a hole for lead wire, which has two kinds: ordinary hole and bullet hole. Circular (conical) needle bends are divided into 1/2 and 3/8 radians according to different radians, and those with larger radians are mostly used in deep tissues. The first half of the triangular needle bend (straight) is triangular and sharp, which is used to suture tough tissues such as skin, cartilage and ligament, and the damage is considerable. No matter whether round needle or triangular needle is used, in principle, the needle with smaller diameter should be chosen, with less damage, but sometimes the tissue has greater toughness, and the needle with too small diameter is easy to break, so it should be chosen reasonably. In addition, when sewing with curved needle, it should be pulled out from the tissue along the arc of curved needle, otherwise it will be easily broken. Generally, sewing needles are used to thread thread, but sewing needles that press thread into the hole of projectile machine from the end of needle are rarely used, because the thread often cracks and is easy to break, which has great trauma to tissue. At present, most developed countries use sewing needles (without pinholes) with integrated needle and thread. This kind of needle and thread has little damage to the tissue (the thickness of the needle and thread is the same), which can prevent the suture from falling off and avoid the trouble of the lead when sewing. Non-invasive suture needle belongs to the category of needle and thread integration and can be used for vascular and nerve anastomosis. According to whether there is an arc between the needle tip and the needle eye, it can be divided into straight needle and curved needle.

Suture

It can be divided into two categories: absorbable suture and nonabsorbable suture.

1. Absorbable suture:

Mainly catgut suture and comprehensive suture.

(1) Intestinal line: It is made of sheep intestinal submucosa. There are two kinds: ordinary and chrome. Ordinary catgut has a short absorption time (4-5 days) and is mostly used for ligation and skin suture. The absorption time of chrome catgut is long (14-2 1) days, and it is used to suture deep tissues. Intestinal line belongs to foreign protein, and the tissue reaction is fierce during absorption. Therefore, when too much and too thick catgut is used, the inflammatory reaction of the wound is obvious. Its advantage is that it can be absorbed without foreign matter.

At present, catgut suture is mainly used to suture the mucosa of internal organs such as stomach, intestine, bladder, ureter and biliary tract. Usually, catgut is made of 1-0 to 3-0 chromium. In addition, thicker (0-2) chrome catgut is usually used to suture deep tissues or inflamed peritoneum. Using catgut in infected wounds can reduce sinus tracts that are difficult to heal due to other nonabsorbable sutures. When using catgut, we should pay attention to the following problems: ① The catgut is hard in texture, so it should be soaked in salt water before use and softened before use, but it should not be soaked in hot water or soaked for too long, so as to avoid the catgut from swelling and breaking, which will affect the quality. ② You can't clamp the intestine with needle forceps or vascular forceps, and you can't screw the intestine, which is easy to tear and break. ③ Generally, the intestine is hard, thick and smooth, and ligation requires triple knots. When cutting the thread, leave the thread end for a long time, otherwise the knot will come loose easily. Generally, continuous suture is used to avoid excessive knotting or foreign body reaction after operation. ④ During pancreatic surgery, it is not necessary to ligate or suture the gut, because the gut can be digested and absorbed by pancreatic juice, and then secondary bleeding or anastomotic rupture will occur. ⑤ Try to use catgut. ⑥ The price of gut is slightly more expensive than that of silk thread. (2) Synthetic fiber thread: There are many varieties, such as Dexon(PGA, polyglycolic acid), Banjarmasin (polyglycolic acid), Vicryl (polyglycerol glycolide 9 10, polylactic acid glycolic acid), PDS (polydioxanone, polydioxanone) and PVA (polyvinyl acetate vinylon). Their advantages are: ① light tissue reaction. ② The absorption time was prolonged. ③ It has antibacterial effect. Among them, Dexon is the main representative, and its appearance is green and white. It is a needle and thread integrated by many tightly woven strands. The thickness varies from 6-0 to 2#. High tensile strength, not easy to break. Soft and smooth, easy to knot during operation, and good operation feel. Hydroxyacetic acid produced after hydrolysis has antibacterial effect. Completely absorbed within 60-90 days. 3-0 thread is suitable for gastrointestinal suture, and 1# thread is suitable for suture peritoneum, tendon sheath, etc.

2. Non-absorbable suture:

There are dozens of kinds such as silk, cotton, stainless steel, nylon, tantalum, silver and hemp. The most commonly used is silk thread, which has the advantages of high flexibility, convenient operation, little reaction to tissues and high temperature disinfection resistance. The price is low and the source is easy. The disadvantage is that the tissue is a permanent foreign body, which is easy to form sinus after wound infection, and the thread is discharged after a long time, delaying healing. Suture of biliary tract and urinary tract can lead to stone formation. Generally, No.0 → No.0 silk thread can be used to suture intestines, blood vessels and nerves, 1 silk thread can be used to suture skin, subcutaneous tissue and ligate blood vessels, No.4 silk thread can be used to suture fascia and ligate larger blood vessels, and No.7 silk thread can be used to suture peritoneum and wound tissue with high tension.

Metal alloy wire is customarily called "stainless steel wire". Used for suture of bone, tendon and fascia, tension-reducing suture or tooth fixation in oral cavity. Nylon thread has little tissue reaction and can be made into extremely fine thread, which is mostly used for small blood vessel suture and plastic surgery. When it is used to suture small blood vessels, it is usually made into a non-invasive suture. Its disadvantage is that the knot is easy to loosen, and it is easy to break at the knot if the ligation is too tight, so it is not suitable for deep tissue suture with tension.

At present, a variety of incision bonding materials have been developed to replace sewing needles and stitches, which are convenient and quick to use and have little scar after incision healing. There are three main categories: ① surgical zipper, which is mainly used to close the skin, and its biggest advantage is that there is no foreign body in the incision. As shown in figure 1-27; ② Medical glue can be divided into chemical glue and biological glue. The former includes epoxy resin, acrylic resin, polystyrene and cyanoacrylate, while the latter includes gelatin. Mytilus glue and human fibrin glue are mainly used to bond skin incision, skin graft and digestive tract leakage. When in use, the glue is directly applied to the wound edge of the incision, and the incision can be opened under pressure. Bio-glue has low toxicity, fast absorption and good application prospect; (3) The metal nail is directly nailed.

XI。 Dressing:

There are generally many kinds of gauze and cloth products. Common dressings are introduced as follows:

(1) gauze piece: used for skin disinfection. During the operation, the oozing blood, pus and secretions are wiped, and after the operation, the suture incision is covered. Warm and moist gauze is used to enter the abdominal cavity, and the water is gently pressed at a vertical angle to remove the water. Don't wipe or pass through it, so as not to damage the tissue.

(2) Ball-like, small (S.S.): The gauze is rolled tightly into a ball with a diameter of 0.5- 1 cm, and clamped with tissue forceps or long vascular forceps for blunt tissue peeling.

(3) Large gauze pad: used to cover skin, peritoneum and wet saline gauze pad can be used to protect abdominal organs, and can also be used to wipe blood. In order to prevent the abdominal cavity from being left behind, a belt, also called a tail towel, is often tied at one corner.

Attachment: Application and Precautions of Sterile Surgical Kit

Surgical aseptic package is to wrap the dressing, instruments and articles needed for operation with cloth (two double-layer cloths), which is autoclaved for later use.

1. There should be a label on the outside of the aseptic package, indicating the name of the contents and the expiration date.

2. It should be kept in a clean and dry place (inside cabinets and tables). If it is found that the cloth is damaged or soaked by water, or the label is lost, it should be suspected that the contents in the bag are contaminated and cannot be considered sterile, and can only be used after re-disinfection.

3. Sterile articles that have not been used for more than 7- 10 days in spring and more than two weeks in winter should be disinfected again before use.

4. A sterile article can only be used by one patient to avoid cross infection.

5. When in use, put it on the surgical instrument table or other safe places. When you open the cloth, you should pay attention to keep its inner surface free from pollution. Do not take sterile items out of the bag or touch the inside of the cloth with unsterilized hands or other unsterilized tools. Operators should keep a distance of 20 cm from sterile articles.

6. If you only need some items, you must keep them sterile after taking them out with sterile holding pliers or tweezers, and wrap them as they are, so you can use them first next time.

Twelve, high frequency electrotome:

Electrosurgery has been widely used in modern surgery. Electronic surgery uses high-frequency current to cut tissue and achieve the effect of hemostasis. Electrosurgical knife is a common instrument in surgery, which integrates cutting, separation and hemostasis, so that these separated operations can be completed at the same time, reducing the number of times of ligation or suture to stop bleeding and greatly shortening the operation time.

The electric scalpel uses high-frequency current to cut the tissue and achieve the effect of hemostasis. Electrosurgical knife can achieve the following functions in surgery: (1) drying: low-power electrocoagulation does not require electro-light; (2) Cutting: releasing electro-light, which can cut the tissue; (3) coagulation: electro-optic light can not cut the tissue, and can be used to stop bleeding and cauterize the tissue; (4) Mixed cutting: it can cut and stop bleeding at the same time.

Commonly used electrotome types include domestic DD-2 high-frequency electrotome, Taiwan Province Yuesheng 500S surgical electrotome, Swiss Prifzer electrotome and American Valleylab electrotome. Its structure consists of three parts: high-frequency electron generator, high-frequency electrode plate and high-frequency electric cutter head. The old electric cutting machine also has a foot switch. High-frequency electron generator and electrode plate are prepared by visiting nurses before operation. The electrode plates are hard and soft, which are in close contact with the patient, and the resistance is 0, so it is not easy to burn in use. Now the soft electrode plate is widely used. It is very important to adjust the power level of high frequency electron generator. The level of power depends on different surgical operations, doctors' skills and electric cutter heads. In general surgery, the principle of unipolar output and high electric energy is: (1) low electric energy, which is used for electrocoagulation hemostasis of minor bleeding, separation of adhesion and anatomical separation of small and medium blood vessels; (2) moderate electric energy, electrocoagulation to stop bleeding, and cutting free organs and tissues in abdominal cavity; (3) High electric energy, liver tissue cutting and cancer cell resection (such as radical mastectomy). The setting of electric energy also needs to be set according to the personal experience of the surgeon. The operator operates the high-frequency electric cutter head. There are two control switch buttons on the electric cutter head. The upper main pipe is electrocoagulation, and the lower main pipe is electrocoagulation. Electrocoagulation is mainly used to stop punctate bleeding. Generally, electrocoagulation of blood vessels with a diameter less than 1mm can control bleeding. Electrocoagulation is mainly used to cut tissue and has the function of hemostasis. The electrodes of the high-frequency electric cutter head are divided into long electrodes and short electrodes. The long electrode is used for deep tissue surgery, and the short electrode is used for shallow tissue surgery.

At present, the high-frequency electrotome has some improvements, and the electrode can be extended and retracted at will to control the length; The tubular electrode and the tail of the electrotome are connected with the suction tube, which is beneficial to suction while operating during the operation, reducing the smoke in the air and attracting blood and exudates in the field of vision; The curette-shaped electrode has the functions of scraping and electrotomy, which is especially beneficial to tumor resection.

The advantages of using high-frequency electrosurgical excision procedure are no need for massive ligation, cutting and hemostasis in one go, no foreign body residue in the incision, clean and clear surgical field, and quick operation, especially the long electrode is beneficial to deep-seated (such as pelvic) surgery.

The disadvantage of high-frequency electrotome is that the thermal scattering of electrotome often damages the small blood vessels around the incision, especially when the cutting operation is slow. It leads to easy liquefaction of surgical incision and delayed healing. The use of high-frequency electrotome in open endotracheal anesthesia will cause explosion and casualties due to the discharge spark of the generator. The electrode plate of high-frequency electrotome should be in close contact with the patient, and poor contact can cause burns to the patient; During electrocoagulation and electrocision, tissue gasification smoke can pollute the air environment, and attention should be paid to sucking the smoke clean with a suction device during operation.