Pelvic reconstructive surgery involves a variety of surgical approaches including vaginal, laparoscopic, robotic, and abdominal. Each different surgical approach poses unique challenges for the gynecologic surgeon. Vaginal surgery requires skill with operating within a narrow and often deep surgical field. Laparoscopic surgery necessitates adept hand–eye coordination, while robotic surgery requires the surgeon to respond to visual cues and without tactile feedback. With the current surgical emphasis on minimally invasive approaches, open abdominal pelvic reconstructive surgery has become less common and is reserved for patients in whom a vaginal or laparoscopic approach is not feasible. Regardless of surgical approach, the choice of appropriate surgical instrumentation is paramount to facilitating surgical fluidity and efficiency. As surgeons adopt a more active role in the design of new technologies to improve surgical efficiency, new instrumentation continues to be developed. The purpose of this chapter is to review the instruments commonly used in pelvic reconstructive surgery, highlighting some that offer solutions to the inherent surgical challenges of this field.

Scalpels are often one of the first instruments used during surgery. The handle of a scalpel can be fitted with various size blades. While a #10 or #20 size blade may be used for skin incisions, a #15 blade offers a good option for making smaller incisions during vaginal and laparoscopic surgery (Figure 27-1). A #11 blade with its sharp-pointed edge is another alternative for laparoscopic skin incisions.

Scissors provide for sharp surgical dissection and transection of tissue pedicles and sutures. Their blades may be curved or straight. Curved Mayo scissors are a staple instrument for transecting tissue pedicles, while Metzenbaum scissors are traditionally used for finer dissection such as dissecting the vaginal epithelium off of the underlying vaginal muscularis (Figure 27-2). The thin, sharp-pointed tips of iris scissors are helpful with the precise dissection involved in fistula repairs (Figure 27-3). Straight scissors are often used to cut suture. Traditional laparoscopic scissors have a curved blade, although laparoscopic scissors with a “parrot” blade are also available.

Forceps serve as an extension of the surgeon’s fingers and have a variety of lengths and tips. DeBakey or smooth forceps have cross-serrated ends and fine tips and are useful for handling fine tissue pedicles and for isolating vessels. Similarly, Russian forceps have cross-serrated blades but wider tips and offer an alternative to DeBakey’s for handling the bladder and rectum during vaginal prolapse repairs. Mouse-tooth forceps, or forceps with teeth, provide for a secure grasp on vaginal epithelium while Adson forceps are used to manipulate the skin (Figure 27-4). Singley forceps have fenestrated atraumatic tips and can be used to isolate more delicate structures such as fallopian tubes.

Needle drivers are essential for both placing a needle through tissue and retrieving it after placement. They can be classified as either curved or straight based on the shape of their tips. Curved needle drivers may be preferred during vaginal surgery as they provide for improved visualization and often easier needle placement. Two commonly used needle drivers include the Mayo-Hegar needle driver that has a straight tip and the Heaney needle driver that has a curved tip. The Capio^® needle driver (Boston Scientific, Natick, MA) has a curved head and a button on the handle to deploy and retrieve suture in a single step and is often used during sacrospinous ligament fixation (Figure 27-5).

Laparoscopic needle drivers by nature are longer than traditional needle drivers and have various tips and handles. They include the conventional German needle driver with a wratchet spring handle, as well as self-righting needle drivers. Self-righting needle drivers automatically place needles at an angle of 45° or 90°. However, the inability to place a needle at any other angle limits their use with suturing in small spaces.