Surgical instruments are designed to extend the capability of a surgeon’s hands and thus are crafted to retract, cut, grasp, and clear the operative field. Tissue types encountered in obstetric surgery vary, and accordingly, so too do the size, fineness, and strength of the tools chosen for a given procedure. Once an instrument is selected, traditional handling strives to maximize its efficiency.

Scalpel and Blades

Typical surgical blades used in obstetric surgery are pictured in Figure 2-1 and include no. 10, 11, 15, and 20 blades. Blade anatomy includes the edge, sometimes referred to as the “belly.” The unsharpened ridge that lies opposite to the edge is the spine. Last, the slot is the opening within the blade that allows it to be articulated and secured to the knife handle.

With surgical blades, function follows form, and larger blades are used for coarser tissues or larger incisions. For example, the no. 20 blade offers a long edge, which is ideal for quickly covering distance during initial skin incisions. The small no. 15 blade is selected for finer incisions. The acute angle and pointed tip of a no. 11 blade can easily incise tough-walled abscesses for drainage, such as those of the Bartholin gland duct.

When the scalpel is correctly held, the surgeon can direct blade movement. Two methods are shown in Figure 2-2. If the scalpel is held like a pencil, this is termed the “pencil grip” or “precision grip.” If the fingers are positioned to straddle the scalpel, this is termed the “power grip,” “violin grip,” or “bow grip.” These grips maximize the use of the knife edge.

With the no. 10 and no. 20 blades, the scalpel is held at a 20- to 30-degree angle to the skin and is drawn firmly along the skin using the arm with minimal wrist and finger movement. This motion aids cutting with the full length of the scalpel edge and avoids burying the tip. In general, a surgeon cuts toward him- or herself and from nondominant to dominant sides. The initial incision should penetrate the dermis, maintaining the scalpel perpendicular to the surface to prevent beveling of the skin edge. During skin incision, firm and symmetrical traction on the lateral aspect of the incision keeps the incision straight and helps avoid multiple tracks and irregular skin edges.

The no. 15 and no. 11 blades, in contrast, are typically held using the pencil grip to make fine, precise incisions. With the no. 15 blade, the scalpel is held approximately 45 degrees to the skin surface. Fine knife dissection is best controlled using the fingers, and the heel of the hand can be stabilized on adjacent tissue. The no. 11 blade scalpel is ideal for stab incisions and is held upright at nearly 90 degrees to the surface. Creating tension at the skin surface is important to reduce the amount of force required for penetration. Omission of this can result in uncontrolled penetration of underlying structures.

Scissors

These are commonly used to divide tissues, and modification in blade shape and size allows their use for various tissue textures (Fig. 2-3). For correct positioning, the thumb and fourth finger are placed within the instrument’s rings, and the index finger is set against the crosspiece of the scissors for greater control. This “tripod” grip allows maximum shear, torque, and closing forces to be applied and provides superior stability and control. In general, surgeons cut away from themselves and from dominant to nondominant sides.

Of scissor types, the fine blades of Metzenbaum or iris scissors are used routinely to dissect or define natural tissue planes. As such, they may be employed to divide thin adhesions or incise peritoneum or vaginal epithelium. During dissection, traction on opposing poles of the tissue to be dissected typically simplifies the process. To begin, a small nick is often necessary to enter the correct tissue plane. The blades are closed and inserted between planes, while following the natural curves of tissues being dissected. The blades are opened, and then slightly closed and withdrawn (Fig. 2-4). After turning both wrist and blades 90 degrees, the surgeon reinserts the lower blade, and tissues are divided. When dissecting around a curve, the scissors should follow the natural curve of the structure. Dissection proceeds in the same plane to avoid burrowing into the structure or deviating away and toward unintended adjacent tissues.

Sturdier scissors such as curved Mayo scissors are used on denser tissue, such as anterior abdominal wall fascia. Similarly, Jorgenson scissors have thick blades and tips that are curved at a 90-degree angle. These are often used to separate the vagina and uterus during the final steps of hysterectomy. Straight Mayo scissors have blunt, flat blades. They are frequently used as suture-cutting scissors and should be reserved for this function. Use of tissue scissors for suture cutting can dull their blades and is ideally avoided.

Clamps and scissors are not designed for ambidextrous use. The easy release of a clamp or use of standard right-handed scissors with the left hand therefore requires a different handgrip and technique than when these instruments are used with the right hand. The surgeon should strive to be facile in the use of these instruments with either hand using the appropriate grip and technique.

Needle Holders

Also called needle drivers, needle holders typically possess either straight or curved jaws (Fig. 2-5). Straight jaws are more frequently used. But curved jaws, such as those of the Heaney needle holder, aid needle placement in confined or angled areas. Needle holder anatomy also varies at the inner surface of each jaw. Surfaces typically contain either transverse serrations or cross hatching to help grip the needle securely. In most cases, the needle holder clasps a needle at a right angle and at a site approximately two-thirds from the needle tip, termed the swage. Unlike the cylindrical body of the needle, the swage is usually flattened, which improves the needle holder’s grasp. If a curved holder is used, the needle is clasped similarly, and the inner curve of the holder faces the needle swage (Fig. 1-4, p. 4).

Traditionally, the needle holder is held with the thumb and fourth finger in the rings. The greatest advantage of this grip is the precision afforded when directing needles. Also, the spring tension of the handles can be relieved from the lock in a controlled fashion, thereby releasing and regrasping the needle more precisely. Alternatively, with the “palmar grip,” the needle holder is held between the ball of the thumb and the base of the remaining fingers. No fingers enter the instrument rings. This grip allows a simple rotating motion for driving curved needles through an arc. Its greatest advantage is the time saved during continuous suturing, as the needle can be released, regrasped, and redirected efficiently without replacing fingers in and out of the instrument rings. Disadvantageously, this grip has the potential to lack precision during needle release. When unlocking the needle driver, release of the spring lock should be smooth and gradual. This avoids an abrupt release, which may suddenly pop the handles apart with potential for awkwardness, loss of needle control, and tissue injury.

Tissue Forceps

Forceps function to hold tissue during cutting, to retract tissue for exposure, stabilize tissue during suturing, extract needles, grasp vessels for electrosurgical coagulation, pass ligatures around hemostats, and pack sponges. Forceps are held so that one blade functions as an extension of the thumb and the other as an extension of the opposing fingers. Alternate grips may appear awkward and limit the full range of wrist motion, leading to suboptimal instrument use.

Several types of forceps are used to handle tissues and to place sutures (Fig. 2-6). Heavy-toothed forceps, such as the Potts-Smith single-toothed forceps, Bonney forceps, and Ferris-Smith forceps, are used when a firm grasp is more important than gentle tissue handling. These tools are often used to hold fascia for abdominal wound closure. Light-toothed forceps, such as the single-toothed Adson, concentrate force on a tiny area and give more holding power with less tissue damage. These are used for more delicate work on moderately dense tissue such as skin.

Nontoothed forceps, also known as smooth forceps, exert their grip through serrations on the opposing tips. They are typically used for handling delicate tissue, such as peritoneum, and provide some holding power with minimal injury. DeBakey forceps are another type of smooth forceps, which were originally designed as vascular forceps but can be used for other delicate tissues. In contrast, the broader, shallow-grooved tips of Russian forceps and Singley forceps may be preferred if a broader or thicker area of tissue is manipulated. These are often used during hysterotomy closure during cesarean delivery.

Retractors

Abdominal Surgery

Clear visualization is essential during surgery, and retractors conform to body and organ angles to allow tissues to be pulled back from an operative field. In obstetrics, retractors may be grouped broadly as abdominal or vaginal and then as self-retaining or handheld.

Abdominal surgery in most cases requires active participation of an assistant surgeon around a confined incision. Thus, retractors that by themselves hold abdominal wall muscles apart, termed self-retaining, are often employed during laparotomy. Styles such as the Kirschner and O’Connor-O’Sullivan contain four broad, gently curved blades and retract in four directions. Blades pull the bladder caudally, the anterior abdominal wall muscles laterally, and the packed upper abdominal contents cephalad. The Balfour retractor retracts in three directions (Fig. 2-7). It can be made to retract in four with the addition of an upper arm attachment. Alternatively, ring-shaped retractors such as the Bookwalter and Denis Browne styles offer greater variability in the number and positioning of retractor blades. However, these usually require more time to assemble and place. With most of these styles, deep or shallow blades can be attached to the outer metal frame according to the abdominal cavity depth.

During self-retaining retractor positioning, attention is focused on blade depth to avoid femoral nerve compression injury. This nerve can be compressed anywhere along its course but is particularly susceptible within the body of the psoas muscle. In prevention, lateral retractor blades are selected and positioned such that only the rectus abdominis muscle and not the psoas muscle is retracted (Chen, 1995). The retractor blades are evaluated when placed, to confirm that they are not resting on the psoas muscle. For thin patients, folded laparotomy towels may be placed between the retractor rim and skin to elevate blades away from the psoas muscle.

In contrast to these reusable types, disposable self-retaining retractors consist of two equal-sized plastic rings connected by a cylindrical plastic sheath (Alexis and Mobius retractors). One ring collapses into a canoe shape that can be threaded through the incision and into the abdomen. Once inside the abdomen, it springs again to its circular form. The second ring remains exteriorized (Fig. 2-8). Between these rings, the plastic sheath spans the thickness of the abdominal wall. To hold the retractor in place, a surgeon everts the entire circumference of the exterior ring multiple times. This folding takes up slack in the sheath until the sheath is tight against the skin and subcutaneous layers. This yields 360-degree retraction, and disposable retractors come in variable sizes.

In addition to or in place of these self-retaining styles, a surgical assistant can use a handheld retractor. These instruments allow retraction in only one direction but can be placed and repositioned quickly (Fig. 2-9). The Richardson retractor has a sturdy, shallow right-angled blade that can hook around an incision for abdominal wall retraction. Alternatively, Deaver retractors have a gentle arching shape and conform easily to the curve of the anterior abdominal wall. Compared with Richardson retractors, they offer increased blade depth and are used commonly to retract bowel, bladder, or anterior abdominal wall muscles. A Harrington retractor, also called a sweetheart retractor, has a broader tip that also effectively holds back packed bowel.

For laparoscopy or minilaparotomy incisions, the preceding retractors are too large, and those with smaller blades such as the army-navy retractor or S-retractor are selected. S-retractors offer thinner, deeper blades, whereas the sturdier blades of the army–navy style allow stronger retraction (Fig. 2-10). Additionally, a metal Weitlaner or small-diameter disposable Alexis or Mobius self-retaining retractor may be used for minilaparotomy incisions.

In certain instances, such as vaginal cuff suturing or uterine artery ligation, a thin retractor blade, termed a malleable or ribbon retractor, may be required. Here, it serves as a metal wall to isolate actively sutured tissue from surrounding organs. This long, flexible metal strip can also be bent to conform to various body contours and can be used to retract. Narrow and wider sizes are available. A ribbon retractor can also be positioned to protect intestines from needle-stick injury during abdominal wall closure. This approach is especially useful in obese women or when anesthetic relaxation is not ideal. The retractor is placed over the intestines beneath the peritoneum and is left in place as a barrier while the fascia is closed. It is removed prior to final fascial stitches. Similarly, using a McNealy-Glassman viscera retainer—a “fish”—can help avoid needle-stick bowel perforation (Fig. 2-11). Prior to closing the final 2 to 3 cm of fascia, the surgeon pulls on the attached ring to remove the flexible retainer.