Suction

Suction will contribute to a clear operating field. Many tips are available but the most useful focal tips are the Adson (4 mm diameter) or Frazier (2.6 mm diameter) types, both of which offer fingertip control of suction by an assistant. For suction of larger volumes of fluid from body cavities when performing abdominal or thoracic surgery the Poole is preferred (Fig. 13-2).

Magnification and light

Use of binocular loupes, which magnify while maintaining a normal working distance, will significantly improve visualization of the operative site. A magnification of 2.5× is sufficient for most procedures. The focal distance should be selected to maintain a normal working distance, usually 380 mm or 430 mm. The addition of a loupe light, either fiber optic or the more economic LED type, will automatically provide surgery light where it is needed (Fig. 13-3).

Soft tissue biopsy instruments

Selection of the appropriate soft tissue biopsy devices will be detailed in the relevant organ specific chapters and more generally in Chapter 14. Several types are available. The TruCut type consists of a slim needle which may be inserted relatively atraumatically into an area of parenchymatous tissue, typically within an organ (Fig. 13-4). A spring loaded cutter is fired within the needle, which excises and traps a sample. Where the sample is to be obtained from the surface of a friable tissue, clamshell type biopsy forceps with cutting jaws enclose and remove the sample (Fig. 13-5). Skin biopsies may be obtained using a punch biopsy, available in a variety of sizes. Although available as a reusable instrument it is normally used as a disposable device.

Vessel sealing devices

Accurate hemostasis is of utmost importance to a patient’s survival and there are a wide variety of hemostatic tools currently available, all with their inherent advantages and limitations. Considerations should include time taken to achieve hemostasis, reliability in vessel sealing, collateral damage, and expense. Temporary application of pressure with sponges or hemostats may be sufficient for capillary or very small vessels, as clotting should occur. For larger vessels, ligation or the use of diathermy or electrosurgical devices will be required. Diathermy and electrosurgical devices have the advantage of sealing vessels in a shorter period of time than that required to place a ligature, and this might be useful in a situation where time is of the essence. In other situations the surgeon may prefer the security and reliability of a suture, for example for ligation of the femoral artery if performing amputation.

The following were compared for their efficacy and security in achieving vessel ligation: braided suture in a surgeon’s knot; a monofilament suture in a granny knot; a metallic clip (Ligaclip, Johnson and Johnson; Fig. 13-6A); a bipolar diathermy system (Ligasure, ValleyLab; Fig. 13-6B); and an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson).² Secure hemostasis was obtained with all the techniques in all vessels below 5 mm in diameter. In vessels over 5 mm, secure hemostasis was obtained with all modalities except the harmonic scalpel. With the harmonic scalpel, leaks occurred in vessels greater than 5–6 mm, confirming that the manufacturer’s claims for each of the hemostatic methods were accurate. The use of hemostatic tools such as the harmonic scalpel and Ligasure has increased with the use of laparoscopic surgery where it is not easy to place traditional surgical knots.

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