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SURGICAL INSTRUMENTS - PG FINAL YEAR VIVA GUIDE

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SECTION 1: NEUROSURGERY / SPECIAL INSTRUMENTS

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HUDSON'S BURR HOLE

• Handle (T-bar/cross-bar type)
• Chuck/chuck key
• Burr (drill bit) - comes in different sizes

1. Evacuation of extradural/subdural hematoma
2. Access for ventriculostomy / ICP monitoring
3. Biopsy of intracranial lesions
4. Preliminary step before craniotomy

• Q: What is the difference between a burr hole and a craniotomy? A: Burr hole = small circular skull opening, bone not replaced. Craniotomy = large bone flap cut and replaced.
• Q: What is a trephine? A: A circular saw used to make larger round holes in the skull; Hudson's burr makes smaller holes.
• Q: At which point do you stop drilling? A: When the inner table of the skull is breached and the dura is visible/bluish; stop to avoid dural tear.
• Q: What are the layers traversed in a burr hole? A: Scalp (5 layers: SCALP) → pericranium → outer table → diploe → inner table → dura.

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WATSON'S SKIN GRAFTING KNIFE HANDLE

• Long flat handle
• Blade (disposable, wide)
• Guard/thickness adjustor

1. Harvesting split-thickness skin grafts
2. Donor site: thigh, back, abdomen
3. Thickness: 0.3 to 0.45 mm (STSG)

• Q: What is the difference between STSG and FTSG? A: STSG - epidermis + part of dermis, contracts more, used for large areas. FTSG - epidermis + full dermis, less contraction, better cosmesis, used for face/hands.
• Q: Other knives used for skin grafting? A: Humby's knife (manual), Braithwaite's knife, Reese dermatome (drum type), Padgett dermatome.
• Q: What is the "take" of a graft? A: Initial adherence by fibrin, then plasmatic imbibition (48h), then inosculation (2-3 days), finally vascular ingrowth (3-5 days).
• Q: Why does STSG contract? A: Primary contraction (elastic recoil of dermis) + Secondary contraction (myofibroblast activity during healing).
• Q: What is "mesh graft"? A: STSG passed through a mesher to expand surface area (ratio 1:1.5 to 1:6), allows drainage of serum/blood.

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SECTION 2: THORACIC INSTRUMENTS

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DOYEN'S RIB RASPATORY

• Handle
• Curved blade with a roughened edge (rasping surface)
• Available in right and left variants

1. Periosteal stripping before rib resection
2. Thoracotomy procedures
3. Rib resection for empyema drainage
4. Access to intercostal spaces

• Q: Why must you stay subperiosteally during rib stripping? A: To avoid injury to the intercostal neurovascular bundle (NVB runs in the costal groove at the inferior border of the rib - nerve, artery, vein from top to bottom: VAN from below).
• Q: Where exactly does the NVB run? A: Along the inferior border of the rib in the intercostal groove. Therefore, incisions/chest tubes go along the UPPER border of the lower rib.
• Q: What is the mnemonic for intercostal NVB? A: VAN - Vein, Artery, Nerve (superior to inferior), hence go above the lower rib.

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RIB CUTTER (GUILLOTINE RIB CUTTER / BETHUNE'S RIB SHEARS)

• Bethune's rib shears (most common)
• Stille-Giertz rib shears
• Lane's rib cutters

1. Rib resection in thoracotomy
2. Empyema thoracis drainage (rib resection drainage)
3. Chest wall surgery

• Q: How do you prevent splintering of rib ends? A: Use bone nibbler/rongeur to smooth edges; periosteum is stripped first with Doyen's raspatory.
• Q: What is the importance of rib resection in empyema? A: In chronic empyema (stage III), rib resection allows adequate dependent drainage and prevents re-accumulation.
• Q: Stages of empyema? A: Stage I - Exudative (watery), Stage II - Fibrinopurulent (fibrin deposition), Stage III - Organizing (thick rind/cortex).

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FERGUSSON'S AMPUTATION SAW

• Metal frame
• Flexible serrated blade (can be changed)
• Handle

1. Bone division during amputations
2. Large bone resections

• Q: What are the levels of amputation of the lower limb? A: Syme's (ankle), below-knee (BK/transtibial), through-knee, above-knee (AK/transfemoral), hindquarter.
• Q: Ideal flap for below-knee amputation? A: Long posterior flap (contains gastrocnemius/soleus - well-vascularized muscle).
• Q: What is the bone-to-skin ratio in BK amputation? A: Bone divided 3-5 cm above skin level to allow tension-free closure.
• Q: What is guillotine amputation? A: Emergency amputation with no flap; wound left open (for gas gangrene, severe crush injury); formal revision done later.
• Q: What is Syme's amputation? A: Amputation at the ankle joint, preserving the heel pad for end-bearing; good for distal foot pathology.

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SECTION 3: UROLOGY

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THOMSON WALKER'S SUPRAPUBIC CYSTOLITHOTOMY FORCEPS (SPCL)

• Long handles
• Ring/cup-shaped jaws
• Allows firm grasp of calculi

1. Suprapubic cystolithotomy (open stone removal from bladder)
2. Evacuation of bladder clots

• Q: What are the approaches for bladder stone removal? A: 1) Cystoscopic lithotripsy/PCNL-equivalent (intravesical), 2) Suprapubic cystolithotomy (open), 3) ESWL (for small stones).
• Q: What are the indications for open cystolithotomy? A: Large stones (>3cm), failed endoscopic removal, associated bladder pathology needing correction (BPH, diverticulum), pediatric patients.
• Q: What is the commonest bladder stone composition? A: Calcium oxalate; in infected/neurogenic bladder: struvite (magnesium ammonium phosphate).
• Q: Instrument of choice for urethral stones? A: Dornier lithotripter (ESWL) or ureteroscopy with Ho:YAG laser.

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SECTION 4: RETRACTORS

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LANGENBECK'S RETRACTOR

• Handle
• Short right-angled blade (various widths)

1. Superficial wound retraction
2. Access to thyroid, parotid, inguinal, abdominal incisions
3. Orthopedic approaches (hip, knee)

• Q: What is the difference between Langenbeck's and Deaver's retractor? A: Langenbeck = small, L-shaped, for superficial/moderate depth. Deaver = large, curved C-shape, for deep abdominal retraction of viscera.
• Q: What is a self-retaining retractor? A: A retractor that holds itself in position without an assistant - e.g., Balfour's, Denis Browne, Finochietto (rib spreader), Norfolk and Norwich.
• Q: Examples of self-retaining retractors? A: Balfour (abdominal), Weitlaner (superficial), Gelpi (spine/perineum), West's (mastoid), Travers (perineum).

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ROUX'S C-RETRACTOR

1. Retraction of viscera in laparotomy
2. Particularly useful for gastric and duodenal surgery
3. Hepatic and biliary surgery

• Q: Why is it called a C-retractor? A: Its blade is curved like the letter C, allowing retraction of deep curved structures such as the duodenal curve.

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DOYEN'S ABDOMINAL WALL RETRACTOR

1. Lower abdominal surgery
2. Pelvic surgery
3. Cesarean section (to retract abdominal wall upward/laterally)

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DEAVER'S RETRACTOR

1. Hepatic/biliary surgery (retract liver)
2. Gastric surgery (retract stomach)
3. Any deep abdominal cavity retraction

• Q: What is the most commonly used retractor in cholecystectomy? A: Deaver's (to retract the liver cephalad to expose the hepatocystic triangle/Calot's triangle).
• Q: What structures are in Calot's triangle? A: Boundaries: cystic duct (inferolaterally), common hepatic duct (medially), inferior surface of liver (superiorly). Contents: cystic artery, right hepatic artery (sometimes), lymph node of Lund.

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INTESTINAL REPOSITOR (DOYEN'S INTESTINAL REPOSITOR)

1. Handling and repositing bowel loops during laparotomy
2. Reduction of intussusception
3. Moving bowel loops out of operative field

• Q: What precautions are taken when handling bowel intraoperatively? A: Warm moist packs, gentle handling, avoid prolonged retraction to prevent ischemia, minimal contact.

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SECTION 5: HEMOSTATIC FORCEPS

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SIR SPENCER WELLS CURVED/STRAIGHT HEMOSTATIC FORCEPS

• Curved (Kocher's modification has teeth at tip)
• Straight
• Sizes: Large, Medium, Small

• Finger rings (2)
• Ratchet lock (box-lock)
• Shank
• Jaw (serrated, no teeth in Spencer Wells; teeth = Kocher's forceps)

1. Clamping blood vessels before ligation
2. Hemostasis
3. Grasping tissue temporarily
4. Traction (curved used as stay suture clamps)

• Q: What is the difference between Spencer Wells and Kocher's forceps? A: Spencer Wells = plain serrated jaws (no teeth), Kocher's = serrated jaws WITH teeth at the tip; Kocher's is more traumatic, used for tough tissues.
• Q: How do you hold a hemostatic forcep? A: Thumb and ring finger in the rings, index finger on the shank for stability.
• Q: What is a mosquito clamp? A: Smallest hemostatic clamp, used for fine vessel clamping in pediatric and plastic surgery.
• Q: Box joint vs. screw joint? A: Box joint (criss-cross, stronger, most surgical instruments) vs. screw joint (older, weaker).

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SECTION 6: SPECIALIZED GRASPERS & HOLDING FORCEPS

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LAHEY'S RIGHT-ANGLED FORCEPS

1. Passing ligatures around the cystic duct/artery during cholecystectomy
2. Dissection around the common bile duct
3. Right hemicolectomy - isolation of mesenteric vessels
4. Thyroid surgery - passing ties around thyroid vessels

• Q: What is the principle of right-angle forceps? A: The 90° angle allows passage of a ligature around a structure (vessel/duct) that cannot be accessed directly - "goes around corners."
• Q: What are other uses of right-angle forceps? A: Tunnel creation for vessel loops, passing umbilical tape/sloops around vessels, mobilizing structures.

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ALLIS' TISSUE HOLDING FORCEPS

1. Holding skin edges (less traumatic than Kocher's)
2. Holding fascia, aponeurosis
3. Grasping cervix during gynecological procedures
4. Holding bowel edges during anastomosis
5. Demonstration of lesions in examination

• Q: Allis vs. Babcock - when to use which? A: Allis = stronger grip, slightly traumatic (for skin/fascia). Babcock = non-crushing, for hollow viscera (bowel, fallopian tube, ureter) where crush injury is unacceptable.
• Q: Can Allis forceps be used on bowel? A: Only for traction on bowel wall in emergency; prefer Babcock for routine bowel handling.

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BABCOCK'S TISSUE HOLDING FORCEPS

1. Holding small bowel, large bowel without crushing
2. Fallopian tube handling
3. Appendix (appendicectomy)
4. Ureter
5. Gallbladder fundus
6. Any hollow viscus that must not be crushed

• Q: Why is Babcock non-crushing? A: The fenestrated jaw distributes pressure, and smooth edges prevent transmural crush injury that could lead to perforation.
• Q: What is the key principle of Babcock's? A: "Hold without harm" - designed for delicate tubular/hollow structures.

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RAMPLEY'S SPONGE HOLDING FORCEPS

1. Primary: Holding gauze swabs for skin preparation (painting the operative field with antiseptic - betadine/chlorhexidine)
2. Holding gauze for packing cavities
3. Passing gauze packs into the peritoneal cavity for hemostasis
4. Helping to display a specimen

• Q: What antiseptic is used for skin preparation? A: 10% povidone-iodine (Betadine) or 2% chlorhexidine in 70% isopropyl alcohol (better for bone surgery as iodine is bone-toxic).
• Q: What is the technique of skin preparation? A: Concentric circles outward from the incision site (clean to dirty direction); OR from incision outward.
• Q: Can Rampley's be used to hold tissue? A: No - it is traumatic to delicate tissue; it is primarily a sponge/swab holder.

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CHEATLE'S FORCEPS

1. Transferring sterile instruments/equipment from one sterile area to another
2. Picking up swabs, gauze, sutures from sterile containers
3. Historically kept in antiseptic (Lysol/hibitane) - now largely replaced by sterile-packed items

• Q: Why is Cheatle's forceps stored in antiseptic? A: To maintain sterility of the forceps between uses in the era before disposable sterile packs; the antiseptic kills surface organisms.
• Q: Is Cheatle's forceps still in common use? A: Largely replaced by sterile packs/autoclaved instruments; mainly used in resource-limited settings. Its use is discouraged as antiseptic jars can become contaminated.
• Q: What antiseptic was used in Cheatle's jar? A: Lysol, Hibitane (chlorhexidine), or 70% alcohol traditionally.

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SECTION 7: DISSECTING FORCEPS

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DISSECTING FORCEPS - PLAIN (NON-TOOTHED)

1. Holding delicate tissue (bowel serosa, peritoneum, dura)
2. Handling suture material
3. Grasping fine structures without trauma

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DISSECTING FORCEPS - TOOTHED

1. Holding skin and subcutaneous tissue
2. Fascia, aponeurosis
3. Securing sutures at skin level

• Q: Why toothed forceps for skin? A: Teeth provide secure grip on tough skin without needing excessive pressure, whereas plain forceps would crush the skin to grip it.
• Q: Can toothed forceps be used on bowel? A: NO - teeth perforate hollow viscera; always use non-toothed/Babcock's for bowel.
• Q: What is McIndoe's forceps? A: Fine-pointed, non-toothed dissecting forceps used in plastic surgery.
• Q: Adson's forceps? A: Fine-toothed forceps used for delicate skin work (face, plastic surgery).

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SECTION 8: SCISSORS

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METZENBAUM TISSUE CUTTING SCISSORS

1. Dissecting planes in deep cavities
2. Cutting delicate tissue (peritoneum, fascia)
3. Dissection around vessels
4. NOT for cutting sutures (will blunt the fine blades)

• Q: Metzenbaum vs. Mayo scissors - difference? A: Metzenbaum = long handle, short blade, for tissue dissection in depth. Mayo = short handle, long blade, for cutting sutures/tough tissue.
• Q: What is the key rule for Metzenbaum scissors? A: NEVER use for suture cutting - the fine blades are expensive and will be damaged.

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MAYO'S THREAD CUTTING SCISSORS

• Straight Mayo (for suture cutting)
• Curved Mayo (for dissecting tough tissue like fascia)

1. Cutting sutures (primary use)
2. Cutting tough fascia, muscle
3. Umbilical cord cutting

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HEATH'S SUTURE CUTTING SCISSORS

1. Cutting skin sutures during wound closure/removal
2. Fine suture work in plastic/ophthalmic surgery
3. Cutting ligatures in restricted spaces

• Q: Why use Heath's rather than Mayo for skin sutures? A: Heath's has fine pointed tips that can be slipped under suture loops precisely without damaging surrounding tissue.

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SECTION 9: NEEDLE HOLDER

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MAYO'S NEEDLE HOLDER

• Ring handles
• Box joint
• Ratchet (3-4 notches)
• Jaws (tungsten carbide inserts = gold-colored handles; cross-hatched serrations)

1. Holding curved needles during suturing
2. Driving needle through tissue
3. Wound closure at all levels

• Q: How do you load a needle into a needle holder? A: 2/3 from the tip (i.e., at the junction of proximal 1/3 and middle 1/3), perpendicular to the jaw.
• Q: What does "gold handle" on needle holder mean? A: Tungsten carbide insert on jaws - harder, longer-lasting grip, prevents needle slippage.
• Q: Hegar vs. Mayo needle holder? A: Hegar = used in gynecology/delicate surgery (no ratchet or gentle ratchet), Mayo = standard surgical needle holder with firm ratchet.
• Q: What is a Castroviejo needle holder? A: Spring-action (no ring), used in ophthalmic and microvascular surgery.
• Q: What is the pronation-supination technique? A: The wrist motion used to drive the needle through tissue - loaded from the right hand, supinate to drive through.
• Q: Can you use an artery forcep instead of needle holder? A: Technically possible but not recommended - will damage artery forcep jaws and give poor needle control.

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SECTION 10: MISCELLANEOUS

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DOYEN'S TOWEL CLIP

1. Securing drapes/towels to the operative field
2. Holding wound edges in emergency
3. Can be used as a periosteal elevator (rarely)

• Q: What is the difference between towel clips? A: Backhaus towel clip (most common) vs. Doyen's. Backhaus = pointed, cross-tip. Both functionally similar.
• Q: Can towel clips puncture gloves? A: Yes - the sharp tips are a sharps hazard; handle carefully.

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YANKAUER SUCTION CANNULA

1. Oropharyngeal/nasopharyngeal suctioning
2. Airway clearance during resuscitation and anesthesia
3. Intraoperative suction of blood/secretions from peritoneal cavity
4. ICU airway suctioning

• Q: What is the thumb hole for? A: Intermittent suction control - occluding with the thumb activates suction; releasing stops it.
• Q: Yankauer vs. flexible suction catheter? A: Yankauer = rigid, for oropharynx (thick secretions, blood, vomit). Flexible = for tracheostomy, nasotracheal deep suctioning.
• Q: What suction pressure is used? A: Usually 80-120 mmHg; too high causes mucosal trauma.

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SECTION 11: LAPAROSCOPIC INSTRUMENTS

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LAPAROSCOPIC SUCTION CANNULA

1. Aspiration of peritoneal fluid, bile, blood
2. Irrigation + suction (lavage)
3. Gentle dissection (hydrodissection)

• Q: What is the standard port size for suction cannula? A: 5mm port.

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MARYLAND DISSECTOR (LAPAROSCOPIC)

1. Dissection of tissue planes
2. Grasping vessels before clipping
3. Blunt dissection
4. With monopolar diathermy: vessel sealing and cutting

• Q: What is Maryland dissector made of? A: Stainless steel; jaws are tungsten carbide-coated.
• Q: Can Maryland be used for monopolar diathermy? A: Yes - it has an electrode connection; used for coagulation.
• Q: What is the key use in laparoscopic cholecystectomy? A: Dissecting the hepatocystic triangle to identify the cystic duct and cystic artery (Critical View of Safety - CVS).

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HOOK DIATHERMY (LAPAROSCOPIC HOOK)

1. Dissection of peritoneal folds
2. Cutting cystic duct and cystic artery (after clipping)
3. Cholecystectomy - detaching gallbladder from the liver bed
4. Division of adhesions

• Q: Monopolar vs. bipolar diathermy? A: Monopolar - current travels from active electrode through patient to ground plate; higher power, used for cutting. Bipolar - current travels between two jaws (e.g., bipolar forceps); safer near vital structures (nerves, vessels).
• Q: What is "thermal spread" in monopolar diathermy? A: Heat spreading to adjacent tissue beyond the intended area - can cause unintended burns to bile duct, bowel. Minimized by using minimum effective power and brief bursts.
• Q: What is the critical view of safety (CVS) in laparoscopic cholecystectomy? A: Strasberg's CVS - 1) Hepatocystic triangle cleared of fat and fibrous tissue, 2) Lower 1/3 of gallbladder separated from liver, 3) Only 2 structures (cystic duct + cystic artery) seen entering gallbladder. Prevents bile duct injury.

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LAPAROSCOPIC GRASPERS - TOOTHED AND TOOTHLESS

• For holding bowel, omentum without trauma
• Fenestrated jaws distribute pressure

• For holding gallbladder fundus, thick tissue
• Provides secure grip

• Q: What grasper is used for the gallbladder fundus? A: Toothed grasper (gallbladder wall is thick and tough).
• Q: What is the "fundus-first" technique in cholecystectomy? A: Retrograde cholecystectomy - start dissection from fundus; used when Calot's triangle is heavily inflamed/fibrosed.
• Q: What ports are used in laparoscopic cholecystectomy? A: 4-port technique: 10mm (umbilical - camera), 10mm (epigastric - Maryland/clip applier), 5mm (right hypochondrium - grasper), 5mm (right iliac fossa - fundus grasper). OR 3-port technique.

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SECTION 12: GI STAPLERS

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GI STAPLER - CIRCULAR (EEA/ILS STAPLER)

• Anvil (head, introduced separately)
• Stapler body with circular blade and double staggered row of staples
• Safety mechanism

1. Anterior resection of rectum (low colorectal anastomosis)
2. Esophagogastric anastomosis (esophagectomy)
3. Sleeve gastrectomy (circular portion)
4. Esophagojejunostomy (Whipple/gastrectomy reconstruction)
5. Hemorrhoid stapling (PPH - procedure for prolapse and hemorrhoids)

• Q: How is a circular stapler used in anterior resection? A: Anvil placed in the proximal bowel end (tied with purse-string suture), stapler introduced transanally, shaft of stapler connected to anvil through the rectal stump, fired to create circular anastomosis.
• Q: What are the "doughnuts"? A: The two circular tissue rings excised during circular stapler firing; must be complete rings to confirm integrity of anastomosis.
• Q: What is a "dog-ear" defect? A: Potential ischemic spot at the ends of a linear staple line; requires inversion suture or can be trimmed.
• Q: What are the advantages of circular stapler over hand-sewn anastomosis? A: Faster, consistent lumen size, allows very low rectal anastomoses where hand-suturing is impossible, reduced anastomotic leak rates (comparable to hand-sewn).
• Q: What is PPH stapler? A: Procedure for Prolapse and Hemorrhoids; circular stapler resects a ring of redundant rectal mucosa/submucosa above the dentate line, pulling prolapsed hemorrhoids back. Advantages: less postop pain (above dentate line), faster recovery.

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GI STAPLER - LINEAR (TA/GIA STAPLER)

1. TA Stapler (Thoraco-Abdominal): Places 2-3 rows of staples without cutting. Closes lumen.
2. GIA Stapler (Gastrointestinal Anastomosis): Places 2 double rows of staples AND cuts between them. Divides and staples simultaneously.

• TA/Linear:
  1. Closing bowel ends (e.g., Hartmann's procedure)
  2. Wedge resection of lung
  3. Gastric sleeve
• GIA/Linear cutting:
  1. Bowel resection (divides and closes both ends simultaneously)
  2. Side-to-side anastomosis (functional end-to-end)
  3. Right hemicolectomy anastomosis
  4. Small bowel resection

• Q: What is a functional end-to-end anastomosis? A: Using a GIA stapler: the antimesenteric borders of two bowel loops are brought together, GIA fired to create a large side-to-side communication, and the enterotomy is then closed with a TA stapler. Result looks side-to-side but functions end-to-end.
• Q: Staple materials? A: Titanium (standard), absorbable (polyglycolic acid) - used in contaminated fields.
• Q: What is the minimum bowel wall thickness for stapling? A: 1-2mm; too thin = staple pull-through; too thick = incomplete staple closure. Most staplers have variable height cartridges (white = thin tissue, blue = medium, green = thick).
• Q: Cartridge colors? A: White (2.5mm, vascular/thin tissue), Blue (3.5mm, medium tissue), Green (4.8mm, thick tissue like stomach).
• Q: What is a "reload"? A: Disposable cartridge inserted into reusable stapler handle for repeated firings.

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MASTER VIVA TRICKS: RAPID RECALL TABLE

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VIVA HOT-TOPICS (PG LEVEL)

1. Critical View of Safety in laparoscopic cholecystectomy (Strasberg) - memorize all 3 criteria
2. Bile duct injury - risk, prevention, management (Bismuth classification)
3. Stapler cartridge colors and tissue thickness matching
4. PPH stapler - indications, technique, complications (bleeding, stenosis)
5. Thermal spread and monopolar vs bipolar diathermy - which is safer near CBD
6. Anastomotic leak - risk factors, clinical signs, management (IR drain vs re-operation)
7. Anterior resection syndrome - after low anterior resection
8. Doyen's instruments - at least 3 different instruments carry Doyen's name (raspatory, abdominal retractor, repositor, towel clip) - expect the examiner to test this!

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QUICK EPONYM SUMMARY FOR VIVA

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1. Name the instrument
2. Type (clamp, retractor, scissors, etc.)
3. Material / parts
4. Uses (at least 3)
5. Special features / precautions
6. Compare with a similar instrument