How to Hold Surgical Instruments Correctly

General Principles

• Always rest the instrument on your fingertips - not deep in the palm. This gives fine motor control using the small muscles of the hand rather than gross shoulder/elbow/wrist movements.
• Use a "finger rest" with your small (little) finger whenever possible. Resting it against a stable surface anchors the instrument and allows micro-adjustments at the tips.
• Do not insert fingers too far into the rings of ring-handled instruments (needle drivers, scissors). Over-insertion makes dexterous movement nearly impossible and makes it hard to switch instruments quickly.
• Keep wrist movements smooth and deliberate. Tense, jerky movements tear tissue and reduce precision.
• For microsurgery, prop your forearms and hands on pads to eliminate tremor from freely held hands.

Scalpel

• Hold the handle between the thumb, index, and middle fingers, exactly like holding a pen.
• The ring and small fingers rest on the patient's skin or drape as a support/stabiliser.
• The index finger rests along the top of the blade/handle to guide direction.

• The handle lies across the palm, gripped by all four fingers with the thumb on the opposite side.
• The small finger still acts as a "finger rest" for control.

• Hold the scalpel at approximately 30 degrees to the skin surface. This allows maximum blade contact with tissue and produces a clean, vertical incision edge.
• Cut with the belly of the blade (the curved mid-section), not the tip or heel.
• Never use a palm grip for fine suturing work - it eliminates fine control.

• To load: grip the blade at its tip (not the cutting edge) with artery forceps and slide it onto the handle tongue until it clicks.
• To remove: grasp the distal end of the blade with forceps, push it slightly sideways, then slide it off away from the tip. Never use fingers directly.

Scissors (and Needle Drivers)

1. Thumb into one ring
2. Ring finger into the other ring
3. Index finger resting flat along the shaft, near the hinge

• Insert only the distal phalanges (fingertips/pads) of the thumb and ring finger into the rings - not the full finger.
• The index finger on the shaft is what gives directional control.
• For cutting: hold the blades partially open, advance forward, then close - maintaining consistent pressure throughout.

Needle Driver (Needle Holder)

• Held identically to scissors (tripod grip above).
• When loading the needle, grasp it at the junction of the proximal two-thirds and distal one-third of the needle body - not at the swaged (suture-attached) end or at the tip.
• The needle should be perpendicular (90°) to the jaws of the driver, or slightly angled depending on the suturing angle required.
• Do not lock the ratchet too tightly - enough to hold the needle securely, but with enough give that you can reposition it.

Tissue Forceps (Thumb Forceps)

• Hold between thumb, index, and middle fingers like a pen.
• Ring and small fingers act as finger rests against tissue for stability.
• Use toothed forceps for handling tissue edges - they hold securely with less crushing force than non-toothed forceps.
• The grip should be gentle: after handling a wound edge, there should be no visible "bite marks."

Ergonomic Tips

• Keep elbows close to the body and avoid prolonged overhead or hyperextended wrist positions.
• For microscopic or fine procedures, prop forearms on rolled pads adjusted to put the hands slightly higher than the surgical field.
• Practicing opening/closing needle drivers and rotating instruments with just fingertips (no wrist) builds the muscle memory needed to operate without consciously thinking about instrument control.
• Review technique photos and video before live practice - then rehearse until the movements are automatic, so full attention stays on the operative field.

• Anatomy of the needle holder with labeled parts (rings, ratchet, jaws, shaft)
• Correct tripod grip - thumb and ring finger in the rings (tips only), index finger along the shaft for directional control, small finger as a stabilising rest
• Correct vs. incorrect finger position - highlighting the common mistake of inserting fingers too deep into the rings
• Needle loading position - placed at the junction of the proximal two-thirds and distal one-third of the needle, perpendicular to the jaws
• Key technique reminders as quick-reference bullet points

Cutting & Dissecting

• Scalpel (handles: No. 3, No. 4, No. 7)
• Blades (No. 10, 11, 12, 15, 20, 22, 23)
• Metzenbaum scissors
• Mayo scissors
• Iris scissors
• Tenotomy scissors
• Potts scissors
• Stitch scissors
• Bandage scissors
• Bone saw (Gigli saw)
• Osteotome
• Chisel
• Rongeur
• Curette
• Dermatome

Grasping & Holding (Forceps)

• Adson forceps
• Tissue forceps (toothed & non-toothed)
• DeBakey forceps
• Russian forceps
• Allis forceps
• Babcock forceps
• Kocher forceps
• Sponge-holding forceps
• Cheatle forceps
• Bonney forceps
• Gerald forceps
• Cushing forceps
• Brown-Adson forceps

Clamping & Hemostasis

• Mosquito clamp (Halsted)
• Kelly clamp
• Crile clamp
• Rochester-Pean clamp
• Rochester-Carmalt clamp
• Kocher clamp
• Mixter clamp
• Right-angle clamp (Lahey)
• Bulldog clamp
• Satinsky clamp
• DeBakey clamp
• Aortic clamp
• Intestinal clamp (Doyen)

Retracting & Exposing

• Langenbeck retractor
• Army-Navy retractor
• Richardson retractor
• Deaver retractor
• Bookwalter retractor
• Balfour retractor
• Weitlaner retractor (self-retaining)
• Gelpi retractor (self-retaining)
• Finochietto rib spreader
• Harrington retractor
• Malleable retractor
• Rake retractor
• Volkmann retractor
• Coronary retractor

Suturing & Wound Closure

• Mayo-Hegar needle holder
• Crile-Wood needle holder
• Castroviejo needle holder
• Webster needle holder
• Heaney needle holder
• Skin stapler
• Skin hooks

Probing & Dilating

• Probe (blunt/grooved)
• Bowman probe
• Hegar dilators
• Bakes dilators
• Trousseau dilator
• Pratt dilator

Suctioning & Irrigation

• Yankauer suction tip
• Poole suction tip
• Frazier suction tip
• Irrigating syringe (Asepto)

Bone & Orthopedic

• Bone hook
• Bone rasp
• Periosteal elevator (Langenbeck, Freer, Cobb)
• Liston bone-cutting forceps
• Bone cutter
• Mallet
• Drill
• Steinmann pin
• Kirschner wire (K-wire)
• Intramedullary nail
• Bone plate and screws

Laparoscopic / Minimally Invasive

• Trocar and cannula
• Veress needle
• Laparoscopic grasper
• Laparoscopic dissector
• Laparoscopic clip applicator (Hem-o-lok)
• Laparoscopic scissors
• Laparoscopic needle holder
• Laparoscopic suction-irrigator
• Harmonic scalpel
• LigaSure device
• Endobag (specimen retrieval bag)
• Endoscopic linear stapler (Endo GIA)

Stapling Devices

• Linear stapler (TA stapler)
• Linear cutting stapler (GIA stapler)
• Circular stapler (EEA stapler)
• Skin stapler

Measuring & Marking

• Ruler/caliper
• Marking pen/marker

Miscellaneous

• Towel clips (Backhaus, Edna)
• Needle counter
• Cautery pencil (monopolar/bipolar)
• Ligaclip applier
• Bulldog clip
• Senn retractor
• Goelet retractor
• Wound protector/retractor (Alexis)
• Vessel loops
• Penrose drain

What Was Completed

1. Surgical Instrument Handling Notes

• General principles (finger placement, finger rest, ring depth)
• Scalpel - pen grip, palm grip, blade loading/removal, 30° angle rule
• Scissors - tripod grip, ring depth, finger rest
• Needle Driver - tripod grip, needle loading position, ratchet tightening
• Tissue Forceps - pen grip, toothed vs non-toothed, avoiding the "CSI grip"
• Ergonomic tips

2. Needle Holder Visual Poster

• Generated and displayed a labeled medical illustration poster showing correct tripod grip, correct vs incorrect finger position, needle loading, and key technique tips

3. Surgical Instruments List

• ~100+ named instruments across 12 categories:
  • Cutting & Dissecting, Grasping & Holding, Clamping & Hemostasis, Retracting, Suturing, Probing & Dilating, Suctioning, Bone & Orthopedic, Laparoscopic, Stapling, Measuring, Miscellaneous

4. Upper Limb Bones Notes (Partial - Interrupted)

• Found the THIEME Atlas of Anatomy as the source (most relevant textbook)
• Located 6 dedicated sections on upper limb bones in the library
• Generated 2 diagrams:
  • Full upper limb skeleton overview (anterior + posterior, all bones labeled)
  • Clavicle and Scapula diagram
  • Humerus diagram (anterior + posterior views)
• 2 more diagrams (Radius/Ulna and Hand/Carpals) were cancelled mid-generation when the session was interrupted

What Was Not Finished

• Radius & Ulna diagram
• Hand, Carpals & Phalanges diagram
• Full written anatomy notes for each upper limb bone
• Textbook images from THIEME Atlas (were queued but cancelled)

• Clavicle - shape, parts, joints, fracture patterns
• Scapula - surfaces, borders, angles, all processes with muscle attachments
• Humerus - proximal, shaft, distal features; torsion explained
• Radius - all landmarks, supination/pronation mechanics
• Ulna - olecranon, trochlear notch, all features
• 8 Carpal bones - two rows, 3 functional columns, carpal tunnel, mnemonic
• Metacarpals - numbered I-V, common fractures
• Phalanges - 14 per hand, all joints explained