If you’re anything like me, when you first started your surgery rotation, your mind was probably far too occupied with figuring out what on earth you were looking at in that gaping incision to worry about what kind of instruments had been used to get there. Which is completely normal!
But, once you feel a little more confident in your ability to recognize the common peroneal nerve, you might find yourself getting a little curious about the difference between a 10-blade and a 15-blade, or what those “Debakeys” are that your attending keeps asking for. And hey, you’re going to be the one asking for those shiny instruments before you know it, so might as well spend a little time learning what they are, right?
We’ve totally got you. Here’s a basic list of 10 instruments you’re likely to encounter on your orthopedics rotation. It’s not exhaustive of course, but hopefully it will make the learning process a bit less overwhelming. That said, the best way to learn is by taking a good look at the instruments up close and in-person, so consider asking your scrub tech to let you peruse the instrument trays after the case is done!
1. Mayo Scissors
Mayo scissors, like the Mayo stand they sit on, were both named for the Mayo Clinic where they were developed (nope, it’s not a coincidence!) These scissors can be straight or curved—the straight ones, also known as suture scissors, are the ones you use to cut your attending’s suture tails too long or too short. The curved version is more commonly used for cutting tissue. The trusty Mayo scissors will probably be the first instrument you ask for in the OR. So, next time you see your team getting ready to close, let the scrub tech know you’re ready to cut those sutures!
2. Debakeys
Debakeys fall under the category of “non-locking” forceps (don’t worry, we’ll get to the locking versions later), which can be controlled like a pair of tweezers. Named after the famous cardiac surgeon, Dr. Michael Debakey, you’ll recognize these because they’re a bit longer and heavier than some of the other non-locking forceps you’ll encounter, such as the Adsons. If you get the chance to take a closer look, you’ll see that the ends of the Debakeys are smooth and flat. That’s because they’re used for atraumatic tissue grasping, i.e. when you want to pick something up without destroying it. On your general surgery rotation, that was probably the bowel. But in ortho, you’re more likely to see them used to keep delicate neurovascular structures out of the way.
3. Adsons
Adsons are the “pickups” often used for skin closures. Unlike the Debakeys, they have little teeth at their tips to help them do their job. Why is it ok to use those sharp teeth on skin? Think of it this way: different tissue types recover from different kinds of damage more readily. Puncturing a vessel with Adsons would make for a bad day. So would crushing fragile skin with Debakeys. But a crush injury to a vessel, or a puncture injury to skin, while not ideal, would be better tolerated. Unsurprisingly, these delicate little instruments were developed by a neurosurgeon—Dr. Alfred Washington Adson.
4. Scalpel and blades
Scalpels come in two parts: a handle and a blade. While there are quite a lot of different blade shapes out there, the three most common ones you’ll see are the 10, 11, and 15 blades. The 10-blade is the workhorse, typically used in bigger soft tissue incisions. The 11-blade is longer and pointier, and often used for the more stab-like incisions needed to open big vessels. The 15-blade is small and delicate. As you might have guessed, it is used for small, precise incisions.
5. Kelly clamps
These are in the family of locking forceps that I alluded to before, in contrast to the non-lockers like the Debakeys and Adsons. Also known as clamps or hemostats, locking forceps have a racheting mechanism that allows you to lock down on the tissue you’re grasping, control bleeding from vessels, or even just secure the suction tubing and Bovie cord to the drapes so they don’t fall off the table again. The many variations of locking forceps can be a little tough to tell apart unless you look at them side by side. Kelly clamps, perhaps the most commonly used, are medium-sized, atraumatic (i.e. toothless, like the Debakeys) forceps used for grasping tissue or vessels. Apparently, they were developed by a gynecologist named Dr. Howard Kelly, who in addition to performing surgical procedures also liked to collect snakes.
6. Retractors
A real favorite among medical students. There’s a good chance you’ve already held one if you’ve ever scrubbed into a case before. And you probably already know their function: they keep stuff out of the way to allow greater visibility. There’s a lot of different types of retractors you’ll be asked to hold, but one super common one is the double-ended Army-Navy (no agreement on which military branch is named for the shorter end), often used for pulling back skin and fascial layers during closure. Another is the Richardson, or “Rich,” whose scooped blade is ideal for keeping deeper incisions open. The Weitlaner, or “Wheaty,” is a commonly used self-retaining retractor that has a ratchet mechanism to spread open tissue layers all by itself, ideal for small (think distal radius procedures), or deep (think spine) incisions. The Hohmann also deserves a special mention, as it is particularly common in ortho—you’ll see it used to elevate soft tissue away from bone, especially in arthroplasty procedures.
7. Bovie
The pencil-shaped Bovie (named for Harvard professor Dr. William Bovie) is an electrosurgery device, which means it uses an alternating electrical current to generate heat for the purposes of either cutting or coagulating tissue. Current is transmitted to the Bovie device from an electrosurgical generator. This current then passes through the patient’s body and is safely directed back to the generator by that blue sticky pad you saw the nurse putting on the patient before the case.The pad is actually functioning as a “dispersive electrode,” which means it returns the current at a lower frequency than was delivered through the “active electrode” (or the Bovie device itself), so that we don’t burn our patient.
The Bovie is often used during approaches, when you’re trying to get through dense tissue layers that tend to bleed a lot. Press the yellow (cut) button and you’ll be delivered a constant, low-voltage waveform that really heats up your tissue—enough to vaporize it out of the way. It’s actually tiny heat-delivering sparks from the Bovie tip that do all the work for you on cut mode, so you should hold your tip ever so slightly above the tissue when using this function. Press the blue (coag) button when you want to dry up bleeding, and you’ll get a pulsed, high-frequency waveform that actually generates slightly less heat than the cut function. Now, instead of vaporizing your tissue, you’re just coagulating it. The Bovie generates a lot of smoke, so it’s often helpful to have your suction ready when it’s being used.
8. Cobb’s periosteal elevator
Here’s a fun fact to break out on your peds rotation: this little tool was designed by Dr. John Robert Cobb, the very same surgeon who came up with the Cobb angle to measure spinal curvature in scoliosis! Look for his periosteal elevator on your spine rotation—you’ll probably see your attending using it to gently push under soft tissue and periosteum to gain better exposure of the underlying vertebrae.
9. Rongeur
Shaped like a heavy pair of pliers, these guys chew through bone and cartilage that’s getting in the way. You can think of them like beaver teeth, especially since “rongeur” comes from the French word for “rodent.” You might see them used to remove osteophytes during a hip or knee replacement, or to grab bits of bone during a laminectomy. If you hear your attending ask for the rongeur, you can be a star assistant by asking for a lap sponge to clean bone fragments off the tips!
10. Kirschner wire
You’ll probably hear them referred to as “K-wire.” These long, thin wires are often used to temporarily hold a reduction in place while your team screws in the plates during an ORIF. That said, they can also be used for definitive fixation in patients with poor bone quality. They were named for the German surgeon, Dr. Martin Kirschner.
Written by: Jessa Fogel, MS4 Vanderbilt University School of Medicine
Sources and further reading:
- Asma, Dr. Syeda. “Debakey Non-Traumatic Forceps.” Surgical Units, 28 Nov. 2018, https://surgicalunits.com/debakey-non-traumatic-forceps-178.html.
- “Bone Rongeur: A Fundamental Need in Orthopedic and Neurosurgeries.” GerMedUSA, https://www.germedusa.com/blog/bone-rongeur-a-fundamental-need-in-orthopedic-and-neurosurgeries.aspx.
- Buraimoh, M Ayodele et al. “Eponymous Instruments in Orthopaedic Surgery.” The Iowa orthopaedic journal vol. 37 (2017): 211-217.
- Cordero, Ismael. “Electrosurgical units – how they work and how to use them safely.” Community eye health vol. 28,89 (2015): 15-6.
- Daniel Richardson and Laura Jayne Watson. “Eponymous Surgical Instruments: Surgery: Operations.” Geeky Medics, 12 Nov. 2021, https://geekymedics.com/eponymous-surgical-instruments/.
- McCauley, Gerald. “Understanding Electrosurgery.” https://www.quickmedical.com/downloads/aaron_understanding-r2_pr.pdf.
- Morgan, Matt A. “K Wire: Radiology Reference Article.” Radiopaedia Blog RSS, Radiopaedia.org, 27 Jan. 2020, https://radiopaedia.org/articles/k-wire?lang=us.
- Principles of Electrosurgery. https://www.asit.org/assets/documents/Prinicpals_in_electrosurgery.pdf.
- “Surgical Blades: Which Scalpels Are Right for Your Operating Room?” USA Medical and Surgical Supplies, https://www.usamedicalsurgical.com/blog/surgical-blades-which-scalpel-is-right-for-your-operating-room.
- “Surgical Instruments.” TeachMeSurgery, 10 Mar. 2021, https://teachmesurgery.com/skills/surgical-equipment/surgical-instruments/.
- Visenio, Michael R. “Commonly Used Surgical Instruments.” American College of Surgeons, https://www.facs.org/-/media/files/education/medicalstudents/common_surgical_instruments_module.ashx.
