BOUGIES

METAL AND OTHER BOUGIES

Clutton’s urethral bougie

Identification points

· It is solid metal instrument with a curve end near the tip.

· The handle is flat and shaped like a violin.

· The other end is blunt.

· The size is written on the handle.

Why is the tip of this instrument blunt?

As the tip is blunt, there is a lesser chance to injure the urethra during a normal and false passage.

USES

· The blunt tip flows easily into the urethra.

· Lubrication is used.

· The curve conforms to the normal anatomical size and shape of the male urethra near the bladder.

· The upper denomination indicates the diameter of the tip (in mm). 6/10 denotes that the tip is 6 mm in diameter and the base 10 mm.

Lister’s bougie

Identification points

· The tip is olive pointed.

· The shaft is more curved.

· The handle is round like a coin.

· The size is marked in English scale.

How to use the Lister’s bougie?

· The instrument is lubricated with sterile KY gelly and passed in urethra with the convex curbe towards the patient.

· The bougie passes with its own weight and reaches the bulbar urethra. At this point, one has to rotate through 180° and depress the bougie when the instrument follows natural curve of urethra and the tip enters the bladder.

Introducer

Identification points

· It is stiff wire instrument with a curvature like a metal bougie and has a blunt tip.

· The handle is of the shape of large elongated ring.

Uses

· This wire instrument can be introduced into the rubber urethral catheter.

· The stiffened rubber catheter can now be introduced like a bougie.

Other Bougies

Filiform bougies are fine soft malleable-gum elastic instruments that are used to treat strictures. These are passed up to the strictures.

Uses

· More than one can be passed. These bougies are graduated in French scale (charriere).

· It is usual to start with 10F, and negotiation is begun till one of them, on rotation, passes through the strictures.

· Some have a screw for large bougie.

· The filiform acts as a guide for this screw on dilator which passes.

· The advantage of this bougie is that there is less risk of trauma to the urethra.

 

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PROBES AND DIRECTORS

PROBES AND DILATORS

What are the features and uses of probes and dilators?

Probes are used to gain entry through small openings to get information about their depth, direction and size; they are usually blunt ended.

Dilators are used to investigate the patency and dilate hollow tubular passages.

Infection, trauma and surgical accidents can result in healing by second intention in hollow organs; this results in strictures.

Dilators are usually made of metal or gum elastic.

Agreed gauge has been utilized to ensure uniform size in all the sets.

This also helps the surgeon to choose the correct size-dilator.

As dilatations are done gradually over a period of time, the surgeon records the degree of dilation achieved, so as to start at the next level on the subsequent attendance or corticosteroids can also be used to minimize oedema and fibrosis.

The dilators in common use are as follows:

· Lister

· Clutton

· Turner-Warwick

· Filiform (Canny-Ryall) bougie

· Jackson oesophageal bougie

· Neoplex

 

 

· Bake’s bile duct

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RETRACTORS 2

SELF RETAINING RETRACTORS

These retractors have at least two blades joined by a bar

or a hinge joint.

It is thus possible to create lateral pressure against both

margins of the wound.

This pressure helps to retain the retractor in the wound

for the entire duration of the operation.

The pressure is constant and adjustable.

Both hands of the assistant are thus free for other tasks

in the procedure.

The retractors in use are:

Travers

Norfolk

Balfour

Jolls

Alms

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RETRACTORS 1

WOUND RETRACTORS

What are the features and uses of wound retractors?

Good exposure is one of the requisites of successful surgery. 

Instruments designed specifically to improve exposure are called wound retractors. These can be hand-held or self-retaining. 

The Handle of the retractors is held by the assistant, the retracting end is usually at a right angle to this. It is smooth, rounded with no sharp corner or edge to avoid injury to the tissues. 

The choice of the retractor can be estimated from the depth to which this retracting end can go.

               The varieties in use are as follows:

&l  Langenbeck

   ;  Ollier

&   Morris

&   Kelly

&   Deaver

&   Lloyd-Davies

Self-retaining retractors, i.e. 

Travers, 

Norfolk, 

Norwich, 

Balfour, 

Alms and 

Jolls have at least two blades joined by a hinge joint or bar. It is thus possible to create lateral pressure against both margins of the wound.

        This helps to retain the retractor in position throughout the duration of the operation.

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CATHETERS AND DRAINS

CATHETERS

The Foley catheter is a plastic two-lumen tube with an integral inflatable balloon. The balloon is inflated via a small channel.

Suprapubic cystostomy is an alternative way of draining the urinary bladder. The Malecot catheter is well suited for this purpose. It is a rubber or latex tube with wings at the tip. The de Pezzer catheter is based on a similar principal except that instead of wings, it has a bulbous end that can be straightened and recoiled back when the wire introducer is removed.

The catheters used are as follows:

·        Foley

·        Gibbon

·        Malecot

·        De Pezzer

·        Tiemann

Catheter is a tube designed for relieving retention of urine.

·        The tip is blunt and closed

·        There is one opening above the tip.

·        The upper end is open.

·        It can be made of rubber or latex rubber.

How is the catheter introduced?

·        The catheter is sterilized.

·        The area around the penis, glans, scrotum and groin is cleaned with Savlon.

·        The surgeon washes hands and wears sterile gloves.

·        The area is draped with the sterile towel.

·        The tip is dipped in sterile lubricant.

·        The catheter is introduced into the bladder and the urine collected in sterile kidney tray.

DRAIN

The different types of drain in use are as follows:

·        Secured tube

·        Corrugated

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TUBES

Nasogastric tube most often used ia Levine tube

Ryles tube

Identification points

·      The tube used most often has blunt end with multiple opening near the lower end which is closed.

·      The Ryles tube has a metal ball around which the tube is moulded. 

     This acts as weight for introducing the tube.

     The tube is made rubber (so that it becomes flexible) and also of transparent protex (because it may cause less irritation).

Marking of Ryles tube

The tube has four marks: mark 1when the tip enters the stomach (40 cm);
second mark 2 when the tip arches antrum (50cm);
mark 3 at 57 cm,  when it indicates the entry into the pylorus;
and mark 4 (at 65cm) indicates entry into the duodenum.

How is Ryles tube introduced?

The patient is asked to sit up. 

The tip is placed in the nose and fed in till it reaches pharynx and the patient is asked to swallow

till the tube reaches the desired mark.

Uses

·      Ryles tube is used to aspirate stomach juices in postoperative period.

·      It is also used to aspirate in cases of acute abdomen–intestinal obstruction, perforation, appendicular mass, acute cholecystitis and strangulated hernia.

·      It is also used in gastric acid-secretion tests.

·      Ryles tube is used in gastric feeding of unconscious patient.

·      It is used to perform gastric lavage.

·      It is also used to confirm the diagnosis of pernicious anaemia.

Stomach tube

Identification points

·      It is wide-bore rubber tube. 

    The tube end is rounded to allow introduction in the body without injury, the upper end has a funnel to allow pouring of lavage fluid.

·      Wash out occurs when this end is lower than the patient.

Uses

Stomach tube is used in the management of alcohol poisoning,

organophosphorus compound poisoning,

barbiturate poisoning and

opium or morphine poisoning.

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TUBES AND CATHETERS

TUBES, CATHETERS AND DRAINS

TUBES

Without endotracheal tubes, modern anaesthesia would be unthinkable. 

The traditional tubes of the Magill pattern are made of red mineralized rubber.

Except these, all have an inflatable cuff near the distal tip to protect the lower respiratory tract from soiling as well as providing an air-tight seal. 

Each number refers to the internal diameter of the tube in millimeters.

            These in the past have been made of rubber and recycled in practice by autoclaving. 

All these instruments and nasogastric tubes are now made of non-reactive plastic marerial and come pre-sterilized in packs. 

These tubes are all disposable and thus do not require recycling.

The tubes in use are:

·       Cuffed oral endotracheal tube

·       Uncuffed oral endotracheal tube

·       Negus tracheostomy tube

·       Chevalier-Jackson tracheostomy tube

Tracheostomy tube

Identification points of tracheostomy tube

·       It has the outer tube that is taped to the neek and always stays in the trachea.

·       An inner tube that can be taken out for cleaning.

·       An abdurator required at the time of introduction.

The Chevalier-Jakson inner tube case locked when in position.

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METAL CLIPS AND STAPLERS

METAL CLIPS

Metal clips include Mitchell’s, Kifa metal clips and Cushing’s. First two are used for skin closure.

Cushings are used for vessal closure in brain surgery

Advantages of metal clips

· Apposition is better.

· Good cosmetic result is achieved.

· Less chances of infection as suture hole is not made.

Disadvantages

· It is more expensive.

· Metal clips require special instruments (applicator and extractor).

When should the clips be removed?

Clips should be removed usually at 6days, i.e. earlier than sutures ( usually removed after 8-10 days)

Staplers are being used in surgery for

Anastomosis(Colectomy-Gastrectomy)

Vessal stapling before cutting(splrnectomy adrenalectomy)

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NEEDLES AND SUTURES

NEEDLES AND SUTURES

NEEDLES

Round-bodied needles

Used most often for suturing

Subcutaneous tissue

and muscle

All internal organs

Cutting

Cutting-edge needles have sharp edges commencing at the point

and prolonged along their shafts

to help them penetrate dense and tough tissues such as skin or tendon.

SUTURES

Absorbable

Catgut(plain) (98% collagen) suture for small vessals

Catgut(chromic) treated in cromic bath blood vessall ligation and internal organn

Polyglycolic acid Synthetic polymers uses similar to catgut

Nonabsorbable

Silk

Linen

Cotton

Synthetic nylon ethilon

Metal wire

 

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NEEDLE HOLDERS

NEEDLE HOLDERS

Needle holders are modified box joint-locking forceps designed to hold curved needles.

The surgeon should thus be able to manipulate the needle with ease during suturing.

Since the function of needle holders is to grasp needles,

The instruments look like artery forceps also it has additional features, which are as follows:

· Serration at the tips to prevent slipping of needle.

· Shafts with rings for thumb and fingers.

· Locking device.

Fine needle holders are damaged by large needles,

and small needles are damaged by large needle holders.

Te varieties in use are as follows:

· Mayo needle holder

· Gillies needle holder

· Naughton-Morgan needle holder

· Kilner needle holder

· Mayo-Hegar needle holder

Micro vascular needle holder

Identification

· They have shorter blades as compared to a haemostatic forceps.

· Blades are serrated in both directions to enable a firm grip on needle.

· There is a catch for long-term holding.

· The blade can be straight or curved.

Needle holders are commonly used in surgery to hold a needle with its suture.

Where to hold the needle with a needle holder?

· Just behind its mid point, which gives maximum advantage in curving action.

 

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