Options for surgical instruments are seemingly endless. If you were to start from scratch, would you know which instrument or instruments are best for your practice? Would you prefer straight vs. curved Mayo scissors? How many mosquito hemostats are needed for a basic surgical pack? Would you prefer to purchase a pre-made surgical instrument pack or design your own? There is a large range in instrument quality, handling, and longevity. Having the correct surgical instruments will make your time in the operating room more efficient and enjoyable. Taking care of the instruments correctly will keep them in your practice for many years. Stainless steel instruments Most of our common surgical instruments are made of stainless steel, an alloy mainly composed of iron, carbon, and chromium. The chromium helps combat corrosion. These types of instruments generally fall into three quality categories: Premium, mid-grade, and economy. Premium instruments are manufactured from high-quality German stainless steel with rigorous quality control throughout the manufacturing process. These instruments generally have a matte or satin finish to minimize glare and are likely to be at a higher price point than other grades of instruments. Mid-grade instruments are generally composed of German stainless steel but may be made outside of Germany and have less-rigorous quality control during manufacturing. Economy instruments are manufactured from various stainless steel sources, have a shiny finish, and tend to rust or corrode more easily than other grades of instruments (Figure 1). Figure 1. Two towel clamps. The clamp on the top has a shiny finish and the clamp on thebottom has a matte finish. Those with a shiny finish tend to rust or corrode more easily. Photo courtesy Dr. Kendra Freeman When deciding which grade of instrument to purchase, the intended use and frequency of use should be taken into consideration. It is worth investing in a higher quality instrument that will be used with high frequency. These instruments tend to have a better feel when handling, a more secure grip on needles or tissue, and a smoother locking mechanism. Premium needle holders may have a higher price point initially but often have carbide inserts at the tips. As these become worn with use, the carbide can be replaced, extending the useful lifespan of the instrument. Premium-grade instruments are made to last a long time; however, they still require meticulous care. General instrument types Cutting instruments Aside from a scalpel blade, scissors are the most common cutting instrument in a basic surgical pack. Commonly, scissors come in the form of Mayo scissors for robust tissue, Metzenbaum scissors for delicate tissue, and utility or bandage scissors, which may be used to cut drape and bandage material. Mayo scissors may be curved or straight based on surgeon preference. It is important to remember instruments designed to cut delicate tissue (i.e. Metzenbaum) should only be used for this purpose. Using these scissors to cut drape material or suture can cause the cutting edge to dull quickly (Figure 2). Figure 2.Metzenbaum scissors on the left are designed for delicate surgeries. Mayo scissors on the right are more robust. Photo courtesy Dr. Kendra Freeman Grasping instruments Grasping instruments are used to pick up and manipulate needles, sutures, and tissue. Needle holders are available in different lengths and sizes, and the choice mostly depends on surgeon preference. Needle holder jaws have grooves that can help grasp the suture needle and minimize needle rotation. The size of the jaws and the depth of the grooves should be relative to the type of suture material used. Large jaws with aggressive grooves are unsuitable for delicate sutures and needles. The two most common types of needle holders used in veterinary medicine are Mayo-Hager (needle holders only) and Olsen-Hager (combination of needle holder and scissors (Figure 3). Figure 3. Two types of needle holders. Olsen-Hager is on top with scissors to cut sutures.Mayo-Hager on the bottom. Photo courtesy Dr. Kendra Freeman Tissue forceps Forceps are designed to grasp, manipulate, and sometimes crush vessels and other tissue. Many varieties are available to accomplish these surgical tasks. Some forceps crush tissue while grasping it. These instruments should only be placed on tissue that will be excised. Examples of crushing instruments include Allis and Babcock forceps. Noncrushing tissue forceps are used to grasp tissue without causing damage like crushing forceps. Examples of this type of forceps include Doyen intestinal forceps to assist with intestinal resection and anastomosis and various vascular clamps, such as Satinsky forceps. Hemostatic forceps are used to clamp blood vessels and limit bleeding and are common in basic surgical packs. They are held like scissors or needle holders and have a locking mechanism. Clamping the vessels stimulates the body’s clotting mechanism. Many types are available, with Kelly and Mosquito forceps being the most common. These are available in different lengths and straight or curved varieties based on surgeon preference. Thumb forceps are nonlocking, usually straight instruments used to grasp and manipulate tissue during surgical procedures. These instruments have a grasping surface and may or may not have teeth at the tips. The two most common thumb forceps used in our clinic are Debakey and Brown-Adson forceps. Brown-Adson forceps have fine teeth to help grip tissue. Debakey forceps are less traumatic to tissue than Brown-Adson forceps and should be the preferred thumb forceps for most delicate soft tissue procedures (Figure 4). Figure 4. Atraumatic Debakey should be the preferred thumb forceps for most delicatesoft tissue procedures. Photo courtesy Dr. Kendra Freeman Retractor instruments Retractors are used to deflect or hold tissue in the surgical field to allow better visualization of an area of interest. Hand-held retractors include Senn, Army-Navy, Hohman, and Spay hooks. These require manipulation by the surgeon or surgical assistant to remain in place or deflect tissue. Self-retaining retractors, such as Balfour and Gelpi retractors, enhance visualization and access to an area of interest in the surgical field without requiring an assistant. Miscellaneous instruments Most surgical packs will need some combination of basic instruments–blade handles, needle holders, forceps, hemostatic instruments, scissors, and towel clamps. Additional instruments can be added based on the intended use of the surgical pack. A pack intended for abdominal exploratory may have needle drivers, forceps, and suture scissors so different sets may be used for closure of intestinal incisions vs. closure of the abdomen. Surgical packs for ovariohysterectomies may also have a spay hook or Dowling Spay Retractor. Orthopedic procedures may require many additional instruments, including rongeurs, periosteal elevators, and various clamps. In our practice, these instruments are packed in a separate instrument pack from our basic instrument packs. Meticulous ophthalmologic procedures are most efficiently completed with specialized, delicate instruments. Again, these may be best packed separately from other instruments. Storing and processing these instruments in an instrument tray can minimize damage to these delicate tools. Pre-made vs. custom packs When putting instruments together to create a pack, several options are available. Pre-made packs are available for specific procedures. They can be purchased with additional instruments added, tailored to surgeon or clinic needs. In our practice (emergency and referral), the packs are custom made. This allows customization of the packs. It also ensures we have high-quality instruments when desired and appropriate numbers of specific instruments, such as hemostats and towel clamps. We have packs designed for general types of surgery–soft tissue vs. orthopedic, as well as packs for specific procedures–perineal urethrostomy, tibia plateau leveling osteotomy, etc. (Figure 5). Figure 5. A custom instrument pack designed for soft tissue surgery. Plenty of needle holders, forceps, hemostats, scissors, grasping instruments, and towel clamps for advanced soft tissue surgery. Photo courtesy Dr. Kendra Freeman Instrument care No matter which instruments you choose for your surgical packs, appropriate use and care will keep them available for a long time. It is crucial to ensure team members responsible for caring for instruments follow a thorough and stepwise process. The first step in cleaning instruments is the removal of organic debris and fluids. This can be done manually, fully submerging the instruments in your preferred cleaner. This process is tedious and potentially exposes employees to the chemicals in the detergents and cleaners. In our practice, after a procedure instruments are immediately placed in water and detergent to limit the amount of blood and organic material that dries on the instruments. Ultrasonic cleaners use the creation of gas bubbles to help with the removal of debris. This cleaning method has the advantage of not exposing employees to chemicals in the same manner manual cleaning can. Once the instruments are cleaned, they should be dried and stored appropriately. Various sterilization methods (steam, gas, plasma, etc.) can be used for the final step in preparing these instruments for surgery; however, this is outside the scope of this discussion. If you can choose instruments for your practice, the options may appear endless. The frequency of use of the instrument, how it is handled, and the budget all play a part in deciding which instrument to choose. Purchasing high-quality, top-of-the-line instruments may be on many surgeon’s wish lists, but it is not always practical. The ability to handle the instruments at a trade show or convention is priceless. No matter which instruments you choose, proper use and care can keep them in your surgical packs long-term and protect your investment. Kendra Freeman DVM, MS, DACVS, is a graduate of Colorado State University and maintains dual certification with the American College of Veterinary Surgeons. Dr. Freeman is an associate surgeon in Albuquerque, N.M. Her case load consists of orthopedics, general soft tissue, and sports medicine cases with the occasional return to her roots in large animal lameness and surgery. References Securos Surgical (January 31, 2025). Understanding surgical instrument quality grades. Securos Surgical. https://www.securos.com/insights/surgical-instrument-quality Tobias, K. M., & Johnston, S. A. (2017). Veterinary surgery: small animal. (Instrumentation).
