Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Organizing the District Hospital Surgical Service
Organizational and management of the district surgical service
The District Hospital
Leadership, team skills and management
Record Keeping
Disaster and trauma planning
The surgical domain: creating the envioronment for surgery
Infection control and asepsis
Operating room
Cleaning, sterilization and disinfection
Waste disposal

Anaesthesia and life support equipment, monitoring devices, lights, the operating table and the operating room itself are all essential to surgical care and need to be cared for and maintained. Equipment should be kept strictly for use in the operating room, treatment room or emergency department in order to ensure that it will be available, in good repair and sterilized or cleaned ready for use.

Equipment and instruments

Care and repair
Surgical instruments and equipment used in the operating room should be dedicated to this use and should not be removed; the surgeon, nurse and anaesthetist will expect them to be available during the next case. It is essential that all personnel check the medications and equipment they will be using prior to beginning a case or procedure.

You must have resuscitation equipment, such as oxygen and suction available wherever critically ill patients are cared for and where medications which can cause apnoea (such as narcotics and sedatives) are administered. The treatment room, emergency department, case room and operating room are obvious examples of such areas.

Medical equipment is expensive and can be quite delicate. Have a regular plan of maintenance for equipment and plan in advance for the repair and replacement of equipment. Create a list (inventory) of the equipment you have, then work out when the various items will need to be serviced and ultimately replaced.

Many types of surgical instruments are available. There are broad groupings within this range:

:: Forceps and instruments for holding tissue
:: Needle holders
:: Scissors
:: Retractors.

The decision about which instrument to use sometimes has to be made on the basis of what is available. When you have a choice between instruments:

:: Choose the shortest instrument that will comfortably reach the operative site
:: If cutting suture or other non-tissue material, avoid using fine scissors that are designed to cut tissue or dissect tissue planes; use larger and blunter scissors for non-tissue materials
:: Choose instruments in good repair; forceps that cross at the tip, scissors that do not cut easily and needle drivers that do not grip the needle securely can be frustrating and dangerous.

When holding instruments:

:: Use three-point control: have three points of contact between your hand and the instrument to stabilize the instruments and increase the precision of use (Figure 2.1)
:: When using instruments that open and close, extend your index finger along the instrument to provide extra control and stability
:: Place only the tips of your fingers and thumb through the handles on instruments that open and close. In this way, rotation of the instrument can come from your wrist and forearm and provide a greater arc of control. It is also quicker and less cumbersome to pick up and put down the instrument.

Figure 2.1
Figure 2.1


The way in which the scalpel is held depends on its size and the procedure being performed. Most procedures are performed with a #3 handle and either a #10, 11 or 15 blade. Use a #10 blade for large incisions, #11 for stab incision and #15 for fine precision work (Figure 2.2). If a larger #4 handle is used, use a #20 or #22 blade.

Figure 2.2
Figure 2.2

When incising the skin or abdominal wall, use the larger scalpel and blade. Hold the knife parallel to the surface with your third to fifth finger, thumb and index finger; this provides the three-point control. Your index finger will guide the blade and determine the degree of pressure applied.

When using the scalpel for dissection, use a smaller knife and hold the instrument like a pen with your thumb, third finger and index finger holding the knife and your index finger controlling the dissection (Figure 2.3).

Figure 2.3


Forceps are either toothed or non-toothed. Toothed forceps are also referred to as “atraumatic” as they are less likely to crush tissue. Hold these forceps like the small scalpel or a pen.
Artery forceps come in many sizes and shapes. Place your thumb and fingers through the handles just enough to sufficiently control the instrument. Place your index finger on the shaft of the instrument to provide three-point control. Hold curved dissection scissors in the same way.

Using your left hand
Scissors are designed so that the blades come together when used in the right hand. When right handed scissors are used in the left hand, the motion of cutting actually separates the tips of the scissors and widens the space between the blades; this makes cutting difficult, if not impossible. In order to use them with your left hand, it is necessary to hold them and apply pressure in a way that brings the blades closer together.

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