Table of contents :

• catheterization : insertion of a catheter (a tubular, flexible, surgical instrument that is inserted into a cavity of the body to withdraw or introduce fluid). Unit of measure of external diameter of catheters, sounds, and other tubular instruments : 1 charrière (Ch) (referred as French gauge (Fg / G) or French (F) in the USA) = 0.333 mm.

Catheterization devices :
• balloon-tip catheter : a catheter whose tip is provided with an inflatable balloon that holds the catheter in place or is used to dilate the lumen of a vessel, such as in balloon angioplasty; common types are :
• Fogarty catheter
• Gruentzig balloon catheter : a flexible balloon catheter with a short guidewire fixed to the tip, used for dilation of arterial stenoses; the balloon is made of low-compliance plastic to reduce the risk of arterial rupture
• Swan-Ganz catheter (SGC) / pulmonary artery catheter (PAC) : a soft (PVC), flow-directed, 110-cm long cardiac catheter with external diameter =  2.3 mm (7 Ch), a 1.5 mL balloon at the tip for measuring pulmonary arterial pressures and preventing the catheter from perforating the vascular wall. the catheter has fine marks every 10 cm and a black gross mark at 50 cm. It is introduced into the venous system by using a large-diameter catheter via the ...
• basilic vein
• right basilic vein (40 cm from venae cavae-right atrium joint; 70 cm from pulmonary artery)
• left basilic vein (50 cm from venae cavae-right atrium joint; 80 cm from pulmonary artery)
• internal jugular vein (15-20 cm from venae cavae-right atrium joint; 40-55 cm from pulmonary artery)
• subclavian vein (10-15 cm from venae cavae-right atrium joint; 35-50 cm from pulmonary artery)


• femural vein (30 cm from venae cavae-right atrium joint; 60 cm from pulmonary artery)
... and is guided by blood flow into the superior vena cava. Once it has reached the joining of the venae cava in the right atrium, the balloon is slowly inflated with air or CO₂ and the valve is closed, so that respiratory oscillations are seen on the monitor. Introduction into pulmonary artery is seen as increase in diastolic pressure. When a wedge pressure is achieved, the balloon should be slowly deflated. It should be pushed rapidly into the right ventricle and pulmonary artery until wedge occurs to prevent coiling. It has 2 openings, a distal one at the tip and a proximal one 30 cm from the tip. A thermistore is located 4 cm from the tip of the catheter on the external surface. to remove coils in right atrium or ventricle push the catheter back by 1-2 cm, then re-inflate the balloon until the minimal wedge pressure is achieved. Additional accessories are :
• additional way opening 14 from the tip used for infusion or for transient passage of pacemaker wires into right ventricle
• optic fiber system for continuous monitoring of hemoglobin saturation in the mixed venous blood
• thermal wire for continue measurement of cardiac output with the thermodilution method
• rapid response thermistore for measurement of right ventricle ejection fraction

Color codes for openings :
• yellow : distal opening for monitoring pulmonary artery pressures
• blue : proximal opening for monitoring right atrium pressure
• red : exit valve of balloon to obtain PCWP values
• red/white : thermistore connector to measure temperature 4 cm from tip
Patency of internal ways should be maintained with heparin wash-outs.
Alterations in CVP patterns :
• atrial fibrillation : loss of "a peak" (no effective atrial systole), rise in "c peak" (greater atrial volume at the beginning of systole due to unemptied atrium)
• tricuspid valve failure : rise in "c peak and "v peak", ventricularization of right atrium pressure


• tricuspid valve stenosis : rise in mean CVP, rise in "a peak" due to compensatory atrial hypercontractility, decrease in "y fall" due to decreased atrioventricular blood flow


• cardiac tamponade : reduced venous return, rise in CVP, equalization of end-diastole pressure in all cardiac chambers, almost monophasic CVP with prominent "x fall" and less accentuated "y fall"


• closed end-hole catheter : one lacking a hole in its tip; used for rapid injection of large volumes of contrast solution
• spiral-tip catheter : a catheter with an off-center filiform tip
• vertebrated catheter : a catheter made in small sections fitted together so as to be flexible
• Dormia basket : to remove multiple stone fragments from ureter or biliary tract


Catheterization routes :
• oesophageal catheter is introduced through the nose
• tracheal catheter : an instrument for removing mucus from the trachea by application of suction
• transtracheal oxygen catheter : a catheter inserted into the trachea through a tracheostomy for patients who cannot tolerate a nasal or oral cannula
• eustachian catheter : an instrument for inflating the eustachian tube for treatment of diseases of the middle ear
• urinary catheter is introduced through the urethra (see also movie)
• urethral catheter : a catheter for insertion through the urethra into the urinary bladder.
• 2-way, double-current or double-lumen catheter : a catheter having 2 channels, one for injection and one for removal of fluid
• 3-way catheter
• prostatic catheter : a urethral catheter having a short angular tip for passing an enlarged prostate.
• catheter coudé / elbowed catheter : a urethral catheter with a sharp bend near the beak; used principally in cases of enlarged prostate
• bicoudate catheter / catheter bicoudé : an elbowed catheter with 2 bends
• female catheter : a short urethral catheter for passage through the female urethra
• Malecot catheter : a 2- or 4-winged female catheter.
• filiform-tipped catheter : a catheter used to dilate tight urethral strictures and to bypass obstructions due to angulations or calculi in the ureter
• indwelling catheter / catheter à demeure : a urethral catheter that is held in position in the urethra
• self-retaining catheter : a urethral catheter constructed to be retained in the bladder and urethra
• flexible catheters (latex or silicone)
• Foley catheter : an indwelling urethral catheter retained in the bladder by a balloon inflated with air or liquid
• Rocco's catheter
• semiflexible catheters (hard rubber)
• Nélaton's catheter : a type of flexible rubber urethral catheter
• Couvelaire's catheter
• Mercier's catheter
• Tiemann's catheter
• Phillips' catheter : a urethral catheter with a woven filiform guide.
• Béniqué catheter
• Freundenberg boring-bar
• bougie [Fr. “wax candle”] : a slender, flexible, hollow or solid, cylindrical instrument for introduction into the urethra or other tubular organ, usually for the purpose of calibrating or dilating constricted areas
• bulbous bougie / bougie à boule : one with a bulb-shaped tip
• acorn-tipped bougie : a bulbous bougie with a tip shaped like an acorn.
• olive-tipped bougie (fig B) : a bulbous bougie with a tip shaped like an olive.
• Otis bougie à boule (fig A)
• conic bougie : one with a cone-shaped tip.
• cylindrical bougie : one with a round or circular section.
• elbowed bougie : one with an elbow or sharp bend near the tip.
• filiform bougie : one of very slender caliber; often used for the gentle exploration of strictures or sinus tracts of small diameter with multiple false passages.
• fusiform bougie (fig C) : one with a belly or expansion in its shaft.
• dilating bougie : a bougie whose diameter can be increased by turning a screw; commonly used for dilating a stricture of the urethra.
• elastic bougie : one made of rubber or other elastic material.
• caustic bougie : one that has a piece of silver nitrate or other caustic agent attached to its end; used as a portcaustic.
• Hurst's bougies : a series of mercury-filled tubes of graded diameter for dilating the cardioesophageal region.
• Maloney bougies : a series similar to Hurst's bougies but having cone-shaped tips.
• rosary bougie : a beaded bougie for use in a strictured urethra.
• wax-tipped bougie : a long, slender, flexible bougie with a wax tip for passage into the ureter through the cystoscope to confirm the diagnosis of ureteral calculus.
• whip bougie : one with a filiform point and a stem of gradually increasing caliber.
bougienage / bouginage : the passage of a bougie through a tubular structure or organ, to increase its caliber, as in the treatment of stricture of the esophagus.

• Braasch bulb catheter : a bulb-tipped ureteral catheter used for dilation and determination of the inner diameter of the ureter
• conical catheter / Garceau catheter : a ureteral catheter that has a cone-shaped tip designed to dilate the lumen
• de Pezzer catheter : a self-retaining urethral catheter having a bulbous extremity
• Gouley's catheter : a solid, curved steel instrument, grooved on its inferior surface so that it can be passed over a guide through a urethral stricture
• Robinson catheter : a straight urethral catheter with 2-6 openings to allow drainage, especially useful in the presence of blood clots which may occlude one or more openings
• winged catheter : a urethral catheter that has winglike projections on the end to retain it in the bladder.
• retrourethral catheterization : passage through the urethra of a catheter first introduced through an incision into the bladder, and then passed through the internal urethral orifice
• vesical catheter
• ureteral catheter : a catheter inserted into the ureter, either through the urethra and bladder or posteriorly via the kidney.
• corn-tipped catheter : one used in ureteropyelography to occlude the ureteral orifice and prevent backflow from the ureter during and following the injection of an opaque medium
• olive-tip catheter : a ureteral catheter with an olive-shaped end, used to dilate a constricted ureteral orifice; larger sizes are also utilized for dilating urethral strictures or for calibrating the diameter of such strictures
• Jackson-Pratt (JP) drains are commonly used after urologic surgery. One of the complications associated with the use of JP drains occurs when the drain breaks, leaving the distal fenestrated part at the time of attempted removal.
Standard sizes : Ch 8 to Ch 26 (Ch 14 is the most used)

size	colour coding	indications for use
10 Ch / 3.3 mm	black	initial catheterisation (female). Clear urine. No grit (encrustation), debris, or haematuria
12 Ch / 4 mm	white	initial catheterisation (male or female). Clear urine, no grit, debris, or haematuria
14 Ch / 4.7 mm	green	initial catheterisation (male or female). Clear urine, no grit or debris, no haematuria
16 Ch / 5.3 mm	orange	initial catheterisation (male). Clear or slightly cloudy urine, both sexes. No or mild grit. Light haematuria with no clots
18 Ch / 6 mm	red	initial catheterisation (male). Moderate to heavy grit and debris. Haematuria with moderate clots
20 Ch / 6.7 mm	yellow	avoid unless urine is very cloudy, with heavy grit and debris. Heavy haematuria with large clots. Following prostatectomy and bladder surgery
22 Ch / 7.3 mm	violet	severe haematuria with large blood clots. Following prostatectomy and bladder surgery
24 Ch / 8 mm	blue	severe haematuria with large blood clots. Following prostatectomy and bladder surgery

There are 3 lengths of catheter currently in use:
• paediatric (30 cm)
• female (23-26 cm)
• standard (40-44 cm) : it is now termed the ‘male-length’ catheter, which is confusing because there is no such thing as a ‘male’ catheter.
Risks associated with over-inflation are:
• balloon rupture leaving fragments inside the bladder
• distortion of the catheter/balloon inside the bladder
• the catheter tip can rise and irritate the trigone area.
• irritation of the detrusor muscle
• pain, spasm, bypassing and haematuria.
Risks associated with under-inflation are:
• catheter dislodgement into the prostatic urethra (males) and urethra in both sexes.
• drainage eyes can become blocked if they enter the balloon area.
• failure of the catheter to drain urine and catheter dislodgement.
• bladder neck and urethral irritation, bypassing, pain, haematuria and urethral trauma
• obstetric catheters
• Drew-Smythe catheter : an instrument used for the artificial rupture of the amniotic membranes to induce labor
• DeLee catheter : a catheter used to suction meconium and amniotic debris from the nasopharynx and oropharynx of neonates
• Tenckhoff catheter : any of several types of catheter commonly used in peritoneal dialysis, consisting of a flexible silicone rubber tube with end and side holes and 1 or 2 extraperitoneal Dacron felt cuffs that help provide a bacteria-tight seal


• thermodilution catheter : a catheter used in thermodilution for introduction of the cold liquid indicator into the cardiovascular system
• toposcopic catheter : a miniature catheter that can pass through narrow, tortuous vessels to convey chemotherapy directly to brain tumors
• vascular access devices (VAD)

Aims :
• administrationof drugs or fluids
• blood sampling
• insertion of intravascular catheters for :
• cruent measure of intravascular or intracardiac pressure :
• fluid-filled catheter : an intravascular catheter connected by a saline-filled tube to an external pressure transducer
• manometer-tipped catheter : one with a small pressure transducer on its tip
• angiographic catheter : a catheter through which a contrast medium is injected for visualization of the vascular system of an organ (selective angiography); it may have a preformed end to facilitate selective locating (as in a renal or coronary vessel) from a remote entry site. Different types may be named according to the site of entry and destination, such as femoral-renal or brachial-coronary
Routes (cannulation) :
• arterial accesses (see also movie and intraarterial injection): arterial puncture may result in vasospasm, intraluminal clotting, or bleeding and haematoma formation, as well as a transient obstruction of blood flow, and infection. These factors may decrease the arterial flow in distal tissues unless adequate collateral arterial vessels are available
• femoral artery has not adequate collateral supplies
• brachial artery has not adequate collateral supplies
• radial artery has good collateral supply from the ulnar artery in case of vasospasm or clotting. Patency should be assessed before with Allen's test : the radial and ulnar arteries are occluded by firm digital pressure while the fist is clenche. The hand is opened and the arteries released one at a time to check their ability to return blood flow to the hand
• arterialised ear lobe samples provide an alternative to arterial puncture for occasional samples. A capillary tube is used to sample blood from a warmed, vasodilated earlobe. The PaCO₂ values agree well with those obtained from arterial samples, but accuracy of the PaO₂ depends on good technique in arterialisation of the ear lobe.
It is kinder to patients to use local anaesthesia over the radial artery before puncture. Analgesic patches can be used for children. Use a 20 or 21 gauge needle with a preheparinised syringe. Express the sodium heparin from the syringe before taking the sample; adequate heparin will remain in the 0.2 ml dead space of the barrel and needle. At least 3 ml of blood is required to avoid a dilution effect from the heparin.
Any sample with more than fine air bubbles should be discarded. Air bubbles result in gas equilibration between the air and the arterial blood, lowering PaCO₂ and increasing PaO₂. The cellular constituents of blood remain metabolically active so arterial gas tensions in the sample will change over time increasing PaCO₂ and lowering PaO₂. If the sample cannot be analysed quickly it should be cooled to 5°C immediately. The sample can then be stored for up to 1 hour with little clinically significant effect on the result.
• arterial catheterization
• atherectomy catheter : a catheter containing a rotating cutter and a collecting chamber for debris, used for atherectomy and endarterectomy; it is inserted percutaneously under radiographic guidance
• directional atherectomy catheter : a type of atherectomy catheter whose direction can be shifted to shave off additional plaque
• transluminal endarterectomy catheter : a type of atherectomy catheter with a conical cutting window, inserted through the lumen of the vessel; debris is collected in a special vacuum bottle
• Fogarty catheter : a type of balloon-tip catheter used to remove thrombi and emboli from blood vessels
• pigtail catheter : an angiographic catheter ending in a tightly curled tip that resembles the tail of a pig
• Judkins pigtail left ventriculography catheter : a specialized pigtail catheter used for left ventriculography
• venous accesses (see also intravenous injection)
• peripheral venous accesses
• upper limb veins
• cubital vein (percutaneous venipuncture)
• basilic vein
• cephalic vein
• lower limb vein
• popliteal or saphenous vein (after phlebolysis)
• external jugular vein (after phlebolysis)
Devices :
• short-term accesses : teflon needle-cannulas


• mid-term accesses : midline catheters (round and closed tip, single-lumen, 3-projection valve, 20 cm in length, 3-4 Fr = 20-18 G, internal volume = 0.2-0.3 ml. May be kept for up to 3 wekks


• long-term accesses
• central venous catheter (CVC) / central venous access devices (CVADs) : a catheter introduced via a large vein into the superior vena cava or right atrium to administer parenteral fluids (as in total parenteral nutrition (TPN)) or medications or to measure central venous pressure.
• internal jugular vein
• subclavian vein
• femoral vein (echo-assited with echogenic needle)

• temporary (non-tunnelled) catheters : single/multi-lumen
• short-term


• hemodialysis/apheresis catheters : double-lumen
• HemoSplit^® Dialysis catheter


• mid-term
• Arrow^® catheter (triple lumen)
• Hohn^® catheter : percutaneously inserted silicone CVCs


• Centrally-Inserted Cook^®
• peripherally inserted central catheters (PICC)
• Groshong^® NXT PICC catheters


• Poly RadPICC^® catheter
• Poly Per-Q-Cath^® PICCs
• long term (tunneled) catheters
• open tip
• Broviac^® catheter : a type of CVC similar to a Hickman catheter but with a smaller lumen


• Hickman^® catheter : a type of CVC used for the long term administration of substances via the venous system, such as antibiotics, total parenteral nutrition (TPN), or chemotherapeutic agents; it can be used for continuous or intermittent administration and may have either a single or a double lumen


• Groshong^® catheter (source : Bard Access Systems) : double-lumen, valve



Advantages :
• decreased risk of blood reflux and gaseous embolism
• no need to clamp catheter
• decreased frequency of catheter washings when nonfunctional
• no need for heparin to maintain catheter patency
• subcutaneously implanted venous ports (long-term)
• Port-A-Cath^®


• Infus-A-Port^®


• Mediport^®
• X-Port^® Isp Port
• long-term hemodialysis/apheresis catheters : double-lumen tunnelled catheters are emerging as an alternative permanent haemodialysis vascular access.
• PermCath™, Quinton Instrument Co, Seattle is a dual-lumen silicone catheter


• Tesio™, Med Comp, Inc, Harleysville PA


• VasCath Soft Cell™, Bard Instrument Company, Toronto


Device occlusion is defined as the inability of infuse fluid or withdraw blood
Aetiology :
• drug precipitation:
• "3 in 1" solution (this is a TPN/lipid solution frequently used with home care patients on TPN):
• lipid precipitate
• calcium/phosphorus precipitate
• known incompatible drugs:
• phenytoin and IV dextrose
• amphotericin and any IV solution with electrolytes (e.g., Na, KCl)
• heparin and aminoglycosides
• heparin and vancomycin
• heparin and doxorubicin
• heparin and idarubicin
• heparin and pristinamycin
• poorly soluble drugs
• calcium/phosphate in TPN (amino acids act as a buffer)
• diazepam
• etoposide can crystallize in aggregates undetectable to the naked eye.
• cotrimoxazole poorly soluble in NA
• when flushing device, ask patient if :
• noise near the ear when flushing may indicate the catheter tip is malpositioned up the jugular vein
• pain, burning or discomfort near the port body may indicate catheter separation from the portal body and infiltration of IV fluid or medication into the subcutaneous tissue
• pain, burning or discomfort near the entry point of the catheter into the blood vessel may indicate infiltration of IV fluid or medication into the subcutaneous tissue.
Treatment :
• prior to using dissolving agents (MD order required), try all of the other conventional methods to restore patency, in the following order:
• remove end cap/positive pressure valve or IV tubing. Attach a 12 ml luer lock syringe filled with 8 ml of normal saline to the hub of the device. Attempt to flush in a push-pull fashion. DO NOT forcefully attempt to flush the device if occlusion is met because excessive pressure may cause catheter breakage.
• change position of patient (try multiple positions). Have patient lift arms overhead or forward to "lift" clavicle off of the subclavian vein, otherwise known as "pinch-off sign".
• have patient take a deep breath and cough forcefully while attempting to irrigate and withdraw blood.
• if the device is an implanted port, flush with 5 ml heparin 100U/ml prior to deaccessing. Reaccess with a new non-coring needle to ensure correct needle placement.
• attempt use of alteplase per policy to dissolve possible intraluminal clots.
• dissolving agents
• do not use ethanol in patients with a history of allergy to alcohol.
• do not use ethanol in Arrow triple lumen catheters or any other polyurethane catheters. Alcohol can break down the polyurethane device material.
• there are no published or anecdotally reported adverse effects or damage to device material from the use of NaHCO₃ or HCl at these concentrations and volumes.
• equipment/supplies
• for acidic precipitates: 1 ml 0.1 N HCl
• for alkaline precipitates: 1 ml NaHCO₃
• for lipid precipitates: 1 ml 95% ethanol
• 12 ml luer lock syringe
• alcohol wipes
• sterile end cap/positive pressure valve, if heparin locking
• prefilled NS syringes
Clamp catheter (do not clamp Groshong catheters and PICC catheters), then disconnect SafSite valve and/or tubing. Attach syringe to device hub and unclamp device. Slowly pull back on syringe plunger to the 8-9 ml mark to remove saline. Slowly allow plunger to move back to neutral position (A gentle push-pull technique will distend the silicone enough to "mix" to the tip. Do not force dissolving agent as it could cause catheter to rupture or dislodge a precipitate). Call the physician if unable to instill dissolving agent. Reclamp catheter (do not clamp Groshongs and PICC catheters), taping syringe in place. Unclamp device and attempt to aspirate dissolving agent. If no blood is aspirated, reclamp device and wait an additional 15 minutes. It may take longer than 30 minutes for dissolution to occur. If a mixed precipitate is suspected, or the precipitate is unknown, HCl, NaHCO₃, and then ethanol can be used successively in an attempt to achieve patency. "Rinse" device lumen between dissolving agents by using 3-4 ml NS in a syringe and alternately pulling on the syringe and letting go to allow saline to go into device. There are no reports of damage to device with using different dissolving agents successively. However, it is prudent to attempt to "rinse" device lumen to allow the dissolving agent to work most effectively. If blood can be aspirated, withdraw 5-6 ml and discard. Irrigate device with 20 ml NS in a push-stop-push fashion. A push-stop-push technique causes turbulence in the device and flushes out blood and drug more effectively.
Catheterized organs :
• cardiac catheter : a long, fine catheter especially designed for passage, usually through a peripheral blood vessel, into the chambers of the heart under radiologic control; used to obtain blood samples and intracardiac pressures, in diagnosing cardiac abnormalities, and in therapeutic intervention.
• Brockenbrough transseptal catheter : a curved steel inner needle that can puncture the interatrial septum; used to catheterize the left ventricle when the aortic valve cannot be crossed in a retrograde approach
• cardiac catheter-microphone / phonocatheter : a device similar in appearance to a conventional catheter, with a microphone at the tip; used in recording the sounds of the heart and great vessels.
• Judkins coronary catheter : a preformed J-shaped angiographic catheter used in coronary arteriography to cannulate and deliver contrast material to one of the coronary arteries via a percutaneous femoral route. It is composed of polyurethane or polyethylene with a fine wire braid within its walls; right and left catheters are shaped specifically for use in the respective coronary arteries
• Amplatz coronary catheter : a preformed J-shaped angiographic catheter used as an alternative to a Judkins coronary catheter in coronary arteriography
• Castillo catheter : similar to an Amplatz catheter in shape and use, but shorter and introduced via the brachial artery.
• Cournand catheter : a single end hole; used for pressure measurement, usually in the right heart
• electrode catheter : containing one or more electrodes; it may be used to temporarily pace the heart (pacing catheter) or to deliver high-energy shocks
• end-hole catheter : a hole in the tip, through which a guidewire may be passed or pressure monitored
• Gensini coronary catheter : a nonpreformed catheter used for coronary arteriography; it has an end-hole to accommodate a guidewire or monitor pressure as well as side holes for rapid injection of large volumes of contrast material
• NIH catheter : a nonpreformed catheter used for coronary arteriography; it has a closed end and several side holes for rapid injection of large volumes of contrast material
• retrograde catheterization : passage of a cardiac catheter along an artery, usually the femoral artery, against the direction of blood flow and into the heart
• left coronary catheter : one designed for coronary arteriography of the left coronary artery
• right coronary catheter : one designed for coronary arteriography of the right coronary artery
• snare catheter : one designed to remove intracardiac catheter fragments introduced iatrogenically
• Sones coronary catheter : a woven Dacron or polyurethane catheter used in coronary arteriography to cannulate and deliver contrast material to the coronary arteries via the brachial artery. It is not preformed and may be used for several tasks or approaches
• transseptal catheterization : passage of a cardiac catheter through the right atrium and across the interatrial septum into the left atrium; used in cases of valve obstruction and in techniques such as balloon mitral valvuloplasty
• hepatic vein catheterization : passage of a cardiac catheter through an arm vein, right atrium, inferior vena cava, and hepatic vein, into a small hepatic venule, for recording of intrahepatic venous pressures.
Techniques :
• Seldinger technique (1950) : a method for introducing a radio-opaque catheter into a hollow lumen structure or body cavity; a narrow Seldinger needle is used to enter the structure, a guidewire is passed through the needle, the needle is removed, and the catheter is advanced over the wire. Used in angiography, cardiac catheterization, and cannulation of the central venous system
• intubation : the insertion of a tube (an elongated hollow cylindrical instrument) into a body canal or cavity
• Casselberry's position : a prone position employed after intubation so that the patient may swallow without danger of fluid entering the tube
• Fowler’s position : elevation of the head of the bed with patient in supine position: low-Fowler’s (6-10 inches), semi-Fowler’s (12-18 inches), Fowler’s (18-20 inches) and high Fowler’s (24-30 inches)
• Bouchut's tubes : a set of tubes for use in the intubation of the larynx.
• Celestin's tube : a plastic tube used to keep the esophagus open in inoperable esophageal carcinoma
• drainage tube : a tube used in surgery to facilitate the escape of fluids.
• empyema tube : a tube for draining a pleural empyema
• T tube : a self-retaining drainage tube in the shape of a T .
• oral intubation : insertion of a tube through the mouth.
• nasal intubation : insertion of a tube through the nose, such as a nasogastric or endotracheal tube.
• endobronchial tube : a double-lumen tube inserted into the bronchus of one lung and permitting the complete deflation of the other lung; used in anesthesia and thoracic surgery
• Carlens' tube : an early type of endobronchial tube equipped with a small hook to hold the tube in position at the tracheal bifurcation; used for ventilation of the left lung.
• Robertshaw tube : an endobronchial tube that has various improvements over the Carlens tube such as lack of the positioning hook and availability for ventilation of either lung
• control of airway patency : 34% of anaesthesiological accidents are due to lack of control on airways^ref. Alternative airway devices :
• basal techniques
• jaw thrust
• chin lift
• airway : a device for securing unobstructed passage of air into and out of the lungs during general anesthesia or when the patient is not ventilating properly.
• esophageal obturator airway : a hollow tube inserted into the esophagus to maintain upper airway patency in unconscious persons and to permit positive-pressure ventilation through the face mask connected to the tube.
• nasopharyngeal airway or cannula : a hollow tube inserted into a nostril and directed along the floor of the nose to the nasopharynx to prevent the tongue from blocking off passage of air in unconscious persons.
• oropharyngeal airway or cannula : a hollow tube inserted into the mouth and back of the throat to prevent the tongue from blocking off passage of air in unconscious persons.
• Mayo oropharyngeal airway is a metal (anatomically not correctly) open-cage oropharyngeal airway. Various modifications of this airway were developed and manufactured :
• modification with side feed tube
• Lumbard modification
• Lumbard modification with bite block section

• Guedel oropharyngeal airway (1933) is a hard rubber oropharyngeal airway with a straight bite-block section, an anatomically shaped pharyngeal curve section, a hole at the distal end of the tube, and a flange at the proximal end to prevent overinsertion. Later, they were made of plastic material


• Safar oropharyngeal airway (1957) for mouth-to-mouth ventilation in resuscitation


• supraglottic ventilatory devices
• facial mask / facemask
• Greenberg's cuffed oropharyngeal airway (COPA™, Mallinkrodt Medical, Inc., Athlone, Ireland)^{ref1, ref2} consists of a Guedel oropharyngeal airway shaped airway with a specially designed cuff and a 15-mm connector. is an inexpensive, disposable device, which combines a Guedel airway with an inflatable distal high volume, low-pressure cuff and a 15 mm proximal adapter. It is designed to create an effective airway without stimulating the larynx and can be used when facemask ventilation has proved to be difficult, as an adjunct to fiberoptic intubation, and with positive pressure ventilation. It can support the airway in spontaneously breathing anaesthetised patients and compares favourably with the laryngeal mask airway for spontaneously breathing adults. Tracheal intubation using fiberoptic guidance requires maintenance of a patent airway during viewing of the vocal cords and passage of the endotracheal tube. In anaesthetised patients, devices such as the LMA are generally limited to the oral route, require a smaller tracheal tube to pass within the device and a technique to exchange or remove the laryngeal mask when tracheal intubation has been accomplished. This can cause airway trauma or even loss of the airway during the maneuver. Intubation using an appropriately sized tracheal tube and without the need for potentially dangerous tube exchange when intubation has taken place would be an advantage. The COPA may allow fibreoptically guided tracheal intubation via either the oral or nasal route, using a tracheal tube of any (appropriate) size, and without the need for subsequent exchange to an alternate tube


• laryngeal tube (LT™, VBM Medizintechnik GmbH, Sulz, Germany) is a newly developed, multi-use, latex-free, single-lumen silicon tube with oropharyngeal and esophageal low-pressure cuffs, a ventilation outlet in between and a blind distal tip (almost like a single-lumen, shortened Combitube). Ventilation and oxygenation capabilities are similar to the LMA and Combitube. Simple handling, possible aspiration protection and availability in newborn-adult sizes are considered to be advantages of this airway device.
• O'Dwyer laryngeal tube (1895) : life-saving alternative to tracheotomy for the treatment of diphtheritic laryngeal obstruction, inserted using a special curved forceps and digital palpation as guide; the upper flange prevented it falling through the larynx.
• Pharyngeal Airway Xpress (PAX™, Vital Signs Inc., Totowa, NJ) is a sterile, latex-free, single-use airway device intende for use during routine anesthesia procedures. It is curved tube designed with ana antomically shaped gilled tip at the distal end, a large oropharyngeal cuff and an open "hooded window" that allows ventilation placed in between. It is placed blindly, without the aid of any instrument, and when positioned correcty should provide an effective seal.
• glottic aperture seal airway (GO₂™, Augustine Medical Inc, Eden Prairie, MN) is a newly developed, disposable, single-lumen airway that is capable of achieving a highly effective seal against and within the laryngeal inlet. It is inserted with the aide of a stainless steel insertion instrument (blade). Thus far, 2 adult sizes have been developed and pediatric sizes are under consideration.
• Esophageal Tracheal Combitube™ (ETC, Tyco-Kendall Co., Manchester, NH) is a disposable double-lumen tube that combines the features of a conventional ET and that of an esophageal low-pressure cuff with 8 ventilatory holes in between. Ventilation is possible with either tracheal or esophageal intubation. It can be used in patients greater than 4 feet in height in elective or emergent situations, both in and out of the hospital environment. Like the Proseal, the Combitube should protect against aspiration. It is especially useful for patients in whom direct visualization of the vocal cords is not possible, as in patients with massive airway bleeding or regurgitation, limited access to the airway and in patients in whom neck movements is contraindicated. 2 adult sizes are currently available and a pediatric version is under development. The blue tube should be placed in trachea and filled with 100 ml of air, while the white tube should finish into esophagus and filled with 15 ml of air. When the oral cavity if closed by the filled balloon of the blue tube and the esophagus is closed by the filled balloon of the white tube, all air exiting the 2 holes at the end of the blue tube enters the larynx and the white tube can be used to empty stomach. Lung expansion is asssed with capnograph, disk or phonendoscope.


If the blue tube is mistakenly placed into esophagus, the white tube is used for ventilation. Prolonged use of the Combitube may incur greater risk of airway complications such as tongue engorgement^ref.
• laryngeal mask airway (LMA™; LMA North America, Inc., San Diego, CA) is the single most importnt development in airway devices in the past 20 years (Archie Brain, 1983). It is a device for maintaining a patent airway without tracheal intubation, consisting of a tube connected to an oval inflatable cuff that seals the larynx. The LMA has revolutionised airway management in anaesthesia and seems set to do so for resuscitation. Since its introduction into clinical practice, has been used in > 100 million patients worldwide without fatality. Although originally developed for airway management of routine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm in 5 different places as either an airway (ventilatory device) or a conduit for endotracheal intubation. It can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Also, it can be used as a "bridge to extubation" and with pressure support or positive pressure ventilation. There have been several new variants of the LMA including the LMA Classic™ (standard LMA), such as the LMA Flexible™ (wire reinforced flexible LMA), LMA Unique™ (disposable LMA), LMA Fastrach™ (intubating LMA) and most recently, the LMA Proseal™ (gastric LMA). The Proseal was designed with a modified posterior cuff to improve the laryngeal seal and incorporates a second tube to provide a channel for gastric tube placement or passage of regurgitated fluid. It is postulated that the Proseal will replace the Classic LMA, as it is designed to provide a better seal, as well as protect the airway against aspiration.
• ProSeal™ LMA (PLMA) : at 60 cmH₂O intracuff pressure, PLMA gives twice the seal  pressure of the standard device (LMA-Classic™) and permits blind insertion of a gastric tube in all cases. It allows fluid in the oesophagus to bypass the pharynx and mouth when the drainage tube is open. Both the LMA, and the PLMA with a closed drainage tube, attenuate liquid flow between the oesophagus and pharynx. It is more difficult to insert unless an introducer tool is used. When correctly positioned, the PLMA isolates the glottis from the upper oesophagus with possible implications for airway protection
• laryngeal tube suction™ (LTS)

Advantages :
• simple to use : inserted blindly into the pharynx and forms a low pressure seal around the laryngeal inlet. Its appeal is based largely on less need for skill and training than with either facemask or an endotracheal tube^ref. All paramedic crews and emergency departments have the laryngeal mask as standard equipment, and its popularity in hospital resuscitation is growing
• atraumatic to insert : minimally stimulating to the airway, thus avoiding the unwanted sympathetic stimulation associated with laryngoscopy
• helpful in overcoming an obstructed airway, filling the gap between tracheal intubation and the use of a face mask.
• reusable : the LMA is constructed of medical-grade silicone rubber with no latex in any part. This allows the LMA to withstand repeated autoclaving.
• cost-effective
The face mask falls short, stopping at the mouth and nares, and the endotracheal tube (ETT) goes too far, penetrating the lumen of the trachea. Furthermore, the ETT cuff applies a high lateral pressure to the delicate epithelial surface of the respiratory tree, provoking undesirable autonomic responses. The LMA was first used at the Royal London Hospital in 1981^ref. It was subsequently used successfully in a pilot series of 23 patients^ref. In 1983, Brain reported the first use of the LMA in a failed intubation. The LMA became commercially available in the UK in 1988, and it has been reported^ref that the device is used in 50% of general anesthetics in some centers there. In August 1991, the LMA was approved by the US FDA. In the USA, interest in the device has increased as more experience is gained with the LMA in elective operations, patients with a difficult airway, and trauma patients. The device has a shaft ranging from 5.25 to 12 mm in internal diameter, depending on the size of the LMA. The shaft is fused at a 30° angle to a distal elliptical spoon-shaped mask with an inflatable rim resembling a miniature face mask. The shaft is marked with a longitudinal black line along the posterior aspect. The shaft opens into the concavity of the ellipse via a fenestrated aperture with 3 orifices to prevent the epiglottis from falling back and blocking the lumen. 5 sizes are now available, and a size 5 LMA that will accommodate a 7.0 ETT will soon be available. Presently, the LMA retails for approximately $200. Studies are under way to determine how many times the device can be reused. It is estimated that each device may be used at least 50 times before cuff deterioration necessitates replacement. Although the cuff survives repeated autoclaving, it is easily torn on jagged teeth. Because these devices tend to be lost or thrown away, some form of accountability is indicated. For routine use, the insertion of the LMA requires an anesthetic depth similar to that which allows insertion of oropharyngeal airway. A recent study looked at end-tidal concentration (ETC) for laryngeal mask airway insertion and for tracheal intubation in children. It was determined that the ETC for laryngeal mask insertion was the same as minimum alveolar concentration for halothane, enflurane, and sevoflurane and was less than ETC required for tracheal intubation^ref. Most induction agents have been used successfully. A study comparing sodium thiopental and propofol as induction agents indicated that propofol resulted in less coughing and gagging as compared with thiopental at appropriate dosing^ref. Insertion of the LMA requires no laryngoscopy. The patient is placed in the sniffing position. The head is held in slight extension by having the nonintubating hand stabilize the occiput. The jaw is allowed to fall open or is held open by an assistant. Brain's original insertion technique describes the distal tip of the deflated LMA cuff as being pressed against the hard palate using the index finger to guide the tube over the back of the tongue. The tube is advanced until a characteristic resistance is felt as the upper esophageal sphincter is engaged. Without holding the tube, the cuff is inflated with the appropriate amount of air. This will result in a characteristic outward movement of the tube of up to 1.5 cm. This occurs as the cuff centers itself around the laryngeal inlet and results in a slight movement of the thyroid and cricoid cartilages. The longitudinal black line on the shaft of the tube should lie in the midline against the upper lip. A deviation may result in misplacement of the cuff and partial airway obstruction. A variation on insertion technique has been described in the pediatric population. McNicol^ref inserts the device upside down, with the laryngeal aperture pointing cephalad. As the LMA enters the pharynx, it is rotated through 180¡. Other maneuvers to aid in insertion include slight inflation of the cuff, a jaw thrust maneuver, and, in the rare instance, laryngoscopy. Spontaneous or controlled ventilation may be chosen once the LMA is correctly placed. The LMA has been used without complications in operations of up to 7 hours in duration. It is important to remember that the silicone rubber cuff of the LMA is highly permeable to nitrous oxide and both cuff volume and pressure increase during N₂O anesthesia^ref. With intermittent positive pressure ventilation, an audible leak at 15 to 20 cmH₂O is common. Correct positioning is achieved on the first attempt in 88-90% of patients, rising to 95% to 98% on the second attempt^ref. When correctly positioned, the tip of the LMA cuff lies at the base of the hypopharynx against the upper esophageal sphincter, the sides lie in the pyriform fossae, and the upper border of the mask lies at the base of the tongue, pushing it forward. The epiglottis often lies within the bowl of the LMA, but the device functions satisfactorily with the epiglottis in the upright horizontal or downfolded position. A radiologic study showed that in 24 elderly men, there was epiglottic downfolding in 66% of these cases^ref. Removal of the LMA as described by Brain4 should be done once the patient is awake and can open the mouth on command. The LMA cuff protects the larynx from pharyngeal secretions and the risk of inducing laryngospasm by early removal. Others believe it is reasonable to remove the LMA at a deeper plane of anesthesia. This allows the anesthesiologist to lighten the plane of anesthesia and have the patient ready for transfer to the post anesthesia care unit. One must be careful to first suction gently around the cuff before deflation, in order to decrease the risk of secretions inducing laryngospasm. An airway with the LMA does not guarantee an airway with a mask. The LMA is reusable, and the manufacturers guarantee each mask for 10 autoclavings^ref. Some institutions have recorded more than 250 cycles with normal function of the LMA. The longevity of the LMA under routine use is being studied. The most vulnerable part of the device is the valve. The LMA is washed with soap and water, then autoclaved at 134¡C for at least 3 minutes. The critical point in the cleaning process is to make sure that the cuff is entirely deflated before autoclaving. The LMA is contraindicated if a risk of aspiration exists. The inflatable cuff does not guarantee an airtight seal to protect the larynx from aspiration of vomitus. Studies have shown that with the LMA in the proper position to provide satisfactory ventilation, the esophagus is visible via fiberoptic evaluation in 6% to 9% of patients. A study compared the incidence of gastroesophageal reflux in anesthetized patients who were being managed with either the LMA or a face mask. Reflux was assessed with small pH probes placed in the esophagus. A significantly higher percentage of LMA patients had pH <4.0^ref. It has also been shown that controlled ventilation via the LMA with high inflation pressure increases intragastric pressure and contributes to gastric regurgitation. Therefore, the LMA should not be used if a high inflation pressure of more than 20 cmH₂O is required. The risk of aspiration is greater in patients who receive positive pressure ventilation via the face mask than in patients spontaneously breathing through the LMA^ref. Brain recommends that a wide-bore tube be passed before the LMA is inserted, or, alternatively, an orogastric tube may be passed later if the LMA is deflated slightly. Others believe that the orogastric tube may compromise the integrity of the lower esophageal sphincter and increase the risk of regurgitation. Measures to decrease the likelihood of aspiration are as follows:
• outinely test the cuff for defects before use
• avoid lubricating the anterior surface of the mask, since the lubricant may be aspirated
• insert the LMA only when an adequate depth of anesthesia has been reached
• avoid disturbing the patient during emergence from anesthesia
• keep the cuff inflated until the patient is awake.
These are the recommendations of the manufacturer. If aspiration occurs, Brain recommends leaving the LMA in place, tilting the patient's head down, and suctioning through the LMA. Cricoid pressure may make the placement of the LMA more difficult. One study showed that only 3 of 22 patients could have the LMA correctly placed when cricoid pressure was being applied. It appears that transient release of cricoid pressure would facilitate the passage of the LMA^ref. One must weigh the risks of aspiration against the ability to maintain a patent airway. In 1991, Benumof^ref reviewed the difficult airway algorithm and included the LMA in the "cannot ventilate, cannot intubate" scenario. In this section, the LMA is grouped with the Combitube and transtracheal ventilation. All techniques have a low risk-benefit ratio and can be instituted quickly and blindly. Several other limitations apply to the LMA. If the mouth cannot be opened more than 1.5 cm, the LMA cannot be used. The LMA does not provide protection against aspiration. It also may be difficult to provide adequate ventilation if large airway pressures are required. Finally, there may be as high as a 10% to 50% failure rate, especially with cricoid pressure. However, it is a reasonable airway to try before attempting a more invasive technique such as transtracheal jet ventilation. When the LMA is correctly positioned, the distal aperture sits directly over the laryngeal inlet. This allows a variety of blind or fiberoptically guided techniques to intubate the trachea. Since the LMA can be inserted rapidly and blind intubation through the LMA does not require additional equipment, it may play a role in both emergency and elective procedures in both anesthetized and awake patients. A number of objects have been described that can be passed through the LMA into the trachea and followed by an endotracheal tube. In one report^ref, a gum elastic bougie was passed through the LMA and the LMA was then removed. Next, an endotracheal tube was "railroaded" over the bougie through the vocal cords into the trachea. The downside of this technique is the period during which the airway is neither controlled nor protected. In addition, this technique is reported to have an 84% to 88% success rate. We elect to pass an uncut, lubricated, 6.0 mm cuffed endotracheal tube through the shaft of a size 3 or 4 LMA. The length of the LMA is such that when the ETT is fully inserted, about 8 cm project beyond the distal aperture and the upper margin of the tube cuff lies approximately 3 cm below the vocal cords. Correct placement of the ETT is confirmed by bilateral breath sound auscultation and positive identification of end-tidal CO₂. If a larger endotracheal tube is needed, we use a endotracheal tube exchanger (preferably one that allows oxygenation), which is placed through the LMA/ETT system. The two devices are then removed as a unit, and an appropriately sized ETT is passed over the tube exchanger. This technique was used in a study of 50 patients, 72% of whom were intubated within 13 seconds and a further 12% after minor adjustments^ref. A similar degree of success was reported using size 1 and 2 LMAs. A study of 100 patients revealed a success rate of 90%. The figure fell to 56% with the application of cricoid pressure. Problems were more frequent in men having a large floppy epiglottis that folded down over the laryngeal inlet. The use of a fiberoptic bronchoscope (FOB) may both enhance placement and confirm correct positioning. There have been attempts at altering the LMA to aid intubation via the LMA. Brimacombe^ref devised an LMA with its distal aperture bars removed and a longitudinal slit up its shaft. A fiberoptic bronchoscope with a mounted tracheal tube is passed through the LMA into the trachea; the LMA is then peeled off and the tube passed over the FOB. These modifications are not simple and are not recommended by the manufacturer. The smaller sizes of the LMA are scaled-down versions of the sizes 3 and 4 used in adults. Brain studied the pediatric airway using infant cadavers and concluded that their airway was similar to that of adults. There are, however, many anatomic differences of which most physicians are aware. These include the infant's relatively large tongue; a higher, smaller, and more anterior larynx; and a more acute angle between the floor of the mouth and the pharyngeal lumen. Experience in using the LMA should be gained in adults before using it in children. Pediatric patients tend to have more complications, particularly with the size 1 LMA. There appears to be a smaller margin of error in positioning the device in children. Even with proper position of the LMA, there may be inflation of the stomach if airway inflation pressure exceeds the LMA cuff seal pressure of 20 cmH₂O. Breath-holding and laryngospasm may be mistaken for incorrect placement. Thus, an adequate depth of anesthesia is necessary and tends to be deeper than that for adults. Other problems that may occur more frequently in the pediatric patient are centered around insertion^ref. Various maneuvers that may be used to minimize these problems include
• inserting the LMA laterally rather than in the midline
• applying the mask firmly against the hard palate
• pulling the tongue forward
• repositioning the head
• adding or removing air from the cuff
• adding constant positive airway pressure
• using a laryngoscope
• using a rotational technique as described by McNicol^ref.
Mitzushima^ref inserted the size 1 LMA in 50 infants. A clinically acceptable airway was obtained in 94% of the cases on the first attempt, though fiberoptic examination showed that perfect positioning had been obtained in only 44%. Mitzushima concluded that a clinically patent airway does not guarantee ideal LMA positioning or continued airway patency in infants. St. Clair Logan studied the use of the LMA in 507 children in Manchester, England. Attempted insertion was unsuccessful in 2%, and there were difficulties with insertion in 7.1%. A total of 31 children (16%) had complications in the recovery period. Most of the complications were related to inadequate depth of anesthesia and were not clinically significant. Excessive secretions led to the potential for clinically significant complications (ie, laryngeal spasm). The author recommended measures to reduce secretions, such as minimizing crying and premedicating with an antisialagogue. One other area of controversy is the proper time to remove the LMA. Some authors recommend removal after allowing the patient to awaken. If this route is chosen, use of a bite block is recommended to avoid the common complication of attempted biting on the LMA. Others prefer to remove the LMA at a deeper level of anesthesia. The reasoning behind this approach is that it is easier to lighten the level of anesthesia as the surgeons are finishing, leading to a more expeditious room turnover, and if one treats the LMA as a glorified face mask, one is less apt to create a problem. With this technique, there does not appear to be an increased incidence of aspiration or laryngospasm. There is also less likelihood of damaging the LMA, and there is no need for a bite block.
Side effects : gas leak => gastric inflation^{ref1, ref2} => gastric dilation => gastric rupture => tension pneumoperitoneum^ref
• gold standard endotracheal intubation in direct laryngoscopy :
• laryngoscope with charged batteries
• lighted stylets :
• Trachlight™ : (Laerdal Medical Corp., Long Beach, CA) consists of 3 parts: a reusable handle, a flexible wand and a stiff, retractable stylet. It is especially useful in situations in which the FOB is unavailable (e.g. ambulances, emergency departments) or in which bronchoscopy is difficult to perform (e.g. airway obscured by blood or secretions, head cannot be flexed or head extended). This device is now provided with 3 stylets which are reusable and will accommodate tracheal tubes from 2.5-10 mm (ID)
• Ventus Seeing Eye Stylet System™ (American West Medical Co., Leneza, Kansas) was recently developed to improve the limitations of the standard flexible FOB. It has the simple form of a standard stylet, but has the advantage of a fiberoptic view and maneuverability of its tip. It can be used alone without difficulty, and is especially useful for thouse unable to maintain skills with a bronchoscope
• AeroView Endotracheal Scope System™ (Imagyn Medical Technologies, Newport Beach, CA) is a new portable fiberoptic management system in which the scope is used to with disposable sheaths. A lever controls its distal tip unidirectionally and the view is projected to and endoview camera system
• Bonfils Retromolar™ (MVM) Intubation Fiberscope (Karl Stortz, Gmb & Co, KG, Tuttlingen, Germany) is a 5.0 mm optical stylet that allows a retromolar approach to the difficult airway. It is designed to position a 6.5 mm or larger endotrcheal tube directly in front of vocal cords with minimal manipulation of the epiglottis
• laryngoscope straight or curved blades with functioning light source
• endotracheal or tracheal tube (ETT) of various diameters : a tube inserted into the trachea through the mouth, the nose, or a tracheostomy for
• administration of anesthesia
• maintenance of an airway
• aspiration of eventual secretions in the tracheobronchial tree
• positive presure mechanical ventilation of the lungs
• prevention of entrance of foreign material into the tracheobronchial tree.
• aspiration system with flexible tubes
• syringe to inflate the cuff of the ETT
• endotracheal tube guides :
• single-use
• Frova Intubating Introducer™ (Cook Critical Care, Bloomington, IN) was recently designed for facilitation of endotracheal intubation to allow simple endotracheal tube exchange. Its distal tip is angulated like the GEB, but it has 2 side ports. It has a hollow lumen and is packaged with  a stiffening cannula, which is not necessary for use, as well as a removable Rapi-fit adapter that permits ventilation.
• Arndt Airway Exchange Catheter Set™ (Cook Critical Care, Bloomington, IN) can be used for the excange of LMAs and ETs using a fiberoptic bronchoscope (FOB). It has a tapered end, multiple side ports, and is packaged with a stiff wire guide, bronchoscopic port, and Rapi-fit adapter.
• Aintree Airway Exchange Catheter™ (Cook Critical Care, Bloomington, IN) can also be used for the exchange of LMAs and ETs using a  FOB. Like the Supkis airway exchange catheter, its hollow lumen allows insertion of a FOB directly through the catheter
• VETT System™ (PulmonX, Inc., Palo Alto, CA) involves integration of ultra thin FOB bundles into ETs, intubation stylets, laryngoscope blades and allows television monitor projection of the image seen from the end of the device. It may be useful adjunct in the management of the difficult airway, as it enables fiberoptic visualization of all airway structures during intubation
• multiple-use
• Eschmann Tracheal Introducer (Eschmann Health Care, Kent; UK or SIMS Portex; US) also known as the gum elastic bougie (GEB) is conidered the first choice of intubation aides in the UK and is also very popular in the US. It is useful in patients with an "anterior larynx" and those with limited mouth opening. Straight Eschmann tracheal tube guides are designed for endotracheal tube exchange :
• Ambu ballooon ventilation apparatus with relative connectors for the ETT
• oropharyngeal airway
• oxygen
• Magill's intubating forceps are used for nasotracheal intubation, endotracheal suctioning, passing gastric tubes, placement of tampons in the nasopharynx and extraction of foreign material from the pharynx. There are several disadvantages of the standard Magill forceps; however: the danger of cuff perforation, the necessity of readjusting the forceps when placing a tube or catheter, and the risk of injury to the mucous membrane. For these reasons the standard Magill forceps have been modified: the jaws of the forceps have been changed to give curved atraumatic parts without any serrations or sharp edges. The resulting benefits are as follows: reduced risk of injuring the mucous membrane and perforating the cuff. Tubes and catheter are safely guided between the semiround jaws, making it unnecessary to open the forceps repeatedly to advance the tube. Tampons being placed in the throat no longer get caught between the serrations, and even small foreign objects can easily be extracted from the pharynx.


• fixatives for the ETT
• phonendoscope to assess positioning of the ETT
• silica gel or lubrifying
Indications :
• vigile patient in respiratory failure
• coma
• patient undergoing general anesthesia

• endotracheal airway : an ETT that serves as an airway.
• Endotrol tube (Mallinckrodt Critical Care, Inc., St. Louis, MO) has a tracheal ending which can be manipulated on a sagitall plane. It is available in 4 sizes :  6.0, 7.0, 8.0, 9.0 mm of inner diameter. Endotrol has been successfully used together with capnography for orotracheal intubation in 80% of awaken patients and in 90% of patientes undergoing general anesthesia and in spontaneous respiration. It can also be used with the Beck Airway Airflow Monitor^® (Great Plains Balli-stics, Lubbock, TX), consisting of a both inspiratory and expiratory whistle which once connected to EET allows detection of breath sounds
• endotracheal intubation : insertion of an ETT
• Sellick maneuver : the application of pressure to the cricoid cartilage in order to compress the esophagus and prevent passive regurgitation during endotracheal intubation.
• orotracheal intubation : insertion of an orotracheal tube
• orotracheal tube : an ETT that passes through the mouth.
• nasotracheal intubation : insertion of a nasotracheal tube. The median distance between narices and carina is ...
• 32 cm in males
• 27 cm in females
• variable according to to size of head and length of trachea
• nasotracheal tube : an ETT that passes through the nose. Prevented by :
• nasal septal deviation
• nasal polyps
• hypertrophied adenoids or palatine tonsils
• edematous uvula
Kuhn endotracheal intubation set (1900)

Unfortunately, most of his surgical colleques did not recognize the importance of tracheal intubation since they were influenced by the outstanding surgeon Ferdinand Sauerbruch (1875 to 1951) who refused this technique.
Cormack-Lehane laryngoscopic vision scale^ref :
• grade 1 : whole larynx visible


• grade 2 : only part of the glottis visible


• grade 3 :


• grade 4 :


Cook’s modified laryngeal classification^ref : the best laryngeal view obtained with or without anterior laryngeal pressure is recorded.
• grade 1 : most of the cords visible
• grade 2a : posterior cord visible
• grade 2b : only the arytenoids or the very posterior origin of the cords visible. Grade 2b denotes a laryngoscopic view that is relatively common and is often associated with difficulty passing a tracheal tube.
• grade 3a : epiglottis visible and liftable
• grade 3b : epiglottis adherent to pharynx
• grade 4 : no laryngeal structures seen
These grades are categorized as :
• easy (E) when the laryngeal inlet is visible (grade 1 and 2a)
• restricted (R) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted (grade 2b and 3a)
• difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible (grade 3b and 4)

Conditions that predispose to a difficult intubation include :
• incorrect position of the patient.
• inadequate or improper equipment
• difficult airway
• anatomy : small mouth opening, protruding upper teeth, macroglossia, micrognathia, retrognathia, immobility of the head, neck and jaw
• Mallampati's scale :


• distances :
• mentohyoid (MH) distance between more protuding point of mental symphiss and upper part of hyoid bone with hyperextended head (< 45 mm)
• interincisive (II) distance between upper and lower incisor teeth with open mouth (< 35 mm)
• thyromental (TM) distance between the most protruding point of mental symphisis and Adamus' pomus with hyperextended head (< 60 mm)
• mentosternal (MS) distance between mental symphisi and upper border of sternum with hyperextended head (< 12 cm)
• infection: epiglottitis, abscesses, croup, bronchitis, pneumonia
• trauma : maxillofacial fractures, cervical spine injury, laryngeal injury
• endocrine : morbid obesity, diabetes mellitus, acromegaly
• foreign body
• inflammatory conditions : ankylosing spondylitis, rheumatoid arthritis
• upper and lower airways tumours
• congenital problems : choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff-François syndrome
• pregnancy
• difficult direct laryngoscopy = Cormack-Lehane grade 3 or 4 (2-8%)
• difficult endotracheal intubation = difficult direct laryngoscopy, or > 4 attempts, or > 5 minutes for execution (1.2-3.8%)
• impossible endotracheal intubation (0.1-0.3%)
• difficult mask ventilation (0.01-0.07%) : inability to maintain SpO₂ > 90% with O₂ = 100% or to correct signs of inadequate ventilation for a single health-care worker
Preoperatory anesthesiological examination detects 90% of difficult airways, so that unexpectedly difficult airway (Cormack-Lehane grade 3 or 4) should occur in < 2%. In 56% of difficult airway sequelae are death or permanent cerebral injury. Anesthesiological conduct is inadequate in 60% of these cases^{ref1, ref2}.
• extreme difficulty : awake intubation in local anesthesia with fibroscope allows patient collaboration and oxygenation and allows better view of anatomical structures
• mild difficulty : induction of anesthesia and following laryngoscopic evaluation +/- myorelaxation; preoxygenation (facial mask with 100% O2 for > 3 min)
Give-up after 3 unsuccessful attempts  by experienced personnel.
Additional maneuvers :
• modified Jackson's maneuver
• backwards-upwards-rightwards-pressure (BURP) of the larynx. It has been shown that applying cricoid pressure causes anatomical distortion of the upper airway and makes airway management more difficult^{ref1, ref2}. The application of cricoid pressure may interfere with laryngoscope blade placement^ref. Furthermore, external laryngeal pressure to improve the view of the larynx may not be performed concurrently with cricoid pressure^ref. Applying cricoid pressure worsens the view of the larynx. A gum elastic bougie is superior to a stylet for tracheal intubation during application of cricoid pressure^ref.
Side effects :
• preparation and intubation :
• fractures and luxation of cervical spine
• ocular lesions
• epistaxis
• dental trauma and damage to prostheses
• nasal injuries
• retropharyngeal dissection
• subcutaneous and mediastinic emphysema
• esophageal perforation
• bronchial inhalation of blood, gastric content, teeth, prostheses, lamps of laryngoscope
• ingestion of tooth, prostheses, or lamps of laryngoscope
• esophageal intubation and gastric distension
• intubation of a bronchus
• laryngeal-vagal and laryngeal-sympathetic or laryngo-spinal reflexes
• complications due to drugs used for intubation
• fixed tube
• obstruction of tube by secretions, blood, fragmens of tube, flexures, dislocation of cuff
• intubation of a bronchus
• esophageal intubation
• accidental extubation
• mucosal ischemia
• inhalation due to poorly inflated c
• bronchospasm due to disinfectants or detergents used for laryngoscopes and tubes (formaldehyde, quaternary ammonium bases, phenol)
• extubation :
• self-extubation
• injury to vocal cords and glottis due to undeflated cuff
• edema of glottis
• edema of uvula due to aspiration with excessive pressure
• laryngeal croup
• sequelae immediately or lately after extubation
• laryngospasm
• vomiting and inhalation
• (persistent) laryngeal and subglottic edema
• dysphagia and hoarseness
• ulcerations
• tracheitis
• paralysis of vocal cords
• dislocation of arytenoid cartilage
• necrosis of nasal pinnae
• the abundant sensory innervation of upper airways (expecially mucous free terminations in larynx and pharynx) may cause reflexed vegetative responses mediated by vagus, glossopharyngeal and upper laryngeal nerves, prevented by deep anesthesia :
• swallowing
• sialorrhea
• relaxation of lower esophageal sphincter (LES)
• conatus of vomiting
• cough
• sense of suffocation
• hypoxia and hypercapnia
• increased airway resistance
• bronchoconstriction
• laryngospasm
• systemic arterial hypotension or systemic arterial hypertension
• bradycardia or tachycardia
• intracranial hypertension and intraocular hypertension
• alternative approaches
• nasal
• oral blind
• semiblind or indirect
• special airway techniques :
• flexible fiberoptic intubation is a very reliable approach to difficult airway management and airway assessment. It has more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited. It can be used in patients of any age and in any position.
• technological advances including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing  procedures have been developed
• rescue techniques such as placing a retrograde guide wire through the suction channel may be employed if the glottic opening cannot be located with the scope, or if blood or secretions are present. Insufflation of oxygen or jet ventilation through the suction channel may provide additional time when difficulty arises in passing the ET into the trachea
• retrograde intubation is an excellent technique for securing a difficult airway either alone or in conjunction with other alternative airway techniques. The technique is simple, straightforward, and should be a skill of every anesthesia care provider. It is especially useful in patients with limited neck mobility (cervical spine pathology) or who have suffered airway trauma. Recent advamcements in the technique include the introduction of the Arndt Airway Exchange Catheter™ (Cook Critical Care, Bllomingoton, IN) and needle holder to the preexisting retrograde intubation set. The Arndt catheter will allow patient oxygenation if necessary during the procedure, and is recommended for use with ETs 5.0 mm or larger
• transtracheal jet ventilation is a well accepted method for securing ventilation in rigid and interventional bronchoscopy. It is applied in rigiid bronchoscopy with a specially designed jet valve and in fiberscopes in which the jet injector is attached to the suction channel without intervening tubing. It may also be used to prophylactically secure a difficult airway by placing a cricothyrotomy catheter, or an airway exchange catheter into the trachea in order to establish effective ventilation prior to induction of anesthesia. There are a number or commercial manual jet ventilation devices currently available. The Enk Oxygen Flow Modulator™ (Cook Critical Care, Bloomington, IN) is a new device, which is recommended for use when jet ventilation is appropriate, yet a jet ventilator is not available.
• surgery : in cannot-ventilate, cannot-intubate (CVCI) option
• cricothyrotomy
• tracheostomy
Web resources : The Airway Site
• gastrointestinal tubes
• esophageal or stomach tube : a tube for feeding or for irrigation of the stomach
• Abbott-Rawson tube : a double barreled tube through which fluid may be both injected and aspirated; it may be used for lavage or decompression of the stomach.
• Ewald tube : a tube of large bore used to evacuate the stomach.
• feeding tube : a tube for introducing fluids of high caloric value into the stomach.
• nasogastric tube (NGT) (the most common kind : see also movie) : a tube of soft rubber or plastic inserted through a nostril and into the stomach, for instilling liquid foods or other substances, or for withdrawing gastric contents.
• nasoduodenal feeding tubes
• Entriflex^® (Sherwood Medical, St. Louis, MO)
• single lumen :
• Levine^® tubes : may be clear plastic, red rubber or white radiopaque. These are usually passed through the nares into the stomach and connected to a Gomco machine for the purpose of emptying the stomach of it's contents.
• double lumen :
• Salem Sump^® tube (Argyle Co, St. Louis, Mo) : this is a double lumen sump designed to empty stomach content : the second lumen creates an airway to prevent the tube from adhering to the stomach  when continuous suction is applied and prevent suction from drawing mucosa into drain lumen. It is hooked up to straight wall (low or medium) suction
• Wangensteen's apparatus or tube : a small NGT connected with a special suction apparatus to maintain gastric and duodenal decompression
• decompressing tubes:
• Anderson tubes : a double lumen tube, one side of which is designed for gentle irrigation to keep the tube open.
• Cantor tube
• Miller-Abbott tube
• percutaneous endoscopic gastrostomy (PEG) tube
• percutaneous endoscopic jejunostomy (PEJ) tube
• Dobhoff tube :


Size :
• small bore long term 8 to 12 Fr
• larger bore short term feeding or continuous suction 12 to 16 Fr.
• intestinal tubes
• Harris tube : a single-lumen tube with a mercury weight, used as a diagnostic aid in the study of the small intestine
• horizontal tube : a metal tube attachment placed in a horizontal position on the buccal surface of each anchor molar.
• Cantor tube : adult or pediatric size, this is a single radiopaque tube with a balloon weighted with 1-2 ml mercury on the end for intestinal intubation (a hard rubber probe about 120 cm in length), introduced via the narix : when in pharynx a mercury bag is screwn down the probe to facilitate descent. Used to resolve intestinal subocclusions : progression is facilitated by aspiration of gastrointestinal content
• Miller-Abbott tube : a double-channel intestinal tube with an inflatable balloon at its distal end, for use in the treatment of obstruction of the small intestine; the balloon is weighted with mercury after placement into the stomach, to aid its passage into the intestine; occasionally useful also as a diagnostic aid.


• Shiner's tube : a flexible plastic radiopaque tube for obtaining biopsy material from the jejunum under fluoroscopic control; the jejunal mucosa is drawn by suction into a small aperture in the knife cylinder head at the end of the tube, and a portion is excised.
• tampon tube : a piece of stout rubber tubing wound with iodoform gauze, used in plugging the rectum to control oozing and at the same time to allow the escape of gas.
• Paul-Mixter tube : a large-calibered, flanged drainage tube of glass used for temporary intestinal decompression.
• Ryle's tube : a thin rubber tube with an olive-shaped end used in giving a test meal.
• Sengstaken-Blakemore tube : a multilumen tube used for the tamponade of bleeding esophageal varices: one lumen leads to a balloon which is inflated in the stomach, to retain the instrument in place, and to compress the vessels around the cardia; another leads to a long narrow balloon by which pressure is exerted against the varices in the wall of the esophagus; and a third provides for aspirating contents of the stomach.


• nephrostomy tube : a tube inserted through the abdominal wall into the pelvis of the kidney, for direct drainage of the urine.
• Malecot nephrostomy catheter


• perecutaneous pigtail nephrostomy catheter with needle (PCN)


• double pigtail ureteral stent


• thoracostomy tube : a tube inserted through an opening in the chest wall, for application of suction to the pleural cavity; used to drain fluid or blood or to reexpand the lung in pneumothorax.
• tracheostomy tube : a curved endotracheal tube inserted into the trachea through the opening made in tracheostomy.
• Durham's tube : a jointed tracheostomy tube
• tympanostomy or ventilation tube : a tube inserted after myringotomy in chronic cases of middle ear effusion, such as in secretory or mucoid otitis media; it provides ventilation and drainage for the middle ear during healing.
• extubation / detubation : the removal of a previously inserted tube
• decannulation : extubation, especially of a tracheostomy cannula
• breast pump : a manual or electric pump for abstracting milk from the breast.
• infusion pump : a device for injecting a measured amount of fluid during a specific interval of time.
• infusion-withdrawal pump : a pump for the simultaneous injection and withdrawal of fluid at the same rate.
• insulin pump / continuous subcutaneous insulin infusion : an externally worn pump that can supply insulin to subcutaneous tissues through a plastic tube; a large bolus is infused before every meal and a continuous basal rate of insulin is maintained at other times
• peristaltic pump : a pump that moves liquid through tubing by alternate contractions and relaxations on the tubing.
• stomach pump : a pump for removing the contents from the stomach.
• cannulation / cannulization : the insertion of a cannula
• cannula : a tube for insertion into a vessel, duct, or cavity; during insertion its lumen is usually occupied by a trocar
• nasal cannula or prongs : a cannula that fits into the nostrils for delivery of oxygen therapy
• perfusion cannula : a double tube for running a continuous flow of liquid into and out of an organ.
• washout cannula : a cannula attached to a manometer and inserted into a blood vessel so that the connection between the artery and the manometer can be irrigated in long observations.
• hollow needle (butterfly)
• plastic catheter over hollow needle


• plastic catheter
• inserted in hollow needle (drum, cavafix)
• catheter over guidewire (Seldinger technique)
• catheter through introduce
• needle : a sharp instrument for suturing or puncturing
• biopsy needles for needle biopsies
• Abrams' needle : a biopsy needle designed to reduce the danger of introducing air into tissues, as in pleural biopsy.
• Cope's needle : a blunt-ended hooklike needle with a concealed cutting edge and snare, used in biopsy of the pleura, pericardium, peritoneum, and synovium.
• Menghini needle : a needle that does not require rotation to cut loose the tissue specimen in a biopsy of the liver.
• Vim-Silverman needle : an instrument for taking tissue specimens in needle biopsy, consisting of an outer cannula, an obturator, and an inner split needle with longitudinal grooves in which the tissue is retained when the needle and cannula are withdrawn.
• needles for bone marrow trephine biopsy (BMTB)
• Gardner needle


• Islam needle


• Jamshidi needle


• Janus needle


• Osgood needle


• Turkel needle


• Williams' and Nicholson's modified Sacker's trephine


• aspirating needle : a long, hollow needle for removing fluid from a cavity.
• needles for bone marrow aspiration biopsy (BMAB)
• Mallarmé needle


• Klima-Rosenthal needle



• Salah needle


• transseptal needle : a needle used to puncture the interatrial septum in transseptal catheterization.
• Brockenbrough needle : a curved steel transseptal needle within a Brockenbrough transseptal catheter; used to puncture the interatrial septum.
• cataract needle : one used in removing a cataract
• discission needle : a special form of cataract needle.
• knife needle : a slender knife with a needlelike point, used in discission of a cataract and other ophthalmic operations, as in goniotomy and goniopuncture.
• ligature needle : a slender steel needle with a long handle and an eye in its curved end, used for passing a ligature underneath an artery.
• aneurysm needle : one with a handle, used in ligating blood vessels.
• Deschamps' needle : one with the eye near the point, and a long handle attached; used in ligating deep-seated arteries.
• Chiba fine or skinny needle : a very thin, highly flexible steel needle (2.1 G = 0.7 mm) with a narrow inner core used to cannulate very small bile ducts to perform percutaneous (or fine needle) transhepatic cholangiography
• Hagedorn's needles : surgical needles which are flat from side to side, and have a straight cutting edge near the point and a large eye.
• hypodermic needle : a short, slender, hollow needle used in injecting drugs beneath the skin.
• Reverdin's needle : a surgical needle having an eye which can be opened and closed by means of a slide.
• Seldinger needle : a needle with a blunt, tapered external cannula with a sharp obturator; used for the initial percutaneous insertion characteristic of the Seldinger technique for arterial or venous access.
• stop needle : a needle with a shoulder that prevents it from being inserted beyond a certain distance.
• swaged needle : one permanently attached to the suture material.
• Tuohy needle : one in which the opening at the end is angled 45° so that a catheter or endoscope through its lumen exits at an angle; used for examination or treatment of the epidermal space or subarachnoid space.
• Veress needle : a hollow needle consisting of a sharp trocar with a slanted end surrounding an inner cylinder with a blunt end; after the trocar is introduced into a body cavity the blunt cylinder is advanced outward so that internal organs are not injured by the sharp edge; used for insufflation of a body cavity, such as for pneumoperitoneum in minimally invasive surgery.
• puncture : the act of piercing or penetrating with a pointed object or instrument
• ventricular puncture
• cisternal puncture
• lumbar puncture
• sternal puncture
• tracheoesophageal puncture / Blom-Singer puncture : a one-way plastic valve placed in a surgically-created tracheoesophageal fistula to restore speech after laryngectomy
• transethmoidal puncture : a technique for obtaining postmortem biopsy specimens of the brain, using a trocar inserted through the nostril.
• splenic puncture : puncture of the spleen to obtain a specimen of splenic tissue for examination or to measure portal pressure.
• eye :
• obturator :
• trocar [Fr. trois quarts = three quarters] : a sharp-pointed instrument equipped with a cannula, used to puncture the wall of a body cavity and withdraw fluid.
• Hasson trocar for laparoscopy :


• mandrin : a stylet or guide which can be inserted into a jacket (trocar, needle or catheter) to close the "windows" and maintain lumen empty during penetration.
• stylet : 1. a wire run through a catheter or cannula to render it stiff or to remove debris from its lumen.  2. a slender probe.
• guidewire : a thin, usually flexible wire that can be inserted into a confined or tortuous space to act as a guide for subsequent insertion of a stiffer or bulkier instrument, such as a catheter.
• Hem-o-lok^® product line (Weck Systems, Triangle Park, NC => Teleflex) is an innovative cold ligation system that combines the security of a 2.0 suture with the speed of a metal clip for open and laparoscopic surgery.
• 4 sizes (M, ML, L, and XL) to ligate from 2mm to 16mm of vessel and/or tissue bundle
• ligate up to 10mm tissue through a 5mm trocar or up to 16mm through a 10mm trocar
• non-absorbable polymer locking clip is inert, non-conductive, CT/MRI compatible
• tactile feedback
• easy loading system
• flexible mechanism virtually eliminates clips falling out of the applier
• remover offers the option of unlocking the clip
• hemoclip : a metal clip used to ligate blood vessels
• Hemoclip^® Traditional ligating clip system has a proven ligation history that spans 40 years. The Hemoclip Plus system combines the security of Hemoclip Traditional with an easy-load system.
• heart-shaped wire design gives clip a firm grip on vessel
• pre-formed chevron clip shape engulfs tissue allowing precise tip-to-tip closure
• transverse grooves make the clip resistant to slippage across the vessel
• open surgical appliers open at boxlock to facilitate thorough cleaning
• Horizon^® Ligation System is designed to meet the needs of surgeons, nurses, and other operating room personnel.
• 5 clip sizes to meet all your ligation needs: Microclip™, S, M, ML, and L
• heart-shaped wire designed to give each clip a firm grip on vessels
• Chevron clip shape engulfs tissue allowing precise tip-to-tip closure
• transverse grooves make clips resistant to slippage across the vessel
• available in 6- and 24-clip cartridges
• convenient adhesive backing keeps clip cartridge in place
• system allows easy and precise clip loading
• open and endoscopic appliers available
• cutting / incision (-tomy)
• knife : a cutting instrument of various shapes and sizes.
• Blair knife : a knife with a long sharp blade used to cut skin grafts
• Buck knife : a periodontal knife with spear-shaped cutting points, used for interdental incision during gingivectomy
• button knife : a small knife used for the cutting of cartilage.
• cataract knife : a knife for cutting the cornea in operations for cataract.
• cautery knife : a knife connected with an electric battery, so that the tissues may be seared while being cut, in order to prevent bleeding.
• electric knife : a knife-shaped electrode or steel needle which cuts by causing dissolution of tissue when activated by a high-frequency current.
• Goldman-Fox knife : any of a group of knives designed for incision and contouring of gingival tissues in periodontal surgery
• Graefe's knife : a slender knife used in linear extraction of cataract
• Humby knife : a knife with a roller attached, used for cutting skin grafts of varying thickness; the distance between the roller and the blade of the knife can be varied by means of a calibration device.
• Joseph knife : a double-bladed knife used in corrective rhinoplasty
• Kirkland knife : a periodontal knife that consists of a thin, flattened blade attached to the handle by an angulated shank, the outer edge being elliptical and the inner straight; used for primary gingivectomy
• Liston's knife : a long-bladed amputation knife.
• Merrifield's knife : a periodontal knife with a long narrow triangular blade; used in gingivectomy
• lancet : a small pointed and 2-edged surgical knife.


• abscess lancet : a wide-bladed lancet with one convex and one concave edge.
• acne lancet : a form with a narrow blade for puncturing the papules of acne.
• gingival or gum lancet : a knife for incising the gingivae in gingivectomy
• spring lancet : one the blade of which is held by a spring
• dissector : one who dissects
• dissector : an instrument with a metal tip that vibrates at ultrasonic frequency (20 kHz) and cause cavitation in water-rich cells (ie. parenchymal cells) while leaving connective-tissue rich structures (blood and lymph vessels, biliary ways and nerves) intact. They are used expecially for surgery of blood vessels-rich organs (e.g. liver, spleen, kidney, thyroid, pancreas, brain and spinal cord)
• Cavitron Ultrasonic Surgical Aspirator (CUSA) : trademark for an ultrasonic dissector and aspirator used in hepatic resection.
• harmonic or ultrasonic scalpel (Ultracision^®, LCS-5^® (Ethicon Endo-Surgery Inc., Cincinnati, Ohio)) : it is composed of a generator, a hand piece and blade. The hand piece houses the ultrasonic transducer which consists of a stack of piezoelectric ceramics sandwiched under pressure between 2 metal cylinders. The transducer is attached to the blade extender and blade. The generator is a microprocessor-controlled, high frequency switching power supply that drives the acoustic system in the handpiece with AC current. This result in vibration of the transducer at its natural harmonic frequency of 55.5 kHz. The microprocessor senses changes in the acoustic system to control power delivery and alert the user of system faults. The mechanical vibration established in the handpiece is conducted to a blade via an extender to make the system the appropriate length depending on the sugical application. The extender and blade shaft are housed in a protective sheat in a variety of diameters for laparoscopic and open surgery. The entire system vibrates harmonically with at a frequency of 55.5 kHz with a maximum longitudinal displacement of 60-100 mm. The basic mechanisms for coagulating bleeding vessels ultrasonically is  similar to that of electrosurgery or lasers. Vessels are coapted by tamponading and sealed with a denatured protein coagulum. The manner in which protein is denatured, however, is different for each of these modalities. Desiccation (temperature above 100°C) is not necessary to coagulate vessels. The temperature threshold for coagulation by denaturation of protein forming the coagulum is 63°C. The tertiary structure of protein uncoils as hydrogen bonds are disrupted. Usually the collagen denaturation is complete at 80 to 100°C. As protein cools, denatured protein forms a sticky coagulum weld, sealing off coapted vessels. The former uses electric current, whereas the latter uses light energy. The harmonic scalpel denatures protein by transfer of mechanical energy  to the tissue, which is sufficient to break tertiary hydrogen bonds and by the generation of heat from internal cellular friction which results from the high frequency vibration of the tissue. Large vessels (in the 2-mm range) bleed when they're cut by the sharp edge of the scalpel, but not when the pressure is applied to them with the side of the blade, and blade is vibrated for 2-3 seconds. The harmonic scalpel in blunt mode is able to coagulate vessels up to 5 mm in diameter in laboratory tests and has been documented in use on 3 mm vessels in a clinical settings. Initial thermal studies indicated that heat generated as a result of stress and friction in the tissue is limited to temperature below 80°C when a short energy time is used. As a result, tissue charring and desiccation from the loss of moisture can be minimized. The limited heat generation also minimizes the zone of thermal injury. This minimal thermal damage may explain the marked reduction in postoperative adhesions to the liver bed following laparoscopic cholecystectomy with the harmonic scalpel (22%) when compared to electrosurgery (66%)  or laser surgery (77%) in experiments performed in pigs. These mechanisms of coagulation offer an advantage for the harmonic scalpel over electrosurgery when coagulating the side wall of a blood vessel. In electrosurgery, the blood vessel is not coapted significantly because of the concomitant reduction in power density as the the surface area of contact increases with coaptation. The blood within the vessel has a high heat capacity and acts as a sink. This allows one side to coagulate prior to the other with resultant bleeding from a hole in the wall of the vessel that was in contact with electrosurgery. In contrast, the harmonic scalpel relies on pressure and coaptation of the vessel walls for maximum energy transfer to the tissue. Thus, the vessel is sealed together without bleeding from the surface closest to the blade. Pressure and coaptation are of paramount importance to the coagulative ability of the harmonic scalpel. In fact, unsupported tissuesuch as transected bleeding vessel in a mesentery that cannot be compressed against a firm surface, is difficult to coagulate with a dissecting hook blade. To obviate this problem, the laparosonic coagulating shears (LCS) was developed to include a vibrating blade with sharp and blunt edges as well as passive (not ultrasonically activated) tissue pad with which tissue is pressed against the active, vibrating blade. This device allows unsupported tissue to be grasped and coagulated without difficulty, or cutted and coagulated like a pair of scissors. The 2 ultrasonic cutting mechanisms of the harmonic scalpel are also different from that observed in electrosurgery or laser surgery. The first mechanism is cavitational cutting and fragmentation. As the blade tip vibrates, it produces large transient pressure changes which cause intracellular and cellular water to vaporize at low temperature, rupturing cells, leading to very precise cutting and dissection. In addition, this cavitationally-created mechanism cause water vapor to expand between tissue planes separating them. This "cavitation effect" does not destroy tissue but enhances the visualization of the vascular plane (dissection). To achieve the cavitational effect (cavitational cutting and tissue plane separation) place the blunt blade surface on the distal tip of the dissecting hook, without applying great pressure on the tissue and activate the system. The second mechanism of cutting by the harmonic scalpel, and the most important, is the actual "power cutting" offered by a relatively sharp blade vibrating 55,000 times per second over a distance of 60-100 mm. The blade edge cuts tissue by stretching it beyond its elastic limit (like breaking a rubber band by stretchin it too far), and on a more microscopic level, by breaking molecular bonds. The mechanical cutting effect is more easily achieved in high protein density areas such as collagen or muscle-rich tissues. In contrast, cutting with electrosurgery or lasers occurs when the temperature of the cells is increased above the boiling temperature of water, causing the water to vaporize, expand, and explode the cells. Animal studies have demonstrated that the harmonic scalpel is similar in efficiency to an electrosurgical unit, with no difference in operative time, complications, or bleeding. The harmonic scalpel is superior with respect to avoidance of inadvertent gallbladder perforations, a finding replicated in humans. In addition, it eliminates many of the disadvantages of monopolar electrosurgery. The harmonic scalpel is able to cut and coagulate tissue with reduced generation of heat compared to electrosurgery and lasers. Thus, there is minimal disruption of visualization during the procedure. Although there is atomization of fluid which creates a transient mist, this does not accumulate, and it does not significatively impair the visual field as the droplets rapidly settle out. Furthermore, the harmonic scalpel eliminates the risk of electric injury. Finally, because there is little or no cutting ability with an unpowered blade, the blunt side of the harmonic scalpel can also be used as a blunt dissector. As a caution, it is suggested that the harmonic scalpel can, under some circumstance, create smoke, spray, and mist, which can be harmful to surgical personnel. Studies on electrosurgical smoke recommend using a surgical mask and adequate ventilation of the smoke using a surgical smoke evacuator or other means. For optimal tissue dissection, the following suggestion should be helpful to surgeons :
• cutting effect in direction of pressure applied to the blade
• as long as pressure is applied to activated blade, it will continue to cut, or penetrate
• there is much less lateral damage with the harmonic scalpel than with electrosurgery or lasers, ie. 4X less lateral damage and no compromise of visualization
• cavitational effect ahead of blade assists separation of tissue planes
• facilitates dissection; verses welding planes together or cuts through them, as with other thermal modalities
• permits more precise dissection
Blunt dissection with inactivated blade is possible with the back of the blade, advanced 10-mm blade sheath, or closed LCS. Dissection with obvious advantages in lysis of adhesions, transection of pedicles.
No risk of stray current travelling path of least resistance, to burn bowel, etc..
In consideration of wound healing, the harmonic scalpel is considered to be helpful by decreasing lateral thermal damage, It can minimize tissue desiccation and charring promotes faster, stronger, healing than with electro and laser surgery. It is well known that necrotic tissue associated with electric surgical char and lateral tissue damage resulting from ischemia inhibits wound healing and compromises strength of healing, then promotes dehiscence. The harmonic scalpel has also been shown to cause less gallbladder perforation when compared with electrosurgey in lap chole procedure and also to produce less postop adhesions in the porcine model. When the harmonic scalpel is used to incise and dissect in fatty or muscular tissues, small vessels and lymphatics are sealed, thereby decreasing seroma, swelling, bruising, and wound drainage. Harmonic scalpel dissection is used in place of blunt dissection and intermittent electric coagulation in many cases. The result is better hemostasis and sealing of lymphatics. Regarding operating pain, the harmonic scalpel can avoid stimulation of nerves and muscles, while decreasing trauma to the tissue. Since there is no flow of current to the patient, HS does not pose the risk of electric nerve or muscle stimulation and therefore may cause less postop pain. Briefly, smokeless coagulation and dissection are achieved preserving surrounding tissues by thermal damage from the electric current flowing in electric bistoury. They are expecially useful for dissection of fibroadipose structures (omentum, adherential threads, ileal and colic mesi) containing blood vessels < 5 mm. The tip reaches temperatures up to 150°C

• Ligasure™ (ValleyLab Corp, a division of Tyco Healthcare Group LP, Boulder, CO, USA : The electrothermal vessel sealing system facilitates operative haemostasis by applying controlled electrothermal energy to blood vessel walls, resulting in a fused collagen seal^ref. The LigaSure™ is the most widely used electrothermal vessel sealing device. There have been several reports in the past few years describing the use of the LigaSure™ in a variety of gastrointestinal, gynaecological and urological operations^{ref1, ref2, ref3, ref4, ref5}. The LigaSure™ is used to achieve haemostasis of blood vessels encountered during dissection, and can also be used to divide certain vascularized tissues such as the mesentery and omentum. Several studies have demonstrated  reduction in operating time when the LigaSure™ is used^{ref1, ref2, ref3, ref4}. The risk of bleeding does not appear to increase with LigaSure™ use, and some reports have even shown reduced operative blood loss^{ref1, ref2}. The LigaSure™ also has a reduced energy spread profile (< 2 mm) when compared with unipolar cautery, with a potential decreased risk of injury to adjacent structures. However, it is not applicable to all operative procedures. For example, one study demonstrated that the LigaSure™ alone was not effective for transecting the cystic duct during cholecystectomy^ref. Some authors have recently reported their experience with the use of new devices to facilitate haemostasis during thyroid surgery. 2 of these reports describe the use of the harmonic scalpel in thyroidectomy^{ref1, ref2}. With numerous institutions beginning to perform minimally invasive or videoscopic thyroidectomy, there is an increased interest in devices or techniques that reduce the need for conventional knot-tying or suture ligation for haemostasis. At the University of California, San Francisco (UCSF), we have used the the LigaSure™ has been used for haemostasis during thyroidectomy for the past 3 years : it reduces operating time while resulting in a similar rate of complications^ref
• water-jet dissector : an instrument consisting of a nozzle that projects a fine stream of water under high pressure and a suction tube, used in hepatic resection to fragment liver parenchyma while sparing the hepatic vessels.
• radiofrequency coagulator : for blood vessels < 7 mm; it has higher hemostatic capacity than ultrasound dissector and the heat generated is entirely entrapped between the 2 poles. A knife is usually associated to resect the coagulated vessel
• cauterization : the destruction of tissue with a hot instrument, an electric current, a caustic substance, or some other agent (cautery)
• actual cautery : the application of an agent that actually burns tissue.
• chemical cautery / chemocautery : destruction of tissue by application of a caustic chemical substance
• cold cautery / cryocautery : cauterization by means of the application of a substance, such as liquid nitrogen or carbon dioxide snow, or an instrument that destroys tissue by freezing;
• electric or galvanic cautery / electrocautery : an apparatus for cauterization of tissue, consisting of a holder with a metal wire that is heated to a red or white heat when the instrument is activated by an electric current
• electrocoagulation / electric coagulation : coagulation of tissue usually by means of an electrocautery with a biterminal high frequency electric current
• gas cautery : cauterization by means of a specially controlled jet of burning gas.
• potential or virtual cautery : cauterization by an escharotic without applying heat
• scalpel : a small surgical knife with a straight handle and, usually, a blade with a convex edge.


• bistoury : a long, narrow surgical knife, straight or curved, used for incising abscesses and enlarging sinuses, fistulas, etc


• tongue puller


• mouth opener in plastic


• tourniquet : an instrument for compression of a blood vessel by application around an extremity to control the circulation and prevent the flow of blood to or from the distal area.
• automatic rotating tourniquet : a system consisting of a motor, air compressor, and 4 blood pressure cuffs for application to the extremities; the cuffs are inflated and deflated in series and in sequence for treatment of acute pulmonary edema.
• Esmarch's bandage or tourniquet
• Spanish, torcular, or garrote tourniquet / Spanish windlass : an improvised tourniquet consisting of a handkerchief tied around a body part and twisted by a stick passed under it.
• pneumatic tourniquet : a narrow rubber bag to be wound around a limb, pressure being applied by pumping air into the inflatable cuff.
• scalp tourniquet : a tourniquet placed around the scalp with enough pressure to occlude the superficial blood vessels and thereby to lessen the risk of drug-induced alopecia
• explorer : an instrument for use in exploration, particularly for foreign bodies.  2. an instrument with a flexible, sharp point, used to examine the crown of a tooth for defects or caries


• probe : a slender, flexible instrument designed for introduction into a wound, cavity, or sinus tract for purposes of exploration
• Anel's probe : a delicate probe for the lacrimal puncta and canals.
• blood flow probe : an implanted cuff that fits around a surgically exposed artery or vein to detect blood flow.
• blunt probe : a probe with a blunt end.
• Bowman's probe : one of a set of probes for use on the nasolacrimal ducts.
• Brackett's probes : delicate and flexible probes of silver wire for exploring dental fistulas.
• bullet probe : one used for detecting the presence or determining the location of a bullet.
• eyed probe : one with a slit near one end through which a ligature or tape may be drawn.
• lacrimal probe : one designed for use on the lacrimal passages.
• periodontal or pocket probe : one graduated in millimeters, used to measure the depth and determine the outline of a periodontal pocket and the condition of the crevicular epithelium.


• root canal probe / pathfinder or smooth broach : in root canal therapy, a hand-operated instrument consisting of a slender, flexible, smooth or edged wire, used for tracing the course of and exploring root canals
• scissors probe : a long, delicate pair of scissors that can be used as a probe.
• uterine probe : a probe for uterine exploration.
• vertebrated probe : a flexible probe made up of joined links
• sound : an instrument to be introduced into a cavity to detect a foreign body or to dilate a stricture


• scissors : a cutting instrument with two opposed shearing blades.
• canalicular scissors : delicate scissors with one of the blades probe pointed; used in slitting the lacrimal canal.
• cannula scissors : scissors used in slitting a canal lengthwise.
• craniotomy scissors : strong F-shaped shears for use in opening the fetal head.
• Fox scissors : delicate, fine-pointed scissors designed to gain access to interproximal areas for the removal of small tissue tabs or slight soft tissue deformities during gingivoplasty or gingivectomy.
• Liston's scissors : scissors for cutting plaster-of-Paris bandages.
• Smellie's scissors : short, strong-bladed scissors with external cutting edges, used in craniotomy.
• forceps : an instrument with 2 blades and a handle for compressing or grasping tissues in surgical operations, and for handling sterile dressings and other surgical supplies.


• alligator forceps (figure A) : a long, sharply angled forceps with a jawlike mechanism at the tip.
• Allis forceps (figure D) : one with opposing serrated edges with short teeth, used for grasping fascia.
• Asch forceps : forceps used for reduction and fixation of nasal fractures
• bayonet forceps : a forceps whose blades are offset from the axis of the handle.
• bullet forceps : a forceps for extracting bullets.
• capsule forceps : forceps for removing the lens capsule in membranous cataract
• clip forceps : a double-action forceps for applying wound clips; also used to designate a McKenzie forceps for applying brain clips.
• Cornet's forceps : a forceps for holding a coverglass.
• dental or extracting forceps : forceps for the extraction of teeth
• disk forceps : a forceps for grasping the scleral disk in trephining the eyeball.
• dressing forceps : forceps with scissorlike handles for grasping lint, drainage tubes, etc., in dressing wounds.
• ear forceps : delicate forceps for ear surgery or extraction of foreign bodies from the ear.
• epilating forceps : forceps for use in plucking out hairs.
• fixation forceps : forceps for holding a part during an operation
• Koeberlé's hemostatic forceps: forceps for controlling hemorrhage
• hemostat : 1. a small surgical clamp for constricting a blood vessel.  2. an agent that checks hemorrhage when properly applied to a bleeding point


• artery forceps : forceps for grasping and compressing an artery.
• bulldog forceps : spring forceps for seizing an artery to arrest or prevent hemorrhage; the jaws are usually covered with rubber tubing to prevent injury to the vascular wall.
• clamp forceps / pedicle clamp : a forceps with an automatic lock, used for compressing arteries, the pedicle of a tumor, etc.
• Péan's forceps : a curved or straight clamp for hemostasis.
• forcipressure : pressure with forceps, chiefly for the arrest of hemorrhage.
• Kocher forceps : a strong forceps with sharp points at the tips and transverse serrations along the full length for holding tissues during operation or for compressing bleeding tissue.
• mosquito forceps : a small hemostatic forceps.
• Halsted mosquito forceps (straight and curved) (figure C)
• torsion forceps : forceps for making torsion on an artery to arrest hemorrhage.
• Kazanjian forceps : cutting forceps used for resection of the nasal dorsal hump.
• lithotomy forceps : forceps for removing stone from the bladder in lithotomy.
• Löwenberg's forceps : forceps for removing adenoid growths.
• McKenzie forceps : a forceps for applying silver clips.
• mouse-tooth forceps : forceps with one or more fine teeth at the tip of each blade.
• obstetrical forceps : an instrument designed to extract the fetus by the head from the maternal passages (forceps delivery) without injury to it or to the mother.
• Piper forceps : a special obstetrical forceps for an aftercoming head.
• axis-traction forceps : specially jointed obstetrical forceps so constructed that traction may be applied in the line of the pelvic axis.
• Tarnier's forceps :
• Bailey-Williamson forceps :
• Barton forceps : an obstetrical forceps with a hinge in one blade, which can be applied correctly to the fetal head without disturbing its relationship to the pelvic axis; used mainly for deep transverse arrests in a flat pelvis.
• Chamberlen forceps : the original form of obstetrical forceps, invented by Peter Chamberlen (1560–1631), and d :closed by Hugh Chamberlen (1664–1728).
• Levret's forceps : modified Chamberlen forceps, curved to correspond with the curve of the parturient canal.
• Elliot forceps : used in vaginal delivery and breech presentations with aftercoming head.
• Luikart or Garrison's forceps : unfenestrated blades
• Haig Ferguson forceps :
• Hawks-Dennen forceps :
• Kielland's (Kjelland's) forceps : no pelvic curve, a marked cephalic curve, and an articulation permitting a gliding movement of one blade over the other, thus allowing the blades to adapt to the sides of the fetal head when the head lies with its long diameter in the transverse diameter of the pelvis.
• Laufe's forceps :
• Simpson's forceps :
• DeLee forceps : a modified Simpson forceps.
• Tucker-McLean forceps : a long obstetrical forceps with a solid blade.
• point forceps : forceps used in root canal therapy to securely hold the cones or points during placement.
• rongeur forceps : a forceps designed for use in cutting bone.
• rubber dam clamp forceps : one for placing rubber dam clamps in position
• sequestrum forceps : forceps with small but strong serrated jaws for removing the portions of bone forming a sequestrum.
• speculum forceps : long slender forceps for use through a speculum.
• suture forceps : forceps used to hold the needle in passing a suture; a needle holder.
• tenaculum forceps : forceps having a sharp hook at the end of each jaw.
• Schroeder tenaculum forceps (figure E)
• thumb or tissue forceps (figure B) : forceps with one or more fine teeth at the tip of each blade, designed for handling tissues with minimal trauma during surgery
• chalazion forceps : a thumb forceps with a flattened plate at the end of one arm and a matching ring on the other; it is an ophthalmologic instrument, also used for isolation of lip and cheek lesions to facilitate removal.
• volsella or vulsellum forceps : a forceps with clawlike hooks at the extremity of each blade for grasping tissues and applying traction.
• Schroeder vulsellum forceps (figure F with side view of blade).
• galea or Willett forceps / Willett clamp : a vulsellum for applying scalp traction in the control of hemorrhage from placenta previa
• Walsham forceps : forceps used for reduction and fixation of nasal fractures
• rongeur : a forcepslike instrument for cutting tough tissue, particularly bone.


• clamp : 1. any device used to grip, join, compress, or fasten parts.  2. a surgical instrument for effecting compression


• Cope's clamp : a crushing clamp with several hinged segments for use in surgery of the colon and rectum.
• Crile's clamp : a rubber-shod clamp to secure temporary hemostasis in suture of blood vessels.
• Doyen's clamp : a forceps with flexible blades for clamping tissues to control bleeding temporarily during operations on the gastrointestinal tract.
• Gant's clamp : a right-angled clamp used in operating on hemorrhoids.
• gingival clamp : a clamp for retracting gingival tissues.
• Goldblatt's clamp : a clamp for the renal artery to produce experimental hypertension
• Joseph's clamp : a clamp used after a nasal operation to improve the alignment of the mobilized fragments of the bony framework of the nose.
• Martel's clamp : a crushing clamp used in resection of the colon.
• Mikulicz's clamp : a clamp used for crushing the septum between the proximal and distal segments of the colon after exteriorization
• Payr clamp : a crushing clamp used in resections of the stomach, intestine, and colon.
• Potts' clamp : an atraumatic clamp used to grasp a blood vessel.
• Rankin clamp : a 3-bladed clamp for crushing the colon during resection.
• rubber dam clamp : a device made of spring metal that is used to retain a rubber dam on a tooth; it has beveled jaws that contact the tooth and a bow that connects the jaws.
• cotton roll rubber dam clamp : a rubber dam clamp with a buccal and lingual wing or flange to hold cotton rolls in position in the mouth; useful in the placement of direct gold or other restorative material in subgingival class V cavity preparations.
• Satinsky's angiostat or clamp :


• Sehrt's clamp or compressor : a clamp for compressing the aorta or for compressing a limb to arrest hemorrhage
• Yellen clamp : a special clamp used for circumcision
• saw : a cutting instrument with a cutting or serrated edge.
• Adams' saw : a small straight saw with a long handle, for osteotomy.
• amputating saw : one for use in performing amputations.
• Butcher's saw : an amputating saw with a blade that can be set at various angles.
• bayonet saw : a surgical bone saw used for the excision of the nasal dorsal hump.
• chain saw : one in which the teeth are set on links, the saw being moved by pulling one or the other handle.
• trephine : 1. a saw for removing a disk of bone, chiefly from the skull.  2. an instrument for removing a circular area of cornea, as in corneal transplant operations.  3. to operate upon with the trephine
• trepan : an obsolete form of the trephine, resembling a carpenter's bit and brace
• crown saw
• hole saw

• Farabeuf's saw : a saw the blade of which can be set at any desired angle.
• Gigli's wire saw : a flexible wire with saw teeth as used in removing segment of the skull.
• Hey's saw : a small saw for enlarging orifices in bones.
• separating saw : a saw for separating teeth.
• Shrady's subcutaneous saw : a saw for bone work operated through a fenestrated cannula which has been introduced alongside the bone by a trocar.
• fraise : a conical or hemispherical bur for cutting osteoplastic flaps or enlarging trephine openings


• drill : a rotating cutting instrument for making holes in hard substances, such as bones or teeth
• cannulated drill : a drill with a hole through the center of its long axis, to be used over a guide wire
• bur / drill : a metal rotary dental instrument with cutting heads of various shapes, held and revolved in a handpiece; used to remove carious material from within decayed teeth, reduce decayed or fractured hard tissues, form the design of the cavity preparation, and finish and polish the teeth and restorations  2. a type of surgical drill for making holes in bones. In both senses, also spelled burr.


• punch : an instrument for indenting, perforating, or excising a disk or segment of tissue or other material.
• biopsy punch : an instrument used to remove a small amount of skin or other tissue; see also punch biopsy, under biopsy.


• pin punch : an instrument for perforating a metal backing to receive the pins for fastening artificial teeth.
• plate punch : a punch for cutting out parts of an artificial dental plate.
• rubber dam punch : an instrument for punching holes in a rubber dam in order to permit passage of the dam over the crowns of teeth.
• bone plate : a metal bar with perforations for the insertion of screws, used to immobilize fractured segments.
• compression plate : a type of bone plate in which the screws are arranged so that they compress the defect and actively promote closure
• Eggers' plate : bone plate used for maintaining apposition of bone segments.
• Lane plates : steel plates with holes for screws, used in fixing the fragments of a fractured bone
• Moe plate : a stainless steel plate for internal fixation of intertrochanteric fractures of the femur
• Sherman plate : a chrome-cobalt alloy or stainless steel bone plate which can be affixed to a fracture site with screws; often used in open reduction of mandibular fractures.

• hook : a curved instrument, usually with a sharp point, designed for holding, elevating, or exerting traction on a tissue.
• blunt hook : an instrument for exercising traction on a dead fetus in breech presentation.
• Loughnane's hook : a double-pronged hook for removing fragments of the prostate in transurethral prostatectomy.
• muscle or squint hook : a hook for securing and isolating an extraocular muscle
• palate hook : hook for raising the palate in posterior rhinoscopy.
• Tyrrell's hook : a slender hook used in eye surgery
• screw : a solid cylinder with a helical thread on its exterior surface, used to hold 2 objects together.
• pedicle screw : a screw that goes into the pedicle of a vertebral arch, often in the lumbar region, used in various types of instrumentation.


• guillotine : an instrument for excising a tonsil or the uvula.


• incision : a cut, or a wound produced by cutting with a sharp instrument


• Bevan's incision : one along the outer border of the rectus muscle, for operations in the upper abdominal quadrants.
• celiotomy incision : an incision made through the abdominal wall to give access to the peritoneal cavity.
• Deaver's incision : incision through the anterior sheath of the right rectus muscle, the muscle then being retracted medially.
• Dührssen's incisions : incisions made in the cervix uteri to facilitate delivery
• Jalaguier-Kammerer-Battle incision : a vertical abdominal incision through the skin and superficial fascia, vertical division of the anterior layer of the rectal sheath, with retraction of the rectus muscle medialward, and vertical division of the posterior layer of the sheath nearer the median line, together with the subserous areolar tissue and peritoneum.
• Kocher's incision : a subcostal incision that, when made on the right, provides exposure of the gallbladder and common bile duct and, when made on the left, provides exposure for splenectomy or splenorenal venous anastomosis.
• gridiron or McBurney's incision : an abdominal incision parallel to the fibers of the external oblique muscle, about one-third the distance along a line from the anterior superior iliac spine to the umbilicus, half the incision being above and the remainder below this point. The skin and subcutaneous fat are incised down to the external oblique muscle, the fibers of which are split; the underlying internal oblique and transversus abdominalis are then split and separated.
• Rockey-Davis incision : an incision similar to McBurney's incision, except that the skin incision is transverse rather than vertical.
• Munro Kerr incision : a transverse incision of the lower uterine segment for cesarean section
• Nagamatsu incision : in renal surgery, an extrapleural retroperitoneal dorsolumbar approach to the kidney that provides an osteoplastic flap of the lower rib cage.
• Schuchardt's paravaginal incision / vaginiperineotomy / vaginoperineotomy : incision of the vagina and perineum in order to secure enlargement of the vulvovaginal outlet, and thereby permit easy access to the vagina in cancer operations and, rarely, to facilitate delivery
• vertical incision : several types of vertical abdominal incisions have been used in gynecologic surgery, including midline, paramedian, and wide paramedian incisions. A midline incision is almost exclusively the type of vertical incision used in gynecologic oncology surgery. The midline incision is the easiest and most versatile vertical incision for performing gynecologic cancer surgery. This incision allows quick entry into the abdominal cavity with little blood loss, and it is easily extended in length to accommodate the operative findings. The presumed disadvantages of a midline incision compared with a transverse incision include an increased risk of wound dehiscence and hernia formation. Most studies that support this idea are retrospective or lack proper statistical design. Recent studies have challenged this dictum and advocate that little difference exists in dehiscence rates between properly closed midline incisions and transverse incisions. For a midline abdominal incision, the skin and subcutaneous fat are incised to the level of the fascia. The scalpel or electrocautery can be used to incise this tissue. Some surgeons believe the infection rate is higher with the use of electrocautery. Studies from the 1980s suggested a 2-fold increased risk of wound infection with electrocautery compared with a scalpel. However, more recent prospective studies indicate no increased wound complications with electrocautery compared with a scalpel in midline abdominal incisions. Using either instrument, the principle is to make long smooth strokes through the subcutaneous fat to the fascia. The subcutaneous fat should not be dissected from the fascia because this creates unnecessary dead space. Next, the fascia is incised, and the rectus muscles are separated vertically in the midline. The midline may not be evident in patients with previous abdominal surgery. Identifying where the rectus muscles diverge around the umbilicus or locating the pyramidalis muscles assists in identifying the midline. Once the rectus muscles are divided, the peritoneum is grasped between 2 hemostats, opened with a scalpel, and extended the length of the incision. If the operative findings necessitate extending the incision above the umbilicus, avoid cutting through the umbilicus. Postoperative wound infections may be increased due to bacterial colonization of the umbilicus. Extension of the incision should pass to the left of the umbilicus to avoid cutting through the ligamentum teres. Closure of the midline incision has evolved over the last 2 decades. Layered closure using interrupted sutures was previously the choice of many surgeons. Today, most surgeons prefer to close the abdominal wall with a continuous running suture using delayed absorbable sutures. The use of a continuous suture to close the fascia is faster, with dehiscence rates comparable to those of interrupted closures. Two basic techniques are used to close the abdomen with continuous suture, the single-layer mass closure and the internal mass closure. The single-layer mass closure involves using a heavy monofilament delayed-absorbable or permanent suture. Fascial closure involves penetrating the fascia 1.5 cm from the edge with the suture. The suture should also include the underlying muscle and peritoneum. Some surgeons close the wound using the internal mass closure technique advocated by Smead-Jones. This is a far-far, near-near suturing technique. The anterior fascia is included in the near-near bite. The initial stitch is similar to the single-layer mass closure. The second bite only includes the anterior rectus fascia, approximately 0.5 cm from the fascial edge. Either technique requires starting from each end of the incision. Securing the suture with 5 knots at each end is sufficient. In patients who are slender, burying the knot is helpful.
• transverse incision : several useful transverse abdominal incisions are available to the surgeon performing gynecologic cancer surgery. Historically, the obstetrician-gynecologist has preferred this type of incision. Reported advantages include better cosmetic results, less pain, and low incidence of hernia formation. Gynecologic oncologists have embraced certain types of transverse incisions for specific gynecologic cancer operations. Several disadvantages of these incisions exist. Transverse incisions limit exploration of the upper abdomen, they are associated with greater blood loss, and they are more prone to hematoma formation when compared with a midline incision. Nerve injury, which can result in paresthesia of the overlying skin, is more frequent in a transverse incision compared with a midline incision.
• Pfannenstiel's incision : a curved abdominal incision, the convexity being directed downward, just above the symphysis, passing through skin, superficial fascia, and aponeurosis, exposing the pyramidalis and rectus muscles, which are separated from each other in the midline, the peritoneum then being opened vertically. It results in good exposure to the central pelvis but limits exposure to the lateral pelvis and upper abdomen. These factors limit the usefulness of this incision for gynecologic cancer surgery. If the patient is thin and has a gynecoid or platypelloid pelvis, this incision can be used for a radical hysterectomy and pelvic lymph node dissection. The incision is usually made 1-2 fingerbreadths above the pubic crest. Use of a marking pen is helpful to keep the incision symmetric. An incision length of 10-14 cm is sufficient. Increasing the length of the skin incision usually does not improve exposure due to the rectus muscles. The incision is made through the subcutaneous fat to the fascia. The superficial epigastric vessels are often near the lateral edges of the incision. The anterior fascia is incised in the midline with a scalpel or electrocautery. Using curved scissors or electrocautery, the fascia is incised in a curvilinear fashion 1-2 cm lateral to the rectus muscle. The upper edge of the fascia is grasped with 2 Kocher clamps on either side of the midline. Using electrocautery, the rectus muscle is dissected free from the fascia. Electrocautery allows coagulation of multiple small vessels that perforate the rectus muscle to the fascia. The rectus muscles are mobilized off the fascia to the level of the umbilicus. Next, the lower fascial edge is grasped with Kocher clamps. Electrocautery is used again to dissect the rectus muscles and the pyramidalis muscle from the fascia. The rectus muscles are separated. The peritoneum is opened and incised vertically to complete a Pfannenstiel incision. Closure of the Pfannenstiel incision is straightforward. The peritoneum does not need to be closed separately as re-epithelization occurs within 48 hours. Closure of the peritoneum does not add to the strength of the incision. Regardless of whether the peritoneum is closed, the rectus muscles should be thoroughly irrigated with water or saline, and any bleeding areas should be cauterized or ligated. Bleeding from small perforating vessels through the rectus muscle is the most common source of subfascial hematoma. The fascia is approximated with a delayed absorbable suture. Usually, a separate suture is started at each end of the fascial incision, and all layers of the anterior rectus sheath are incorporated. Unless a large area of dead space exists between the fascia and the skin, closure of the Scarpa fascia is not needed. Placement of a closed drainage system, like a Jackson-Pratt drain, may be needed if a large amount of fluid collection is anticipated.
• Maylard incision : in an effort to improve surgical exposure to the lateral pelvic sidewall with a transverse incision, Maylard proposed a transverse muscle-splitting incision. This incision usually refers to a subumbilical transverse incision. For gynecologic surgery, the incision is made 3-8 cm superior to the pubis symphysis. The anterior rectus sheath is cut transversely. The inferior epigastric vessels are identified under the lateral edge of each rectus muscle and then are ligated. Patients with significant peripheral arterial disease may experience ischemia from ligation of the inferior epigastric vessels. These patients may have collateral flow from the epigastric vessels to the lower extremities. After ligation of the inferior epigastric vessels, electrocautery is used to transversely cut the rectus muscle. The peritoneum is opened and cut laterally. To facilitate closure of a Maylard incision, flex the operating table. Close the peritoneum with an absorbable suture. Next, inspect the ties placed on each inferior epigastric vessel, and irrigate with water. Examine the cut edges of the rectus muscles for any bleeding areas. The fascia and underlying rectus muscle can be closed with a monofilament absorbable suture.
• Cherney incision : Cherney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The skin and fascia are cut in a manner similar to a Maylard incision. The rectus muscles are separated to the pubis symphysis and separated from the pyramidalis muscles. A plane is developed between the fibrous tendons of the rectus muscle and the underlying transversalis fascia. Using electrocautery, the rectus tendons are cut from the pubic bone. The rectus muscles are retracted and the peritoneum opened. Closing a Cherney incision begins with closure of the peritoneum. Attach the cut ends of the rectus muscle to the distal end of the anterior rectus sheath with interrupted nonabsorbable sutures. Fixing the rectus muscle to the pubis symphysis can result in osteomyelitis. Next, the fascia is closed with 2, running, continuous, delayed-absorbable sutures. Several types of incisions facilitate extraperitoneal para-aortic lymph node dissection. An upper abdominal transverse incision, which is a high Maylard incision, is made approximately 2 cm above the umbilicus. The incision is extended laterally and caudad to the anterior superior iliac spines. The fascia and rectus muscles are incised transversely, usually requiring ligation of the inferior and superior epigastric vessels. Next, the transversus abdominis muscle is cut, exposing the peritoneum. Using blunt dissection, the peritoneal sac is dissected caudad to cephalad to expose the psoas muscle, the aorta, and the common iliac vessels. Often, a drain needs to be placed in the area of the lymph node dissection.
• modified Gibson incision : some gynecologic oncologists perform an extraperitoneal lymph node dissection using a modification of the Gibson incision. This incision can be made on each side of the midline, but often, the skin is cut only on the left. The incision is started 3 cm superior and parallel to the inguinal ligament. Extension is made vertically 3 cm medial to the anterior superior iliac spine to the level of the umbilicus. The fascia is cut and the peritoneum bluntly dissected, as described above. The round ligament and the inferior epigastric vessels are ligated to facilitate surgical exposure. Care is needed when exposing the lymph nodes using only a left-sided incision. Too much traction on the peritoneum can result in avulsion of the inferior mesenteric vessels.
• relief incision : one made to relieve tension in tissue.
• xiphopubic incision passing on the right of the navel to spare the round ligament of the liver
• Warren's incision : an incision following the thoracomammary fold, permitting access to any part of the breast.
• suture / stich : a loop of thread, catgut, or similar material used to secure apposition of the edges of a surgical or accidental wound


• apposition or coaptation suture : a superficial suture used for bringing together the cutaneous edges of a wound.
• Donati's everting suture : a method by which the approximated edges of a wound are turned outward; formed by encircling with the needle a larger amount of tissue at the depth of the wound than at the periphery
• approximation suture : a deep suture for bringing together the deep tissues of a wound.
• atraumatic suture : a suture fused into the end of a small eyeless needle.
• bolster suture : a suture the ends of which are tied over a tiny roll of gauze or a piece of rubber tubing, in order to lessen the pressure on the skin.
• button suture : one in which the stitch is passed through a button-like disk to prevent the suture material from cutting through the skin.
• circular suture : one that is applied to the entire circumference of a hollow viscus to secure closure, or to a portion of a visceral wall to achieve inversion of the enclosed circular area.
• cobblers' suture : one made with suture material threaded through a needle at each end.
• parallel to and about 4 mm from the edge of the wound, and passing through all the layers of the bowel
• continuous suture : one in which a continuous, uninterrupted length of material is used to approximate the cut edges of one or more layers of tissues.
• Appolito's or Gély's suture : a continuous suture for repair of intestinal wounds, made by a thread with a needle at each end, and consisting of a series of cross-stitches closing the wound.
• chain suture : a continuous suture in which each loop of thread is caught by the next adjacent loop.
• Connell suture : a U-shaped continuous suture used in intestinal anastomosis, the stitches being placed
• purse-string suture : a continuous suture placed around a circular opening that is to be inverted; commonly used for the stump of the appendix or a hernia sac
• quilt or quilted suture : a continuous mattress suture.
• interrupted or loop suture : a noncontinuous suture; one in which each stitch is made with a separate piece of material.
• Czerny's suture : an intestinal suture in which the thread is passed through the mucous membrane alone.  2. a method of uniting a ruptured tendon by splitting one of the ends and suturing the other end into the slit.
• Albert's suture : a form of Czerny's suture in which the first row of stitches is passed through the entire thickness of the intestine.
• Czerny-Lembert suture : a combination of Czerny and Lembert sutures in circular enterorrhaphy.
• double-button suture : a form of stitch in which the suture material is passed deep across the edges of the wound, between two buttons placed on the surface of the skin, one on either side of the suture line.
• figure-of-8 suture : one in which the thread follows the contours of the figure 8 .
• Bunnell's suture : a figure-of-8 zigzag suture used for tendon repair.
• Gussenbauer's suture : a figure-of-8 suture used in repairing a rent of the intestine.
• harelip suture : a figure-of-8 suture used in the correction of cleft lip.
• furrier's suture : a method of stitching intestinal wounds by piercing first one margin of the incision and then the other from within outward; overlying sutures are placed through the seromuscular layers to reinforce the closure and prevent leakage.
• Gaillard-Arlt suture : a suture used in correction of entropion
• hemostatic sutures : sutures used to control oozing of blood from raw areas.
• inverting suture : a seromuscular stitch used in intestinal anastomosis to appose and invert the serosal surfaces of the 2 segments, as in
• Cushing suture : a continuous inverting suture used for closing the seromuscular layers in surgery of the gastrointestinal tract
• Lembert suture : an inverting suture commonly used in gastrointestinal surgery: the needle is inserted about 2.5 mm lateral to the incision, through the serous and muscular tunics but not the submucosa, and brought out near the edge of the incision, then inserted near the edge on the opposite side and brought out at the more distant point, without having entered the lumen of the gut. It may be either interrupted or continuous.
• Dupuytren's suture : a continuous Lembert suture
• Halsted suture : a modification of the Lembert suture, consisting of a stitch parallel to the wound on one side, with the two free ends of the material emerging on the other side, where they are tied
• Le Dentu's suture : for a divided tendon: 2 stitches are passed on each side, right and left, and are tied in front; a third is taken from right to left above and below the cut and is tied on one side.
• Le Fort's suture : for a divided tendon: a single loop is passed above the cut, entering at one side, coming out and going in at the front; it is then passed below the cut at each side, coming out in front, and is there tied.
• glover's or lock-stitch suture : a continuous hemostatic suture used in intestinal surgery: the needle is passed through all layers of the bowel and the loop of suture material is made to fall over the point of emergence of the needle, which comes up through the loop, forming a self-locking stitch when the strand is pulled taut
• Bell's suture : a form of lock-stitch in which the needle is passed from within outward alternately on the 2 edges of the wound.
• horizontal mattress suture : a method in which the stitches are made parallel with the edges of the wound, the suture material crossing deeply from one side to the other
• right-angle or vertical mattress suture : a method in which the stitches are made at right angles to the edges of the wound, taking both deep and superficial bites of tissue, the latter achieving more exact apposition of the cutaneous margins
• over-and-over suture :  a method in which equal bites of tissue are taken on each side of the wound; it may be either interrupted or continuous
• Paré's suture : the use of strips of cloth applied along the edges of a wound, and then stitched together to bring the margins of the wound into apposition.
• plastic or tongue-and-groove suture : a method in which a tongue is cut in one lip of the wound and a groove in the other, the tongue and groove then being stitched together, and the ends of the thread tied over a roll of adhesive plaster.
• Pancoast's suture : a form of tongue-and-groove suture
• presection suture : a stitch or series of stitches placed in the tissues before an incision is made.
• relaxation suture : any suture placed to close a wound but so formed that it may be loosened in order to relieve the tension should it become too great.
• retention suture : a reinforcing suture for abdominal wounds, utilizing exceptionally strong material like braided silk or stainless steel, and including a large amount of tissue in each stitch; intended to relieve pressure on the primary suture line and prevent postoperative wound disruption or evisceration.
• primary suture : prompt surgical closure of a wound.
• secondary suture : delayed closure of an operative or accidental wound, usually because of the presence or expectation of infection or resuture of an operative wound following disruption.
• seroserous suture : a suture which apposes 2 serous surfaces.
• shotted suture : one in which the two ends of the suture wire are passed through a split or perforated lead shot, which is then compressed.
• Sims' suture : a shotted suture.
Suture depth :
• intradermic suture : a suture applied parallel with the edges of the wound, but within the layers of the skin, usually a continuous stitch.
• subcuticular suture : a method of skin closure involving placement of stitches in the subcuticular tissues parallel with the line of the wound; continuous or interrupted sutures may be used
• superficial suture : one that is placed through the superficial fascia only.
• buried suture : one that is placed deep in the tissues and concealed by the skin.
Incisions are practiced parallel to expression lines (not into expression lines as they are usually hard to disinfect and contain germs) : e.g. periareolar in breasts, ... In abdomen, xiphoabdominal or xiphopubic incisions spare abdominal muscles but not linea alba.
wound dehiscence : separation of the layers of a surgical wound; it may be partial and superficial only, or complete, with disruption of all layers
• abdominal wound dehiscence occurs in 0.3-0.8% of sutures and has a mortality of 6-38%. It occurs within 14 days (on average 8 days)
Aetiology :
• abdominal hypertension
• hematomas/infections
• operatory technique
• ileus following open surgery causes increased gas content
• vertical wounds are more subjected (the linea alba is poorly vascularized and surgery injures the few vessels supplying this area, impairing cicatrization)
• metabolic causes
Sutures needs not to create dead spaces which represent an ideal proliferation field for germs : anatomical layers have to be joined one by one.
When suturing be sure of :
• hemostasis
• dead spaces
• perfect border approximation
• lack of necrotic debris
• lack of hypertension
• early removal of sutures
• drainages are a source of infections and diminish the strenght of the suture
Tools :
• glues (cyanoacrylates) which are removed during reepithelization
• steril strips to strenghten wound borders
• intradermic sutures are preferred to antiaesthetic epidermal sutures
Threads : fiber crossing increases resistance but facilitate infection and are not used for skin sutures
• absorbable suture : a surgical suture that closes a wound and later either is digested by proteolytic enzymes derived from inflammatory cells or is hydrolyzed by water.
• absorbable surgical suture : a sterile absorbable suture made of collagen derived from healthy mammals or from a synthetic polymer, available in various diameters and tensile strengths; it may be treated to modify its resistance to absorption, impregnated with a suitable antimicrobial agent, and colored.
• surgical gut / catgut : an absorbable sterile strand obtained from collagen derived from healthy mammals, originally prepared from the submucous layer of the intestines of sheep; used as a surgical ligature. No longer used due to risk of BSE. Natural threads are rarely used nowadays as they have lower resistrance and greater diameter than synthetic ones
• flax
• silk
• animal
• chromic or chromicized gut : surgical gut treated with a chromic salt to increase its resistance to absorption in tissues
• ribbon gut : an absorbable ribbon of the intestinal tissue of animals used for suturing where broad support is to be secured.
• synthetic
• polyglycolic acid (Dexon^®)
• polyglyconates (Maxon^®)
• polydioxanes (glycoles or lactides)
• polyesthers (Vycril^®)
• glycomer 631 (Biosyn^®)
• coated braided lactomer (Polysorb^®).
Defects : absorbable sutures have a progressively decreasing strength and disappear within 2-3 months.
Anyway they prevent formation of foreign body granulomas over skin
• rapid (total disappearance within 40 days; tension decreases by 70-80% within 7-10 days) for closure of vessels, whose repair is very fast
• retard : skin
• normal (50-60 days)
• nonabsorbable suture : material for closing wounds which is not absorbed in the body, e.g., silk, cotton, and stainless steel, or synthetic material such as nylon.
• nonabsorbable surgical suture : a strand of material resistant to the action of living mammalian tissue, available in various diameters and tensile strengths. There are 3 types:
• class I is composed of monofilament, twisted, or braided silk or synthetic fibers; if there is a coating, it does not significantly affect the thickness
• class II is composed of cotton or linen fibers or of coated natural or synthetic fibers having a coating that significantly affects the thickness but not the strength
• class III is monofilament or multifilament wire.
• steel is used for sternotomy and bones
• nylon (Ethilon^®; the highest rersistance for thickness, very used for vascular anastomoses, when excessively large threads may result in hemorrhages)
• Ethibond^®
• polypropylene (Prolene^®)
• Novafilm
Threads are directly mounted on the needles as the eye of a needle could damage the tissues. The suture forceps should be sterile.
knot : an intertwining of the ends or parts of one or more threads, sutures, or strips of cloth so they cannot easily be separated
• clove-hitch knot : a knot consisting of 2 contiguous loops that are applied around an object, the ends of the cord being toward each other; used for making traction on a part for the reduction of dislocations.
• flat knots
• double or friction knot : a knot in which the ends of the cord are twisted around each other twice.
• granny knot (1x1) : a double knot in the second loop of which the end of one cord is over, and the other under, its fellow, so that the loops do not lie in the same line and the knot will not hold.


• modified granny knots (1x1=1=1=1=1)
• reef or square knot : a double knot in which the free ends of the second knot lie in the same plane as the ends of the first knot (1=1=1=1=1=1)


• 1-hand technique


The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch), while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. The grasped fingers apply constant tension to the suture ends. The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers, ring fingers, small fingers, and the palm of each hand (grip activity).

The first throw of the square knot is initiated by the tip of the left index finger that passes its free suture end over the fixed suture end held between the tips of the right index finger and thumb. The tip of the left index finger begins to flex around (arrow) the fixed suture end held by the right hand. Note that the left hand forms the suture loop and passes the free suture end through the suture loop. Consequently, knot construction can be safely accomplished without detaching the needle from the fixed suture end.

As the index finger passes down into the suture loop, flexion of the tip of the left index finger continues until the dorsal surface of its distal phalanx contacts the free suture end held by the left hand. After the free suture end rests on the dorsal surface of the tip of the left index finger, extension of the finger will begin withdrawal (arrow) of the free suture end up through the suture loop.

Extension of the distal phalanx of the left index finger brings the suture end held by the left hand upward (arrow) through the loop

For the left index finger to bring the entire suture end up (arrow) through the loop, the left hand must release its grip of the suture. During this interval, tension cannot be maintained continually on the first throw, allowing the first-throw suture loop to widen, with subsequent partial separation of the wound edges.

With the suture ends grasped in the palms of the surgeon's hands, the tips of the thumbs and index fingers position the suture ends in a direction (arrows) perpendicular to that of the wound. The surgeon applies constant tension to the suture ends, which advances the first, single-wrap throw of the square knot to the surface of the wound. Advancement of the first throw is complete when the divided skin edges of the mid-portion of the wound are approximated.

While grasping the suture end exiting from the farther side of the wound between the tips of the left thumb and index finger, the surgeon supinates the left wrist so that the free suture end is positioned over the tips of the long, ring and small fingers.

With continued supination of the wrist, the tips of the left long and ring fingers advance their free suture end under the suture end held by the right hand to form a suture loop.

Continued flexion (arrow) of the distal phalanx of the left long finger allows the tip of the finger to pass beneath the free suture end held between the tips of the left thumb and index finger

Once the dorsum of the distal phalanx of the left long finger is beneath the free suture end held between the tips of the left thumb and index finger, extension of the distal phalanx of the long finger begins to withdraw (arrow) the suture end down through the loop. For the left long finger to withdraw the entire free suture end down through the loop, the left thumb and index finger must release their grip of the suture. During this interval, tension cannot be maintained continually on the first throw, allowing the first-throw suture loop to widen with subsequent partial separation of the wound edges.

During withdrawal (arrow) of the free suture end through the loop, it is held loosely between the tips of the left long and ring fingers. This loose grasp (key pinch) between the ulnar side of the distal phalanx of the left long finger and the radial side of the distal phalanx of the left ring finger does not allow constant tension to be maintained on this suture end. For the left long and ring fingers to withdraw (arrow) the entire suture end through the loop, the tips of the left thumb and index finger must release the suture.

The second throw is advanced and set against the first throw by applying tension in a direction (arrows) perpendicular to that of the wound. Advancement of the second throw is complete when the second throw contacts the first throw to form a square (1=1) knot. Ideally, the surgeon should be able to advance the two-throw, square knot to allow meticulous approximation of the wound edges. Once exact approximation of the wound edges is accomplished, the surgeon will construct a knot with a sufficient number of throws and 3mm cut "ears" so that knot security is determined by knot breakage, rather than by slippage.
• 2-hands technique


The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch), while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. The grasped fingers apply constant tension to the suture ends. The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers, ring fingers, small fingers, and the palm of each hand (grip activity).

The first loop is formed by the tip of the left index finger that passes its suture end over the other suture end held by the right hand. As the tip of the left index finger passes its suture end over the suture end held by the right hand, the left thumb passes under (arrow) the suture end held by the right hand. Note that the fixed suture end without its needle is being used as the free suture end by the right hand.

The tip of the left thumb advances up through the suture loop, replacing the tip of the left index finger.

The free suture end, held by the right hand, is passed over (arrow) the suture loop.

After the suture end is grasped between the tips of the left thumb and index finger, the pinched suture end is passed downward through, the suture loop. The right hand releases its free suture end so that it can be passed down through the suture loop. The free suture end is regrasped between the tips of the right thumb and index finger to withdraw (arrow) it through the suture loop to form a single-wrap throw.

With the suture ends grasped in the palms of the surgeons's hands, the tips of the index fingers and thumbs position the suture ends in a direction (arrows) perpendicular to that of the wound. The surgeon applies constant tension to the suture ends, which advances the first single-wrap throw of the square knot to the surface of the wound. Advancement of the first throw is complete when the divided skin edges of the mid-portion of the wound are approximated.

The dorsum of the tip of the left thumb is passed under its suture end in order to direct it beneath (arrow) the other suture end that is held by the right hand. During formation of the second throw, constant tension is applied to the suture ends to maintain wound approximation.

The left thumb advances its suture end beneath the other suture end to form a suture loop. The tip of the left index finger passes down (arrow) to touch the left thumb

After the tip of the left index finger contacts the tip of the left thumb (tip-to-tip pinch), both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the loop.

The free suture end held by the right hand is passed under the suture loop to be positioned (arrow) between the tips of the left index finger and thumb.

The free suture end grasped between the tips of the left thumb and index finger is advanced upward through the suture loop. The right hand releases its free suture end to allow its passage through the suture loop, after which it regrasps the free suture end to withdraw (arrow) it through the suture loop.

The second throw is advanced and set against the first throw by applying tension in a direction (arrows) perpendicular to that of the wound. Advancement of the second throw is complete when the second throw contacts the first throw to form a square (1=1) knot. Ideally, the surgeon should be able to advance the two-throw, square knot to allow meticulous approximation of the wound edges. Once exact approximation of the wound edges is accomplished, the surgeon will construct a knot with a sufficient number of throws and 3mm cut "ears" so that knot security is determined by knot breakage rather than by slippage
• stay knot : a knot made with 2 or more ligatures, each being tied with the first half of a square knot; then all the ends of one side are taken in one hand, and all the ends on the other side in the other hand, and tied as if they formed one single thread
• surgeon's or surgical knot  (2=1=1=1=1) : a knot in which the thread is passed twice through the first loop to prevent slippage



The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch), while tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. The grasped fingers apply constant tension to the suture ends. The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers, ring fingers, small fingers and the palm of each hand (grip activity).

The first suture loop is formed by the tip of the left index finger that passes its suture end over the other suture end held by the right hand. As the tip of the left index finger passes its suture end over the suture end held by the right hand, the left thumb passes under (arrow) the suture end held by the right hand. Note that the fixed suture end without its needle is being used as a free end by the right hand.

The tip of the left thumb advances up through the suture loop, replacing the tip of the left index finger.

The free suture end, held by the right hand, is passed over (arrow) the suture loop

After the free suture end is grasped between the tips of the left thumb and index finger, the pinched suture end is passed downward through the suture loop. The right hand releases its free suture end so that it can be passed through the loop. The tips of the right thumb and index finger regrasp the free suture end to withdraw (arrow) it through the suture loop to form a single-wrap throw.

The rectangular configuration of the suture loop is maintained by keeping the tip of the index finger (arrow) in the suture loop

The left thumb passes up (arrow) through the suture loop, replacing the left index finger in preparation for the formation of the double-wrap first throw

The free suture end held by the right hand is passed over (arrow) the suture loop and grasped between the tips of the left thumb and index finger.

The free suture end grasped between the tips of the left thumb and index finger is passed down (arrow) through the suture loop. The right hand releases its suture end so that it can be withdrawn through the suture loop. As the free suture end passes through the loop, it is regrasped by the right hand to withdraw it through the suture

With the suture ends grasped in the palms of the surgeon's hands, the tips of the index fingers and thumbs position the suture ends in a direction (arrow) perpendicular to that of the wound. The surgeon applies constant tension to the suture ends, which advances the double-wrap, first throw of the surgeon's knot square to the surface of the wound. Advancement of the first throw is complete when the divided edges of the mid-portion of the wound are approximated.

The dorsum of the tip of the left thumb is passed under (arrow) its suture end in order to direct it beneath the other surface end that is held by the right hand. During formation of the second throw, constant tension is applied to the suture ends to maintain wound approximation.

The left thumb advances its suture end beneath the other suture end to form a suture loop. The tip of the left index finger passes down (arrow) to touch the left thumb

After the tip of the left index finger contacts the tip of the left thumb (tip-to-tip pinch) both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the suture loop.

The free suture end held by the right hand is passed under the suture loop to be positioned (arrow) between the tips of the left index finger and thumb

The free suture end grasped between the tips of the left thumb and index finger is advanced upward through the suture loop. The right hand releases its free suture end to allow its passage through the suture loop, after which it regrasps the free suture end to withdraw (arrow) it through the suture loop.

The single-wrap throw is advanced and set against the first double-wrap throw by applying tension in a direction (arrows) perpendicular to that of the wound. Advancement of the second throw is complete when the second throw contacts the first throw to form a surgeon's knot square (2=1). The direction of tension applied to the suture ends of the first throw is opposite to that exerted on the suture ends of the second throw. Once exact approximation of the wound edges is accomplished, the surgeon will construct a knot with a sufficient number of throws and 3 mm cut "ears" so that knot security is determined by knot breakage, rather than by slippage.3
• 2 knots practiced in the same sense block the knot (1=1)
• 2 knots practiced in opposed directions : the last knot removes tension applied on the first one (1x1)
• sliding or slip knot (S)
• modified identical sliding knot (S=SxSxSxSxS)
• non-identical sliding knot (SxSxSxSxSxS)

The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch), while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. The grasped fingers apply constant tension to the suture ends. The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers, ring fingers, small fingers and the palm of each hand (grip activity).

The first suture loop is formed by the tip of the left index finger that passes its suture end over the other suture end held by the right hand. As the tip of the left index finger passes its suture end over the suture end held by the right hand, the left thumb passes under (arrow) the suture end held by the right hand. Note that the fixed suture end without its needle is being used as the free suture end by the right hand.

The tip of the left thumb advances up through the suture loop, replacing the tip of the left index finger.

The free suture end, held by the right hand, is passed over (arrow) the suture loop

After the suture end is grasped between the tips of the left thumb and index finger, the pinched suture end is passed downward through the suture loop. The right hand releases its free suture end so that it can be passed down through the suture loop. The free suture end is regrasped between the tips of the right thumb and index finger to withdraw (arrow) it through the suture loop.

The first throw of the slip knot is completed by first applying tension (arrow) to the suture held by the left hand causing this suture end to be straight and taut. The suture end held by the right hand forms a loop around the straight, taut suture held by the left hand.

The tip of the right index finger slides (arrow) the loop along the straight, taut suture end held by the left hand until the loop contacts the wound. Advancement of the first throw is complete when the divided skin edges of the mid-portion of the wound are approximated.

The dorsum of the tip of the left thumb is passed under its suture end in order to direct it beneath (arrow) the other suture end that is held by the right hand. During formation of the second throw, constant tension is applied to the suture ends to maintain wound approximation.

The left thumb advances its suture end beneath the other suture end to form a suture loop. The tip of the left index finger passes down (arrow) to touch the left thumb.

After the tip of the left index finger contacts the tip of the left thumb (tip-to-tip pinch), both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the suture loop

The free suture end held by the right hand is passed under the suture loop to be positioned (arrow) between the tips of the left index finger and thumb

The free suture end grasped between the tips of the left thumb and index finger is advanced upward through the suture loop. The right hand releases its free suture end to allow its passage through the suture loop, after which it regrasps the free suture end to withdraw (arrow) it through the suture loop.

The tension applied (arrow) to the suture end held by the left hand causes this suture end to become straight and taut. The suture end held by the right hand forms a second loop around the straight, taut suture end held by the left hand

The tip of the right index finger slides (arrow) this second throw against the first throw, completing the slip knot (S=S), while the left hand maintains tension (arrow) on its suture end. The slip knot will become a square knot by applying tension to the suture end held by the right hand (insert). The square knot can be converted to a slip knot by applying tension primarily to one suture end.
• endoscopic knots
• intracorporeal knot :


• extracorporeal knots : the structure is surrounded, the endings of the thread are placed extracorporeally, the knot is practiced and then inserted back into the cavity
• Roeder knot : for ligation of vessels < 5 mm (cystic duct, caecal appendix, ...) using dehydrated catgut or silk (rehydration improves strength)


• Meltzer knot (1991) :
• Fisher knot :
When sutures have to be removed, the knot is lifted with pinches and then displaced on one side : a lancet is then used to cut the thread on the opposite side near skin entry (with blade directed toward the operator to prevent injuries to the patient). Side displacement allows cutting of the thread in a region previously held below skin and hence more sterile, preventing spreading of germs when the thread slips into the skin.
Mechanical staplers : mechanical sutures in surgery were first used in 1908 by Hultl.
• linear staplers work with metal clips and polyglactin
• circular and linear anastomosis staplers function with metal clips and the Murphy principle
• ligating clips
Compared to hand suturing staplers have not only the advantage of saving time but they also provide for a simple closure of the duodenal stump, the bronchus and the safe anastomosis of the rectum and the esophagus. The clipless compression-anastomosis seems to have a promising future. Its advantages include the absence of a foreign body, larger diameter of the anastomosis and no risk of postoperative haemorrhage.
• hinged-jaw stapling device (TA-Premium, Auto-Suture)
• stapling device of parallel pattern (RLV 30 Ethicon)
• endoscopic gastrointestinal automatic stapler (Endo-GIA)
• skin stapler : Visistat^® disposable skin stapler is loaded with 35 regular or wide medical grade stainless steel staples.
• sharper staple results in less tissue trauma
• tall staple for easier, less painful removal
• non-stop feed action reduces jamming
• pre-cock staple function for exact staple positioning

Endoscopic linear stapler with 45° foldable tip :
• single fire
• multifire

• clip applier
• Vascular Clip System (VCS^®) clip applier *Ethicon Ltd, Edinburgh, UK(, forceps and clip remover


• strip : a thin, narrow, comparatively long piece of material
• abrasive strip : a strip of linen or polymer film having abrasive material such as silica or garnet bonded to one side; used for polishing and contouring of the proximal surface of a tooth or denture.
• linen strip : an abrasive strip with a linen backing.
• excisions (-ectomy)
• creation of openings (-stomy)
• outer openings
• inner openings
• drainage : the systematic withdrawal of fluids and discharges from a wound, sore, or cavity. (-centesis)
• paracentesis : surgical puncture of a cavity with an aspirating needle (agocentesis) or other hollow instrument for diagnostic or therapeutic aspiration of fluid.
• colon fluid or gas (colocentesis / colopuncture)
• culdocentesis : aspiration of fluid from the rectouterine space by puncture of the apex of the vaginal wall.
• laryngeal exudate (laryngocentesis)
• chorionic villus sampling (CVS) or biopsy / chorial villi sample : a procedure used for prenatal diagnosis at 9 to 12 weeks' gestation (7 to 10 weeks after fertilization) in which 10-15 mg of villous chorion (chorion frondosum) are collected under ultrasonic guidance after echography to assess fetal heartbeat, gestational age (CRL), position and thickness of trophoblast, multiple pregnancy and gross malformations
• transabdominal CVS


• transcervical CVS


Indications : mendelian diseases (a- and b-thalassemias, muscular dystrophies, cystic fibrosis, hemophilia A and B). False positives (1-2%) in short-term cultures (within 48 hours) are eliminated in long-term cultures.
Side effects :
• abortion (4-10%)
• endouterine infection
• rupture of amniochorial membranes
• subchorial hematomas
• abruptio placentae
• Rh alloimmunization (prevented in Rh^- pregnants by i.m. administration of anti-Rho(D) globulins 200 mg within 72 hrs from sampling)
• amniotic fluid (amniocentesis) : percutaneous transabdominal puncture of the uterus for prenatal screening. 10-15 mL are collected at pregnancy week 15-18, when amniotic fluid volume is > 100 mL and there are enough desquamated amniocytes (a cell of fetal origin obtained in an amniotic fluid specimen). The collection shouldbe preceded by echography to assess fetal heartbeat, gestational age though measurementof BPD and/or femur length, multiple pregnancy, anencephaly, gynaecological disease, position of placenta, location and depth of an amniotic fluid pouch from which collection is practiced.

Indications :
• maternal age > 35
• previous newborn affected by Down syndrome (risk of a second affected newborn = 1-2%)
• increased risk at Triplo-test
• fetal anomalies diagnosed with echography
Side effects :
• uterine contractions
• amniorrhexis
• intrauterine infections
• rarely Rh isoimmunization (prevented in Rh^- pregnants by i.m. administration of anti-Rho(D) globulins 200 mg within 72 hrs from sampling)
• spontaneous abortion (< 1%)

• lecithin-sphingomyelin (L/S) ratio : the ratio of lecithin to sphingomyelin concentration in the amniotic fluid, used to predict the degree of pulmonary maturity of the fetus and thus the risk of respiratory difficulties for the newborn.
• blood : H₂O and soap washing => dysinfection with 3% tincture of iodine => 3' waiting => collection of 10 mL of blood (as bacteriaemias usually give 0.5 bacteria / mL, sample contains ~ 5 bacteria; 0.5÷4 mL are collected in newborns) into a vacu-tainer containing 0.025% sulfated polysaccharides (SPS : unfractioned heparin, LMWH, pentosanpolysulfate, lactobionic acid, ...) as anti-coagulant => + 90 mL nourishing broth (i.e. 10 times diluition of antibacterial factors (C, Abs, ...)) => skin clearing with isopropylic alcohol. As every sample must test both aerobic and anaerobic microorganisms, 20 mL per time are collected. Collection must be done between 30' before and 2h30' after fever peak. 3 collections (5 if endocarditis is subspected) in 24 hrs (separated by at least 45÷90' (usually 8 hrs.) : this is clearance time for transient bacteraemias), i.e. 60 mL, give 99% sensitivity in 7-days cultures at T= 35÷37 °C.
• umbilical cord blood (cordocentesis / percutaneous umbilical blood sampling (PUBS)) : percutaneous puncture of the umbilical vein under ultrasonographic guidance to obtain 1-3 mL of fetal blood for prenatal screening at pregnancy week 20-22


Indications : X-linked diseases (including fragile X syndrome), biochemical (hemoglobinopathies, thalassemias, coagulopathies), immunological or infectivological (fetal IgM anti-rubella virus, Toxoplasma gondii, CMV, B₁₉ parvovirus) investigations, fetal transfusion of compatible blood for Rh immunization and direct drug infusions, fetal malformations (omphalocoele, duodenal atresia, obstructive cardiopathies and uropathies, cystic hygroma, nonimmunological hydrops, plurimalformative syndromes), mosaicisms found at amniocentesis or CVS,
Side effects : abortion (2%; at second trimester : 1%)
Fetal karyotype within 3-4 days with lymphocyte cultures, microbiological cultures within 3-4 weeks.

BD Vacutainer® stopper color	anticoagulant	specimen type	instructions	indications
(plain) red	none	10 mL serum	do not shake or mix	alcohol  salicylate  acetaminophen  antibiotics metabolic profiles  hepatic profiles  renal profiles  IgG  IgA  IgM  IgE  high sensitivity CRP  cortisol  thyroid hormones  PSA  vitamin B12 folate  testosterone  CEA  most specialty tests and antibody testing iron and iron binding  cholesterol  triglycerides  HDL  LDL
red mottled / gold / gray and red tiger  (SST/Corvac)	none; contains silicone gel for separating cells from fibrin clots in the serum	10 mL serum	do not shake or mix; may cause a problem when evaluating for the presence of drugs in a patient’s serum because it may draw the drugs out of the serum	the same as the red, except drug levels and a few other tests (when in doubt, draw a red)
lavender / light purple	potassium EDTA in powder form	5 mL plasma / whole blood	draw minimum 1/2 full; mix gently after collection	CBC  platelet count  reticulocyte count  malaria smear (make 2 thick and 2 thin films from EDTA sample; refrigerate EDTA tube and send EDTA tube cold) blood bank tests (type and screen, crossmatch)  HbA1c ESR  BNP  lead red cell folate Kleihauer test
green	lithium or sodium heparin in powder form	5 mL plasma / whole blood	mix gently after collection	metabolic profiles  hepatic profiles  renal profiles  digoxin  dilantin  theophylline  CRP  CPK  troponin  myoglobin  cholesterol  triglycerides HDL  LDL  ammonia (must be on ice) occasionally used for platelet counts in the presence of abnormal platelet clumping
(light) blue	sodium citrate in liquid form	5 mL plasma / whole blood	draw last of after discard specimen. fill completely and mix gently after collection	PT  aPTT  INR  fibrinogen  anti-thrombin 3 (AT3)  protein C  protein S  D-dimer  platelet count if the patient’s platelets tend to clump together in the EDTA tubes virology
gray	sodium fluoride and potassium oxalate in powder form	5 mL plasma / whole blood	mix gently after collection	lactic acid  alcohol  glucose (may also be collected in green, red, or gold)
royal blue	sodium heparin (trace element tube)	plasma / whole blood
royal blue	none	serum
yellow	ACD solution A or ACD solution B	10 mL plasma / whole blood	mix gently after collection

BD Microtainer^® is a very small collection tube that contains the same anticoagulants and have the same color tops as the larger vacutainer.
The specimen is then centrifuge (centrifuge: An apparatus that uses centrifugal force to separate particles from a suspension) d to separate plasma from blood cells. Plasma can be frozen below -80°C nearly indefinitely for subsequent analysis. For many biochemical laboratory tests, plasma and blood serum can be used interchangeably. Serum resembles plasma in composition but lacks the coagulation factors. It is obtained by letting a blood specimen clot prior to centrifugation. For this purpose, a serum-separating tube (SST) can be used which contains an inert catalyst (such as glass beads or powder) to facilitate clotting as well as a portion of gel with a density designed to sit between the liquid and cellular layers in the tube after centrifugation, making separation more convenient. Tests of coagulation (coagulation: The process of forming semisolid lumps in a liquid)  (such as the INR and aPTT) require all clotting factors to be preserved. Serum, therefore, is inappropriate for these tests. A citrated evacuated blood collection tube (e.g. vacutainer or Vacuette^®) is usually used, as the anticoagulant effects of citrate is dependent upon concentration and can be reversed for testing. Serum is preferred for many tests as the anticoagulants in plasma can sometimes interfere with the results. Different anticoagulants interfere with different tests; using serum means the same sample can be used for many tests. In protein electrophoresis, using plasma causes an additional band to be seen, which might be mistaken for a paraprotein
• bone marrow aspiration (BMA)
• cerebrospinal fluid (CSF), for diagnostic or therapeutic purposes : after > 12 hours of lying at bed and fastig, CSF is collected by syringe aspiration of 5÷6 mL (1÷2 mL in babies) in seated position or lateral decubitus (the latter is preferred to prevent falls due to vasovagal syncope and decrease brain weight in order to prevent tonsillar transoccipital hernia). The spine has to be hyperflexed to enlarge intervertebral spaces. Skin has to be disinfected with iodine tincture in a centrifugal sense and local anesthesia with ethyl chloride or 1% novocaine is practiced.
• ventricular puncture : puncture of a cerebral ventricle for the purpose of withdrawing fluid
• from the subarachnoid space
• cranial, cisternal, intracisternal or suboccipital puncture : puncture of the posterior cerebellomedullary cistern through the posterior atlanto-occipital membrane
• basal drainage : withdrawal of the CSF from the basal subarachnoid space for the relief of ICP
• rachicentesis / lumbar, spinal or thecal puncture / spinal tap : the rachicentesis needle (diameter = 1-1.5 mm; 2-ways for Claude's manometer and for CSF sampling) is inserted parallel to and between the spinous processes of L3 and L4 (point obtainable by drawing an imaginary line between the upper posterior iliac spines (bisiliac line)) or L4 and L5 vertebrae, passes the resistance due to yellow ligaments and enters the subarachnoid space, extracts the mandrin : the CSF outflows spontaneously and is serially collected in 3 test-tubes.

Indications :
• absolute indications
• meningitis
• encephalitis
• meningeal carcinomatosis
• Guillain-Barré syndrome (GBS)
• acute demyelinizing diseases
• acute demyelinizing encephalomyelitis
• transverse myelitis
• brainstem encephalomyelitis
• benign intracranial hypertension (pseudotumor cerebri)
• unexplained neurological disorders
• epileptic crisis
• stroke
• polyneuropathy
• dementia
• alteration of level of consciousness
• possible indications (according to clinical situation)
• multiple sclerosis
• subarachnoid hemorrhage (SAH) (if CT is negative)
Claude's manometer can be used to measure CSF pressure ... :
• in basal conditions
• < 100 mmH₂O in patients with previous rachicentesis, dehydratation, spinal subarachnoid block, liquoral fistulas
• Ayer's test (for spinal block): with a spinal manometer, the pressure in lumbar puncture and that in a cisterna magna puncture should be identical in the normal subject
• > 200 mmH₂O in patients with intracranial hypertension
... and calculate the Ayala's index / rachid quotient (Q_r) = (P_after ^. V_subtracted) / P_before = 5
• > 5 in inflammatory processes
• < 5 in space-occupying processes
• during maneuvers that normally increase the CSF pressure up to 200-400 mmH₂O by causing intracranial hypertension (it comes back to normal values within 20" from removal of stimulus) : this doesn't occur (positive test) in patients with spinal subarachnoid block
• Valsalva's maneuver (forced expiration with closed glottis)
• Queckenstelt-Stookey maneuver : manual compression of both jugular veins in neck for 20"
• abdominal compression
• coughing
Other parameters are obtained by in vitro CSF analysis. After the sampling the patient has to lie at bed with the head lower than feet
Contraindications : if intracranial hypertension is present (detected with examination of fundus oculi), intravenous mannitol and ventilation with P_CO2 = 25÷30 mmHg are needed to prevent tonsillar transoccipital hernia. Anyway lumbar puncture is safe, in the absence of certain clinical signs and symptoms, or they explicitly debunk the myth raised by the authors^{ref1, ref2, ref3}. 3 samples are usually collected for cell count, biochemical tests and bacterial isolation, respectively
Side effects :
• post-lumbar puncture syndrome
• subarachnoid hemorrhage (SAH)
• radicular syndrome
• lumbalgia
When evaluating possible neoplastic meningitis in a patient with a high-grade lymphoma, oncologists often give a first dose of empirical intrathecal chemotherapy at the time of the initial lumbar puncture. Vancomycin can be safely given intrathecally, and this route is routinely used by neurosurgeons to treat patients with infected hardware^ref. Empirical intrathecal vancomycin given after the lumbar puncture would bypass the problem of penetration of the blood–brain barrier without undue complication of the workup and treatment of patients with suspected infectious meningitis. However, in a previous study of neonates with gram-negative meningitis and ventriculitis, intrathecal gentamicin failed to produce measurable ventricular concentrations, and intraventricular administration of this agent was associated with a higher mortality rate than was the systemic therapy alone^{ref1, ref2}. Although similar data are not available for vancomycin, it might be assumed that distribution of that drug into the cerebral ventricles would be similar to that with gentamicin and that adequate ventricular concentrations of vancomycin might not be attained after intrathecal administration^ref
• mastoideocentesis : surgical puncture of the mastoid antrum
• tympanocentesis : surgical puncture of the membrana tympani for removal of fluid from the middle ear
• serosal cavity (thoracentesis / pleuracentesis / pleurocentesis / thoracocentesis)
• pleural exudate. When patient is seated and with flexed back, pleural exudate collection is made by siringe aspiration after inserting it through the upper border (the lower one contains intercostal artery) of a rib (usually at the 7^th or 8^th intercostal space, along mid-axillary line), with or without ecographic guidance (localization by percussion and auscultation). Usually 20÷30 mL are preleved, but if for therapeutic aims, up to 1 L can be aspired.
• pericardial exudate (pericardiocentesis) : the needle is placed at the bottom of the xiphoid process
• peritoneal exudate (laparocentesis / abdominocentesis / celiocentesis / celioparacentesis). Therapeutic laparocentesis in patients with ascitis removes also proteins, that should be replaced with albumin.
• diagnostic peritoneal lavage (DPL) looks for hemoperitoneum in patients with blunt abdominal trauma (BAT). Along the median line (linea alba) a needle is inserted at 45° into pelvis (where blood falls by gravity) and aspiration is practiced. If no blood is collected, wash with 1 liter of previously heated Ringer lactate or physiological solution and recover the fluid after 5 minutes collecting it into a down sac. The fluid is analysed and considered positive if RBC > 100,000, WBC > 500 or bacteria are detected. DPL carriese a small but significant risk of intra-abdominal injury and is time-consuming. There is also some evidence that with the trend towards conservative management of intra-abdominal solid organ injury it may be too sensitive. As the technique of DPL involves introducing fluid into the abdomen it may make subsequent investigation more difficult to interpret
• synovial exudate (arthrocentesis) (see also movie)
• transcricothyroideal injection
• endotracheal aspiration or bronchoaspirated (it is less invasive but it may be not representative of pulmonary infection, but just of tracheal infection !) : sample is positive if it contains > 10⁶ CFU / mL.
• bronchoalveolar lavage (BAL) : sample is diluited by washing liquids. It is considered positive if contains > 10⁴ CFU / mL  or > 7% infected cells.
• bronchoalveolar lavage (BAL) protected by a telescopic drawer : BAL fluid (BALF) is good if it contains > 10³ CFU / mL. Normally BALF consists of 80-85% macrophages, 1-2% PMN, 7-12% lymphocytes, 1-5% ciliated cells
• laryngeal aspiration is used when anaerobic germs (from regurgitation) are suspected as the cause of the pneumonia.
• button drainage : drainage of a peritoneal transudate by means of a special button affixed to all layers of the abdominal wall.
• capillary drainage : drainage effected by strands of hair, surgical gut, spun glass, or other material of tiny diameter which induces capillary attraction.
• closed drainage : airtight drainage of a cavity carried out so that the entrance of air or contaminants is prevented.
• suction drainage : closed drainage of a cavity, with a suction apparatus attached to the drainage tube.
• open drainage : drainage of a cavity through an opening into which one or more rubber drainage tubes are inserted, the opening not being sealed against the entrance of outside air.
• percutaneous drainage : drainage of an abscess or collection of fluid by means of a catheter inserted through the skin and positioned under the guidance of computed tomography or ultrasonography.
• postural drainage : removal of secretions in bronchiectasis and lung abscess by changes in the patient's position with accompanying repetitive striking of the chest
• through drainage : drainage achieved by passing a perforated tube or other type of drain through a cavity, so that irrigation may be effected by injecting fluid into one aperture and letting it escape through another.
• tidal drainage : drainage of the urinary bladder by an apparatus which alternately fills the bladder to a predetermined extent and then empties it by a combination of siphonage and gravity flow.
• Wangensteen continuous suction drainage : continuous drainage by suction through an indwelling gastric or duodenal tube; for treatment of intestinal obstruction, paralytic ileus, etc.
• anchorages (-pexy) to correct herniations and prolaxuses (-coele)
• shaping (-plasty)
• dressing : any of various materials utilized for covering and protecting a wound
• adhesive absorbent dressing : a sterile individual dressing consisting of a plain absorbent compress affixed to a film or fabric coated with a pressure-sensitive adhesive substance.
• antiseptic dressing : a dressing of gauze impregnated with an antiseptic material.
• cocoon dressing : a dressing of gauze affixed to the surrounding skin by collodion or other liquid adhesive in such fashion that its elevated appearance resembles a cocoon
• dry dressing : dry gauze or absorbent cotton applied to a wound.
• fixed dressing : a dressing impregnated with plaster of Paris, starch, or silicate of soda, utilized to secure fixation of the part when the material dries.
• occlusive dressing : one which seals a wound from contact with air or bacteria.
• pressure dressing : one by which pressure is exerted on the area covered to prevent the collection of fluids in the underlying tissues; most commonly used after skin grafting and in the treatment of burns.
• protective dressing : a light dressing to prevent exposure to injury or infection.
• stent dressing : a dressing in which is incorporated a mold or stent, to maintain position of a graft.
• tie-over or bolus dressing : a dressing placed over a skin graft or other sutured wound, and tied on by the sutures which have been made of sufficient length for that purpose
• strapping : the application of strips of adhesive tape, one overlapping the other, to cover and exert pressure upon an extremity or other area of the body
• strap : a band of adhesive tape used in attaching parts to each other
• Montgomery straps or tapes : straps made of lengths of adhesive tape, used to secure dressings that must be changed frequently

• bandage : a strip or roll of gauze or other material for wrapping or binding any part of the body.  2. to cover by wrapping with a strip of gauze or other material
• gauze : a light, open-meshed fabric of muslin or similar material used in bandages, dressings, and surgical sponges. Before use in surgery, it is usually sterilized and frequently impregnated with various antiseptics.
• absorbable gauze : gauze made from oxidized cellulose.
• absorbent gauze : a plain woven cloth of cotton or of a mixture of cotton and rayon; it is classified as Type I (the heaviest) to Type VIII (the lightest) on the basis of thread count and weight. It is supplied in various lengths and widths in the form of rolls and folds.
• sterile absorbent gauze : absorbent gauze that has been sterilized and subsequently protected from contamination
• petrolatum gauze : absorbent gauze saturated with white petrolatum; used as a protective covering for wounds.
• zinc gelatin impregnated gauze : absorbent gauze impregnated with zinc gelatin that may contain a small amount of ferric oxide as coloring matter

• Borsch's bandage : an eye bandage covering both the diseased and the healthy eye.
• Buller's bandage or shield : a watch glass fitted over the unaffected eye to guard it from infection from the affected eye
• capeline bandage : a bandage applied like a cap or hood to the head or shoulder or to an amputation stump.
• circular bandage : a bandage applied in circular turns, usually about a limb.
• roller bandage : a tightly rolled, circular bandage of varying widths and materials, often commercially prepared.
• spiral bandage : a roller bandage applied spirally around a limb.
• spiral reverse bandage : a spiral bandage applied with reverse turns in order to fit more snugly the varying contours and dimensions of a limb
• demigauntlet bandage : a bandage that covers the hand but leaves the fingers exposed.
• Desault's bandage or apparatus : a bandage binding the elbow to the side, with a pad in the axilla, for fractured clavicle
• elastic bandage : a bandage of elastic material applied to an area to exert continuous pressure upon it.
• Ace bandage : trademark for a bandage of woven elastic material
• compression bandage : a bandage by which pressure is applied to a limb to prevent edema.
• Esmarch's bandage or tourniquet : a rubber bandage applied around a part from distal to proximal in order to expel blood from it; the limb is often elevated as the elastic pressure is applied
• figure-of-8 bandage : a bandage in which the turns cross each other like the figure 8
• Barton's bandage : a figure-of-8 bandage supporting the lower jaw below and in front
• spica bandage : a figure-of-eight bandage with turns that cross one another regularly like the letter V, usually applied to anatomical areas of quite different dimensions, as the pelvis and thigh or the thorax and arm
• gauntlet bandage : a bandage that covers the hand and fingers like a glove.
• gauze bandage : Type I absorbent gauze containing no dyes or additives; it may be sterilized.
• adhesive bandage : a sterile compress of 4 layers of Type I absorbent gauze affixed to a fabric or film coated with a pressure-sensitive adhesive.
• Gibney bandage or strapping : strips of 1/2 -inch adhesive overlapped along the sides and back of the foot and leg to hold the foot in slight varus position and leave the dorsum of the foot and anterior aspect of the leg exposed
• hammock bandage : a bandage for retaining dressings on the head; it consists of a broad strip placed over the dressing, brought down over the ears, and held in place by a circular bandage around the head.
• immobilizing bandage : a bandage for partially immobilizing a part.
• 4-tailed bandage : one with each end cut into 2 strips of equal width, which are used to secure the center portion under or over the jaw or other prominence
• many-tailed bandage : a wide bandage with each end cut into several strips of equal width which may be overlapped as the bandage is applied, usually to the abdomen or chest.
• Scultetus bandage : a many-tailed b. applied with the tails overlapping each other and held in position by safety pins
• Martin's bandage : a roller bandage of thin elastic rubber.
• plaster bandage : a bandage stiffened with a paste of plaster of Paris, which sets and becomes very hard.
• pressure bandage : a bandage for applying pressure.
• recurrent bandage : one used on a distal stump, such as a finger, toe, or amputation stump, that is turned lengthwise to cover the end of the stump and is secured in place by circular turns
• oblique bandage : a bandage applied obliquely up a limb without reverses
• reversed bandage : one applied to a limb in such a way that the roll is inverted or half-turned at each revolution, so as to make it fit smoothly the varying dimensions of the limb.
• suspensory bandage : a bandage for supporting the scrotum.
• crucial or T bandage : a bandage shaped like the letter T
• Y bandage : a bandage shaped like the letter Y .
• triangular bandage : a triangle of cloth used as a sling or bandage.
• Velpeau's bandage : a bandage to support the arm and provide immobilization of the elbow and shoulder; it is useful in supporting the upper extremity in severe injuries involving the shoulder girdle and upper end of humerus.
• boot : an encasement for the foot; a protective casing or sheath.
• Gibney's boot : an adhesive tape support used in treatment of sprains and other painful conditions of the ankle, the tape being applied in a basketweave fashion with strips placed alternately under the sole of the foot and around the back of the leg.


• De Lorme quadriceps boot : a metal plate that fits over the sole of a shoe and can be fitted with weights of various sizes for therapeutic exercise of the quadriceps muscles
• Unna's paste boot : a dressing for varicose ulcers, consisting of a paste made from gelatin, zinc oxide, and glycerin, which is applied to the entire leg, then covered with a spiral bandage, this in turn being given a coat of the paste; the process is repeated until satisfactory rigidity is attained.
• the glue secreted by blue mussels (Mytilus edulis), which glue themselves to rocks, ropes and boats, is based on crosslinked protein molecules, but Fe³⁺ is the curing agent that sets it solid. It is compatible with biological tissue, and forms a strong bond in wet conditions. Knowledge of the glue's chemistry could also benefit the shipping industry. Without protection, ships quickly become covered with barnacles, algae and other organisms, which slow them down. Many current protective paints work by releasing toxic copper ions into the water, eradicating the animals before they can attach themselves. More environmentally friendly coatings might release specific chemicals to interrupt the setting process

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