Clinical overview
Surgical instruments are the registrar's extension of hand and intent, and the gulf between a safe operation and a catastrophe is very often a matter of how an instrument is selected, loaded, held, and watched. The FCOG(SA) objective is to demonstrate safe use — a HOTS, psychomotor-plus-judgement competency — across the three operative platforms of our discipline: open (laparotomy and open pelvic surgery), vaginal (vaginal hysterectomy, repair, instrumental delivery), and minimally invasive surgery (MIS — laparoscopy and hysteroscopy). "Demonstrate" means more than naming instruments; it means showing, in theatre, that you can choose the correct tool for the tissue and the task, handle it with controlled force in a known plane, anticipate its failure modes, and recover safely when it does fail.
The clinical stakes are high and concrete. Energy devices cause thermal bowel and ureteric injury; sharp trocars and the Veress needle cause vascular and visceral entry injuries; a uterine manipulator or sound perforates a soft pregnant or postmenopausal uterus; a poorly applied clamp crushes a ureter or slips off a pedicle into a torrential bleed. In the South African context the same skills must be deliverable across a district-to-tertiary gradient — a regional hospital with a limited reusable instrument set and an intermittently serviced diathermy machine, and a tertiary unit with stapling devices and advanced bipolar energy. Safe instrument use therefore includes knowing what your level of care actually has, what it can sterilise, and when the instrument list (not the surgeon) dictates referral. This chapter is deliberately weighted to Assessment (instrument selection and pre-use checks) and Management (safe handling, energy, and complication drills), in line with the objective's verb. It connects closely to Electrosurgery safety, MIS complication prevention, Pneumoperitoneum, Operative hysteroscopy and ERAS principles.
Core knowledge
Figure F6.1 — Right tool, right tissue: instrument families (cut, grasp, toothed, clamp, retract, needle-holder, dilate) matched to tissue and task, with the 5-step selection flow and a pre-use checklist.
Instrument families and what they are for
Every gynaecological instrument belongs to a functional family, and safe use begins with matching the family to the tissue.
- Cutting/dissecting — scalpel (Bard-Parker handle, no. 10/15/22 blades), Mayo (heavy) and Metzenbaum (fine, curved) scissors. Principle: scissors cut by shear between two blades; force them and they tear. Metzenbaums dissect, Mayos cut tough tissue and suture — never the reverse.
- Grasping/holding — tissue forceps (toothed/Bonney for fascia, non-toothed for bowel/bladder), Allis (atraumatic-ish, holds tissue to be removed), Babcock (encircles, for bowel/tube/appendix), Littlewood, sponge-holding (Rampley) forceps, tenaculum/vulsellum (single- or multi-tooth, for cervix). Principle: the more aggressive the teeth, the more tissue trauma — never grasp viscera you intend to keep with a toothed instrument.
- Clamping/haemostatic — artery forceps (mosquito, Spencer Wells, Kelly), and the heavy pedicle clamps of the hysterectomy set: straight and curved Kocher, Heaney (curved, for vaginal pedicles), Maingot/Zeppelin, right-angled Mixter. Principle: a clamp's job is to occlude before you cut and tie; a clamp placed blindly near the ureter or great vessels is the commonest mechanism of major operative injury.
- Retracting — handheld (Langenbeck, Deaver, Morris, Czerny) and self-retaining (Balfour, Bookwalter, Gosset for abdomen; Auvard weighted speculum and Sims for the vagina). Principle: retraction injures by pressure and stretch — femoral/lateral cutaneous nerve palsy from a deep self-retainer blade on psoas, and bowel serosal tears from a Deaver lifted blindly.
- Suturing/needle handling — needle holders (Mayo-Hegar, Crile-Wood), and the load-bearing relationship between needle, holder and tissue.
- Vaginal/obstetric — cervical dilators (Hegar — blunt, sized in mm; Hawkin-Ambler), uterine sound, curettes (sharp and blunt), Sims and Auvard specula, the obstetric forceps (Wrigley's, Neville-Barnes, Kielland's) and the ventouse/vacuum cup (see Instrumental delivery).
- MIS-specific — Veress needle, trocars (bladed, blunt, optical/visual-entry), graspers (Maryland, atraumatic bowel), laparoscopic scissors, energy instruments (monopolar hook/scissors, bipolar forceps, advanced vessel-sealing devices, ultrasonic shears), the suction-irrigator, and uterine manipulators (e.g. Spackman, Valtchev, RUMI); for hysteroscopy the resectoscope, bipolar/monopolar loops, and distension-fluid system.
How instruments injure — the mechanisms to internalise
Safe use is really injury-mechanism awareness. The recurring mechanisms are: direct sharp trauma (scalpel, scissors, trocar, Veress); crush (clamp on ureter/bowel); avulsion/tearing (toothed forceps on friable tissue, traction on a pedicle); thermal spread (monopolar lateral spread, capacitive coupling, direct coupling, residual heat of ultrasonic blades — covered in depth in Electrosurgery safety); pressure/stretch neuropraxia (retractors, lithotomy positioning); and retained instruments/swabs (the never-event that the count exists to prevent). Each platform foregrounds a different subset: open surgery foregrounds clamp and retractor injury; vaginal surgery foregrounds perforation and blind-field bleeding; MIS foregrounds entry injury and out-of-view thermal damage.