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.
Sterilisation, the surgical count and the WHO checklist
An instrument is only "safe" if it is sterile, complete and accounted for. Reusable gynaecological steel is processed through cleaning → ultrasonic/washer-disinfector → steam (autoclave) sterilisation; heat-sensitive items (some laparoscopes, light cables) may need low-temperature methods. The swab, instrument and sharps count is a shared scrub-nurse/surgeon responsibility performed before the case, before closure of any cavity, and at skin closure; an incorrect count mandates a search and an intra-operative radiograph before the patient leaves theatre — retained foreign body is a recognised litigation and morbidity event. The WHO Surgical Safety Checklist (Sign-in, Time-out, Sign-out) is the institutional backbone for all three platforms in SA NDoH facilities, confirming patient, site, consent, antibiotic and VTE prophylaxis, equipment availability and the anticipated count.
Assessment
Because the verb is demonstrate, the examinable competency is largely the pre-use assessment and selection that a safe surgeon performs reflexively. Treat instrument selection as a clinical decision with a stepwise logic.
Selecting the right instrument for the tissue and task
- Match aggressiveness to tissue. Use atraumatic graspers and Babcocks on bowel, bladder and ureter; reserve toothed forceps and Allis clamps for tissue being excised or for fascia. Asking "what will this instrument do if it slips?" is the single best safety habit.
- Match the clamp to the pedicle. In abdominal hysterectomy, straight Kochers/Maingots take the round ligament and broad ligament; the uterine artery pedicle is clamped at the level of the internal os, after the bladder is reflected, with the tip on the uterus, sliding off the lateral uterine wall to keep clear of the ureter. In vaginal hysterectomy, curved Heaney clamps take the uterosacrals, cardinals and uterine pedicles under direct vision with the heel against the uterus.
- Match cut to cutter. Metzenbaum for fine dissection in planes; Mayo for fascia and suture; scalpel for the controlled, full-thickness incision.
- Match the dilator/sound to the uterus. Sound the uterus to confirm length and axis (anteverted vs retroverted) before dilating; progress Hegar dilators sequentially without skipping sizes; recognise that the postmenopausal, pregnant, or previously-instrumented uterus is soft and perforates easily.
Pre-use instrument checks (the "before you cut" assessment)
For every instrument you are about to use:
- Integrity — jaws meet and ratchet holds (clamp), blades are sharp and approximate (scissors), needle holder grips the needle without rotation, insulation on every energy instrument is intact end-to-end (a breach is a fire/burn hazard — see electrosurgery-safety).
- Assembly and patency — resectoscope and suction-irrigator assembled correctly; laparoscope white-balanced and focused; light cable not kinked.
- Energy system — diathermy plate (return electrode) correctly sited on well-vascularised muscle, generator settings dialled to the lowest effective power, foot pedals identified, bipolar vs monopolar confirmed.
- MIS entry readiness — Vegress needle spring/patency tested, insufflator tubing and CO₂ supply checked, trocar valves working; patient flat (not yet Trendelenburg) for primary entry.
- Count and consent — baseline count done; site and procedure match the consent and the Time-out.
Assessing the field and patient before instrumentation
- Confirm positioning: safe lithotomy (hips flexed, no excessive abduction/external rotation, calves supported, arms tucked) to prevent common peroneal and femoral neuropraxia; supine arm abduction <90°.
- Identify landmarks and danger structures before applying force: the ureter (crossing the pelvic brim near the bifurcation and tunnelling under the uterine artery — "water under the bridge"), the bladder reflection, the inferior epigastric vessels relative to lateral port sites, and the great vessels/aortic bifurcation under the umbilicus for primary entry.
- Anticipate the difficult field: previous surgery and adhesions change the safe primary-entry strategy (consider Palmer's point / left upper quadrant or open Hasson entry); a large fibroid uterus distorts the uterine artery–ureter relationship.
Management
This is the demonstrable core. Organise it by platform.
Open surgery — safe handling principles
- Hold instruments correctly. Scalpel in a pencil or palmed grip for the relevant cut; scissors and needle holders with thumb-and-ring-finger in the rings, index finger on the shank for control; never "palm" a ratcheted clamp closed by accident.
- Cut in a known plane under vision, with countertraction, sharp dissection along tissue planes and blunt only where the plane is established. Pass sharps safely — neutral/hands-free "safe zone" passing of scalpels and needles reduces sharps injuries (a real occupational-HIV concern in SA — see hiv-counselling).
- Clamp–cut–tie discipline: apply the clamp, divide on the specimen side, transfix or ligate the pedicle, and only then release — never release a bleeding pedicle before it is secured. Keep clamp tips away from the ureter and bowel; if a pedicle slips, control with pressure and a fresh clamp under vision, do not grab blindly.
- Retract by pressure not by point; pad self-retaining blades, release periodically, and keep retractor blades off named nerves and the bowel.
Vaginal surgery — the blind-field discipline
The vagina is a deep, narrow, partly out-of-view field, so safe instrument use depends on traction, exposure and tactile control. Use the Auvard weighted speculum posteriorly and Sims/Breisky retractors laterally; apply a vulsellum/tenaculum to the cervix for controlled traction. Take pedicles with Heaney clamps under direct vision, clamp–cut–ligate sequentially, and keep the bladder reflected and protected. In dilatation and curettage, sound first, dilate sequentially with Hegars, curette gently and systematically; perforation is recognised by sudden loss of resistance and an instrument passing further than the sounded length — stop, do not curette further, and manage as below. For instrumental delivery, instrument choice (forceps vs ventouse) and application are covered in instrumental-delivery and perineal-protection; the safe-use principle is correct application, axis traction with contractions, and a pre-declared abandonment rule.
Minimally invasive surgery — entry and energy safety
MIS concentrates risk at entry and in out-of-view energy use (full treatment in mis-complication-prevention and pneumoperitoneum).
- Entry: there is no single "safe" technique mandated, but the principles are: stabilise/elevate the abdominal wall, confirm intraperitoneal placement before insufflation (Veress safety tests are confirmatory not definitive), insufflate to an adequate pneumoperitoneum pressure before primary trocar entry, and place secondary ports under direct laparoscopic vision lateral to the inferior epigastric vessels. Use open (Hasson) or optical entry where previous surgery raises adhesion risk. RCOG GTG 49 frames the recognition and management of laparoscopic injuries.
- Energy: keep the active electrode in view and away from bowel/ureter; respect lateral thermal spread (greater with monopolar; ultrasonic blades retain damaging heat for seconds after activation); avoid capacitive and direct coupling; activate only when the tip is visible. See electrosurgery-safety.
- Hysteroscopy: select the distension medium for the energy (isotonic saline for bipolar; electrolyte-free media for monopolar) and enforce a strict fluid-deficit limit — track input/output continuously and stop at the deficit threshold, because excess absorption of hypotonic media causes life-threatening dilutional hyponatraemia and fluid overload. AAGL and RCOG GTG 59 (outpatient hysteroscopy) inform safe practice; operative detail is in operative-hysteroscopy.
Emergency drills — when an instrument causes harm
These drills must be reflexive.
Major vessel injury at laparoscopic entry (Veress/trocar):
- Do NOT remove the trocar (it may be tamponading).
- Call for help, alert anaesthetist, declare an emergency, large-bore IV access, cross-match, activate massive-transfusion if needed.
- Convert to immediate laparotomy to obtain proximal/distal control; involve vascular surgery early.
- Resuscitate per shock-management and obstetric/surgical haemorrhage principles.
Suspected bowel/visceral injury (entry or thermal): maintain a high index of suspicion; thermal injuries may present late with delayed perforation and sepsis. Inspect under and around all entry sites; if injury is found or strongly suspected, repair or call general surgery — do not simply close and hope.
Uterine perforation (sound/dilator/curette/manipulator): stop instrumentation immediately; if the patient is stable and the perforation is by a blunt instrument with no suction/energy used, observe with serial vitals and abdominal examination; if an energy device, suction curette or sharp instrument was used, or there is bleeding/instability, proceed to laparoscopy/laparotomy to exclude bowel and vessel injury.
Slipped pedicle / sudden brisk bleeding (open or vaginal): apply direct pressure, restore exposure and light, get suction working, secure the bleeding point under vision with a fresh clamp and transfix — never clamp blindly into a pool of blood near the ureter or great vessels; call for senior help early.
Sharps injury to staff: stop, encourage bleeding, wash, and initiate the SA occupational HIV post-exposure prophylaxis protocol immediately (source and recipient testing per institutional policy) — relevant given high HIV prevalence (see hiv-counselling).
South African platform realities
Instrument safety in SA is also a systems skill. District (Level 1) units may have only a basic open/vaginal set and a single monopolar diathermy machine; advanced bipolar/vessel-sealing and laparoscopic stacks live at regional (Level 2) and tertiary (Level 3) units. Know your set: if the safe instrument (e.g. a working insufflator, an appropriate clamp, a functioning resectoscope with fluid monitoring) is not available and cannot be made available, the safe decision is to modify the approach (open rather than MIS) or refer rather than proceed under-equipped. Reusable-instrument sterilisation capacity and CSSD turnaround constrain list planning. The WHO Surgical Safety Checklist is embedded in NDoH theatre practice, and operating economically (avoiding wasteful single-use opening, reliable counts) is part of resource-respectful surgery consistent with ERAS principles (eras-principles).
Red flags / pitfalls
- Applying a clamp or energy near the ureter without first identifying it. The ureter is injured most often at the uterine artery, the pelvic brim, and the cardinal ligament. Identify it; do not assume.
- Removing the trocar after a suspected major vessel injury — it may be the only tamponade. Leave it, convert, control.
- Dilating before sounding, or skipping Hegar sizes, or pushing against resistance — the classic mechanism of uterine perforation, especially in the soft pregnant/postmenopausal uterus.
- Trusting Veress "safety tests" as proof of safe entry — they are confirmatory, not definitive; injuries still occur with a "good drop test".
- Energy activation with the electrode tip out of view, ignoring lateral thermal spread, capacitive/direct coupling, or insulation breaks — thermal bowel injury presents late.
- Ignoring the hysteroscopy fluid deficit — silent absorption of hypotonic media causes dilutional hyponatraemia, cerebral oedema and death. Watch the deficit, set a limit, stop.
- Releasing a pedicle before it is secured, or clamping blindly into a bleeding field near great vessels/ureter.
- Proceeding without the instrument you actually need because referral feels like failure — under-equipped surgery is the unsafe choice.
- An incorrect swab/instrument/sharps count waved through — never let the patient leave theatre with an unresolved count; search and X-ray.
- Retractor and lithotomy nerve injury from prolonged pressure/stretch — a preventable, examinable complication.
Evidence anchors
- RCOG Green-top Guideline No. 49 — Preventing Entry-Related Gynaecological Laparoscopic Injuries — entry techniques, recognition and management of vascular/visceral injury.
- RCOG Green-top Guideline No. 59 — Best Practice in Outpatient Hysteroscopy — safe hysteroscopic technique.
- AAGL electrosurgery and hysteroscopy safety statements — energy principles and hysteroscopic distension-media fluid-deficit limits (the precise deficit thresholds are protocol-/medium-specific; confirm against your unit's policy and the current AAGL statement before quoting a number — flagged as not line-itemed with an exact figure in the verified-sources list).
- WHO Surgical Safety Checklist — Sign-in/Time-out/Sign-out, embedded in SA NDoH theatre practice.
- ERAS Society gynaecologic/oncology guidelines — minimal-access where appropriate and resource-respectful surgery; see eras-principles.
- South African National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) — operative obstetric context (caesarean, instrumental delivery) and the level-of-care/referral framework that determines which platform is safely available; see safe-caesarean-technique and instrumental-delivery.
- Saving Mothers / NCCEMD reports — operative and anaesthetic-related deaths and avoidable factors underpinning safe-surgery and referral discipline in SA.
- South African occupational HIV post-exposure prophylaxis policy for sharps injuries (institutional/NDoH protocol; high-prevalence setting); see hiv-counselling.
Note: specific instrument-handling techniques, grips, clamp-application sequences and the perforation/entry-injury drills above are standard operative-surgical teaching; they are described cautiously and are not line-itemed with numeric thresholds in the verified-sources list. No doses, deficit figures, or trial results have been invented.