For most operations you will need about 50 general purpose instruments called ''the general set', with a few special ones when necessary. You can handle additions to the general set in three ways: (1) You can keep special instruments in the cupboard, and sterilize them when needed. (2) You can make them up into incomplete special sets, such as a burr hole set or an orthopaedic set, which you use with the general set when necessary. (3) If you have enough instruments, particularly haemostats, you can make complete special sets. This is the best method, and the one which we follow here, but it requires many more instruments.
You can do an occasional emergency operation with only one general set, but when you have a list of patients to operate on, you will need several general sets[md]if you are not to wait too long between operations. Boiling a set takes at least 15 minutes, and autoclaving one at least half an hour. A set costs between $750 and $1000, about a third of which is the cost of the haemostats.
If instruments are limited, start by collecting a general set adapted for Caesarean section and laparotomy, and also the more important special instruments. Once you have all these, try to complete a tracheostomy set, and a chest drainage set, three cut down sets, and a second laparotomy set. When you have these your next objective should probably be a minor set for such operations as wound repairs and circumcisions. If you do many uterine evacuations. two or more sets for these would be useful.
A Caesarean section is only a particular kind of laparotomy. A set for it differs from a laparotomy set mainly in that it includes four Green[nd]Armytage forceps, and that Doyen's retractor, which is specially designed for pelvic operations, replaces Balfour's.
The sets below mostly start with six towel clips and a towel holder, which you can also use to hold the sucker tube. Next come four Rampley's sponge-holders, the first two of which are used for preparing the patient's skin, after which they are discarded. The remaining two are for ''swabs on sticks', and for swab dissection. Then come toothed and plain dissecting forceps, two scalpel handles, and a heavy and a light needle-holder. There are also four pairs of Allis' tissue forceps, and various retractors, depending on the set. The expensive items, because of the large number you need, are the haemostats, straight, curved, big, and small, clipped together in groups of six on Mayo's pins. The more experienced you are, the fewer of these you will need. We list six of each, which is a generous number for a beginner. Finally, there is the Yankauer sucker and its tube; this is an angled suction tube with a handle.
Keep an inventory of equipment and a check list for each set. Nice instruments tend to disappear. One aid to keeping instruments together is to provide them in pairs, or in even- numbered quantities where possible. For example, the nurses will find it useful to remember that haemostats and towel clips should always be in sixes.
The theatre is the best place in the hospital for sterilizing equipment. So try to develop a simple ''central sterile supply' service which can prepare sets for the wards.
INSTRUMENT SETS You will want the following sets, some of which are described elsewhere[md]a ''D and C' set (two if possible), a general purpose set (preferably two sets), a Caesar set, a cut down set (preferably two sets or more), an abscess set, a minor set (for hernias, etc.), an orthopaedic set (for drilling for osteomyelitis, etc.), an intestinal clamp set (for resecting gut), a fine instrument set (for hand surgery), an eye set (24.1), a burr hole set (63.1), a chest drain set (65.2), and a tracheostomy set (52.2). The equipment we have listed in all the various sections of these manuals is summarized in Appendix A and should be enough to make up the following sets.
SHARP EQUIPMENT needs to be kept separately, because it gets blunt if it is autoclaved too often. Keep scissors in dishes of antiseptic fluid (2.5). Keep osteotomes and gouges in a cupboard and put them in sterilizing fluid 30 minutes before you use them. Autoclave the bone saw when you want it. Keep the bone drill and the twist drills to go with it in a special sterile pack.
CAUTION ! Re-autoclave the packs and drums regularly. A pack which has not been resterilized for some time is a risk, especially if it is only covered in towels. You may find termites inside it!
THE CONTENTS [s7]OF PARTICULAR INSTRUMENT SETS THE GENERAL SET (including the instruments for laparotomy $800). Six towel clips. One Backhaus towel forceps. Four Rampley's sponge-holders. One toothed dissecting forceps (Treves). One plain dissecting forceps (Bonney's). One No. 4 and one No. 5 scalpel handle. Two needle-holders, a heavy and a light. Two Allis' tissue forceps. Two Lane's tissue forceps. Six 200 mm curved haemostats (Spencer Wells). Six 200 mm curved haemostats (Spencer Wells). Six 120 or 140 mm straight haemostats (Halstead's or Crile's). Six 120 or 140 mm curved haemostats (Halstead's or Crile's). Two Kocher's artery forceps. Two Czerny's (or Langenbeck's) retractors. Two Morris' retractors. Yankauer's sucker tube. One 20 cm receiver and two gallipots.
Desirable additions include Lahey's curved gallbladder forceps.
CAESAR SET ($950). Six towel clips. One Backhaus' towel forceps. Four Rampley's sponge holders. One 18 cm toothed dissecting forceps. One 18 cm plain dissecting forceps. Two No.4 scalpel handles. Two 180 mm needle-holders. Two Allis' tissue forceps. Six Green[nd]Armytage forceps. Twelve 150 mm straight Spencer Wells haemostats. Six 230 mm curved Spencer Wells haemostats. One Morris' retractor. One Doyen's retractor. Yankauer's sucker and tube. One 300 mm bowl (for blood clot), one 200 mm receiver and two gallipots.
Desirable additions include a tenaculum, and a self- retaining retractor.
MINOR SET ($750). Six towel clips. Two Rampley's sponge holders. Four Backhaus' towel forceps. One No. 4 scalpel handle. One No. 5 scalpel handle. One toothed dissecting forceps (Treves). One plain dissecting forceps (Bonney's). Four Allis' tissue forceps. One West's self-retaining retractor. Two Czerny's retractors (or Langenbeck's). Twelve 125 mm curved haemostats (Spencer Wells). Six 200 mm curved haemostats (Spencer Wells). One 20 cm receiver and two gallipots.
Desirable additions include a dissector and a Volkmann's spoon.
ABSCESS SET. Two Rampley's sponge-holding forceps. Four towel clips. One knife handle. One sinus forceps. One Mayo's scissors. One toothed dissecting forceps. One 150 mm receiver, two gallipots and some gauze swabs. Two towels.
''D and C' SET. Four Rampley's sponge-holding forceps. One Sims' vaginal speculum. One Auvard's speculum. Two Teal's vulsellum forceps. One uterine sound. One set of Hegar's dilators. A uterine curette with one sharp and one blunt end. One 200 mm Kocher's forceps. One toothed dissecting forceps.
ORTHOPAEDIC SET. Six towel clips. Four Rampley's sponge holders. Four dissecting forceps (one heavy toothed 180 mm Lane's or Charnley's, one light Adson's 125 mm, one plain 180 mm, one McIndoe's 180 mm). Six curved 150 mm Spencer Wells haemostats. Six curved 200 mm Spencer Wells haemostats. One No. 4 and one No. 5 scalpel handle. Four 220 mm light bone levers, Lane's or Trethowen's. Four 275 mm heavy bone levers. One Faraboef's elevator. One large periosteal elevator (for the femur and humerus) and one small one. One Size C double-ended bone scoop Volkman's. One 350 g mallet. One sequestrum forceps. One 180 mm Read Jensen bone nibbler. One bone file or rasp. One 220 mm Liston's bone cutters. One 200 mm bone hook.
BURR HOLE SET. One Hudson's standard perforator 12 mm. One Hudson's set of conical burrs 13 mm and 16 mm. Hudson's brace. One West's self-retaining retractor. One 60 mm brain sucker. One 14 Ch soft rubber catheter. One 20 ml syringe for washing out with saline.
SMALL (hand) INSTRUMENT SET. Two small sponge holding forceps. One plain 150 mm McIndoe dissecting forceps. One plain 100 mm Silcock's ophthalmic dissecting forceps. One toothed Adson's 120 mm dissecting forceps. Four 165 mm Gilles skin hooks. One light 190 mm McIndoe dissecting scissors. One light 140 mm curved Aufrecht's scissors. Twelve curved Crile's mosquito haemostats. One Bard Parker No. 4 scalpel handle. Two 114 mm Derf needle holders. Two small 178 mm Meydering retractors. Two 114 mm Harlow Wood tendon hooks. One small curette. Two assistant's scissors. One fine probe.
KIRSCHNER WIRE PACK. Six wires of each size 0.75 mm, 1.0 mm, 1.5 mm. One Pulvertaft's Kirschner wire introducer. One pair of Kirschner wire cutters.