Scalpel 07 How to use a scalpel

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Welcome to Professor Standfield.

Please note that this basic surgical skills training program can be studied within or outside EWTD hours and anywhere, including remote areas and war zones.

Michael Edwards 27 September 2010


Scalpel 07 How to use a scalpel

This subsection has text and images from an interactive multimedia training program on basic 
surgical skills called PrimeSkills in Surgery.
You can use this subsection on its own or follow the whole program (further details at the end of 
this subsection).


Introduction

Holding a scalpel

How to cut with a scalpel.

Planning.


Introduction


A scalpel may appear alarming at first.


This is a useful safety reaction and should mean that you will learn carefully and steadily.


A small minority of trainees develop an aggressive gung-ho tendency when holding a scalpel.


This should be suppressed completely.


If it persists, the trainee should not continue with the program.


Holding a scalpel


For fine work with a No 15 blade, hold the scalpel like a pen.


Correct pencil grip 001.jpg


This is the correct way of holding a pen, using a tripod grip.


Other ways of holding a pen, commonly seen with poor school teaching, do not have the essential advantages of the tripod grip.

Incorrect grip.

Incorrect pencil grip 003.jpg

Another incorrect grip.

Elizabeth's hand grip.jpg


The three parts of the tripod are the side of the middle finger and the tips of the index and thumb.

113000710-Hold-15-scalpel-l.jpg

The tripod grip enables the surgeon to:


Flex and extend the digits, so that the scalpel moves in and out during delicate dissections.


Rotate the handle of the scalpel with the thumb, so the scalpel can cut small diameter curves.


For larger work with a No 10 or 22 blade, the most usual grip is as if you are holding a table knife.


This is the polite way of holding a table knife.


Table knife grip.jpg


The handle rests in the palm of the hand.


113000711-Hold-22-scalpel-l.jpg


The digits and hand are largely on top of the scalpel unlike with the pen grip.


This means that the scalpel can be held close to the surface of the tissues when cutting, without the digits and hand getting in the way as in the pencil grip.


This allows the curved part of the blade to cut the skin, rather than the point of the blade tending to just scratch the skin with the tripod grip.


The grip is quite gentle.


For tougher tissues, such as the skin on the back, grip more firmly and place your index finger on the top of the handle rather than on the side.


113000712-Index-finger-on-b.jpg


This will let you increase the downward pressure of the blade on the tissue.


For more delicate tissue, hold the handle between the thumb on one side and the four fingertips on the other.


The handle does not touch the hand.


113000713-Fingertips-on-han.jpg


Holding the scalpel in the fist or like a dagger is far too clumsy.


113000714-Scalpel-like-a-fi.jpg


DO NOT dissect with the handle of the scalpel.


113000716-DO-NOT-dissect-wi.jpg


You will be concentrating on the site of dissection and may accidentally cut your assistant.


DO NOT hold the scalpel in your hand while using another instrument.


113000715-DO-NOT-Scalpel- -.jpg


You may accidentally cut the patient as you concentrate on the dissection area.


ALWAYS pass the scalpel to someone else handle first.


113000717-Hand-scalpel-hand.jpg


Preferrably, place the scalpel in a dish for the scrub nurse to pick out.


13000900.jpg


DO NOT throw the scalpel down onto the bench (or onto the patient.)


How to cut with a scalpel.


The part of the blade that does the cutting is the curve and not the tip.


This means that you need to drag the curve of the blade across the tissue.


Scratching with the tip of the blade is a beginner's error.


You will feel the blade cutting into the tissue.


Go slowly and gently at first with repeated strokes in the same place, until you see how much the blade is cutting the tissue.


Brace your hands and fingers so that you make controlled movements without the blade suddenly slipping.


113000721-Brace-fingers.jpg


Press harder at the beginnings and ends of incisions to allow for the less efficient cutting action at the tip and the back of the blade.

Rock the handle to enhance this effect.


13000720 straight incision.gif


For a right handed surgeon, incisions are most easily made from left to right, cutting towards the surgeon.


Cutting from right to left is more difficult.


Curved incisions are made by rotating the scalpel.


Curves up to 4cm. radius or so are best made by rotating the scalpel between finger and thumb.


13000723 short curved incision.gif


Curves larger than 4cm. need rotation of the scalpel using the wrist, elbow, and finally the shoulder.


13000724 long curved incision.gif


For a right handed surgeon, clockwise curves are easier to do than anticlockwise ones.


Be prepared for a greater tendency to miss the planned track and more slips when cutting an anticlockwise curve.


Incisions need to be made with the blade perpendicular to the tissues to avoid slicing.


Slicing will devascularise the thinner side of the incision.


(NB. Slicing with the blade held at an angle to the tissues is done deliberately when dissecting with a scalpel.)


Planning.


As well learning HOW to cut with a scalpel, learning WHERE to cut is vitally important.


Each incision has a start point, a path, a depth and a finish point.


e.g. The positions of the start and finish points of an ellipse incision will determine the final line of the scar.


113000855-Missing-the-apex.jpg


The path and the depth of the incision determine whether there is enough clearance around a tumour.


With real tissues, once an incision is made, there is no going back.


Mistakes are not acceptable.


On simulated tissue, learn to plan your incisions with this degree of precision.


Next subsection, click on Scalpel 08 Exercises
Last subsection, click on  Scalpel 06 How scalpels work
Surgical Education and Training page, click on Surgical Education and Training
Whole program on WikiSurgery, click on PrimeSkills in Surgery
Whole program on CD-ROM, click on Michael Edwards