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.

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

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

(Other ways of holding a pen, such as placing it between the sides of the thumb, index and ring finger, are unacceptable.)

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.

The most usual grip with a No 10 or 22 blade is as if you are holding a table knife.

(This is the polite way of holding a table knife)

The handle rests in the palm of the hand.

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.

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.

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.

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

DO NOT dissect with the handle of the scalpel.

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.

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

ALWAYS pass the scalpel to someone else handle first.

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

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.

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.

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.

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

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.

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