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Surgical Instruments

Surgical instruments

Definition

Surgical instruments are tools or devices that perform such functions as cutting, dissecting, grasping, holding, retracting, or suturing. Most surgical instruments are made from stainless steel. Other metals, such as titanium, chromium, vanadium, and molybdenum, are also used.


Purpose

Surgical instruments facilitate a variety of procedures and operations. Specialized surgical packs contain the most common instruments needed for particular surgeries.

In the United States, surgical instruments are used in all hospitals, outpatient facilities, and most professional offices. Instrument users include surgeons, dentists, physicians, and many other health care providers. Millions of new and replacement instruments are sold each year. Many surgical instruments now have electronic or computerized components.


Description

Basic categories of surgical instruments include specialized implements for the following functions:

  • cutting, grinding, and dissecting
  • clamping
  • grasping and holding
  • probing
  • dilating or enlarging
  • retracting
  • suctioning

Scissors are an example of cutting instruments. Dissecting instruments are used to cut or separate tissue. Dissectors may be sharp or blunt. One example of a sharp dissector is a scalpel. Examples of blunt dissectors include the back of a knife handle, curettes, and elevators. Clamps, tenacula, and forceps are grasping and holding instruments. Probing instruments are used to enter natural openings, such as the common bile duct, or fistulas. Dilating instruments expand the size of an opening, such as the urethra or cervical os. Retractors assist in the visualization of the operative field while preventing trauma to other tissues. Suction devices remove blood and other fluids from a surgical or dental operative field.

Sharps and related items should be counted four times: prior to the start of the procedure; before closure of a cavity within a cavity; before wound closure begins; and at skin closure or the end of the procedure. In addition, a count should be taken any time surgical personnel are replaced before, during, or after a procedure. Instruments, sharps, and sponges should be counted during all procedures in which there is a possibility of leaving an item inside a patient.

The misuse of surgical instruments frequently causes alignment problems. Instruments should always be inspected before, during, and after surgical or dental procedures. Inspection is an ongoing process that must be carried out by all members of a surgical team .

Scissors must be sharp and smooth, and must cut easily. Their edges must be inspected for chips, nicks, or dents.

After a procedure, staff members responsible for cleaning and disinfecting the instruments should also inspect them. The instruments should be inspected again after cleaning and during packaging. Any instrument that is not in good working order should be sent for repair. Depending on use, surgical instruments can last for up to 10 years given proper care.


Preparation

Instruction in the use and care of surgical instruments may range from the medical training required by physicians and dentists to on-the-job training for orderlies and aides.

Surgical instruments are prepared for use according to strict institutional and professional protocols. Instruments are maintained and sterilized prior to use.

Surgical instruments must be kept clean during a procedure. This is accomplished by carefully wiping them with a moist sponge and rinsing them frequently in sterile water. Periodic cleaning during the procedure prevents blood and other tissues from hardening and becoming trapped on the surface of an instrument.

Instruments must be promptly rinsed and thoroughly cleaned and sterilized after a procedure. Ultrasonic cleaning and automatic washing often follow the manual cleaning of instruments. Instruments may also be placed in an autoclave after manual cleaning. The manufacturer's instructions must be followed for each type of machine. Staff members responsible for cleaning instruments should wear protective gloves, waterproof aprons, and face shields to protect themselves and maintain instrument sterility.


Aftercare

Observation of the patient after surgical or dental procedures provides the best indication that correct instrument handling and aseptic technique was followed during surgery. After an operation or dental procedure, individuals should show no evidence of the following:

  • retained instruments or sponges
  • infection at the site of the incision or operation

Risks

Risks associated with surgical instruments include improper use or technique by an operator, leaving an instrument inside a person after an operation, and transmitting infection or disease due to improper cleaning and sterilization techniques. Improperly cleaned or sterilized instruments may contribute to postoperative infections or mortality. Improper use of surgical instruments may contribute to postoperative complications.

See also General surgery


Resources

books

Bland, K.I., W.G. Cioffi, and M.G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001.

Burke, K.M., P. Lemone and E. Mohen-Brown. Understanding Medical Surgical Nursing. Upper Saddle River, NJ: Prentice Hall, 2002.

Caruthers, B.L., and P. Price. Surgical Technology for the Surgical Technologist. Albany, NY: Delmar, 2001.

Grace, P.A., A. Cuschieri, D. Rowley, N. Borley, and A. Darzi. Clinical Surgery, 2nd ed. Londin, 2003.

Schwartz, S.I., J.E. Fischer, F. C. Spencer, G.T. Shires, and J.M. Daly. Principles of Surgery, 7th ed. New York: McGraw-Hill, 1998.

Townsend, C., K.L. Mattox, R.D. Beauchamp, B.M. Evers, and D.C. Sabiston. Sabiston's Review of Surgery, 3rd ed. Philadelphia: Saunders, 2001.

periodicals

Beesley, J. "Creutzfeldt-Jakob DiseaseThe Perioperative Connection." British Journal of Perioperative Nursing 13, no.1 (2003): 21-3.

Guyton, S.W. "Robotic Surgery: The Computer-Enhanced Control of Surgical Instruments." Otolaryngology Clinics of North America 35, no.6 (2002): 1303-16.

Pisal, N., M. Sindos, and G. Henson. Risk Factors for Retained Instruments and Sponges after Surgery." New England Journal of Medicine 348, no.7 (2003): 1724-5.

Vrancich, A. "Instrumental Care. Creating Longevity through Proper Maintenance." Materials Management in Health Care 12, no.3 (2003): 22-5.

Williams, D. "Public Confidence in Medical Technology." Medical Device Technology 13, no.10 (2002): 11-13.


organizations

American Board of Surgery. 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA 19103. (215)568-4000, fax: (215) 563-5718. <http://www.absurgery.org>

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000. Fax: (312) 202-5001. E-mail: <[email protected]>. <http://www.facs.org>.

Association of Perioperative Registered Nurses, Inc. 2170 South Parker Road, Suite 300, Denver, CO 80231-5711. (800) 755-2676. <http://www.aorn.org>

Association of Surgical Technologists. 7108-C South Alton Way, Suite 100, Englewood, CO 80112-2106. (800) 637-7433.

other

Surgical 911. [cited May 6, 2003] <http://www.surgical911.com>.

United States Bureau of Labor. [cited May 6, 2003] <http://www.bls.gov/oco/ocos106.htm>

University of California-Irvine. [cited May 6, 2003] <http://www.ucihealth.com/News/Releases/DaVinci2.htm>.

University of Indiana. [cited May 6, 2003] <http://www.indiana.edu/~ancmed/instr1.html>.

University of Virginia. [cited May 6, 2003] <http://hsc.virginia.edu/hs-library/historical/antiqua/instru.html>.


L. Fleming Fallon, Jr., M.D., Dr.PH.

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Surgical Instruments

Surgical instruments

Surgery has been performed since ancient times. The earliest recorded surgical operations were circumcision and trepanation. (Circumcision is the removal of the foreskin of the penis. Trepanation involves making a hole in the skull to relieve pressure and/or release spirits.) The earliest instruments used in these procedures were flint or obsidian (shiny stone) knives and saws. Stone Age skulls from around the world have been found with holes in them from trepanning. Primitive people also used knives to cut off fingers damaged in accidents.

Ancient Surgery

Ancient Mesopotamian (an area in southern Asia between the Tigris and Euphrates rivers) cultures practiced surgery to some degree. Small copper Sumerian (present-day southern Iraq) knives of about 3000 b.c. are believed to be surgical instruments. The Babylonian Code of Hammurabi of about 1700 b.c. mentions bronze lancets (sharp-pointed two-edged instruments used to make small incisions). Because the Code provided harsh penalties for poor medical treatment outcomes, surgery was prac-ticed only sparingly. Ancient Chinese and Japanese cultures were opposed to cutting into bodies, so surgical instruments were not used much.

By contrast, the ancient Egyptians recorded surgical procedures as early as 2500 b.c. Egyptians fashioned sharper instruments with a new metal, copper. They designed special tools to remove the brain from the skull when preparing bodies for mummification.

Hindus Excel at Surgery

The ancient Hindus of India excelled at surgery. The great surgical textbook, Sushruta Samhita, probably dates back to the last centuries b.c. This work described 20 sharp and 101 blunt surgical instruments. These instruments included forceps, pincers, trocars (sharp-pointed instruments fitted with a small tube), and cauteries (irons to heat and sear tissue). Most of these surgical tools were made of steel. The ancient Hindus also used lancets to carry out cataract surgery, scalpels to restore amputated noses via plastic surgery, and sharp knives to remove bladder stones. At about the same time, ancient Peruvians were performing trepanation. They left behind various surgical instruments, including scalpels and chisels made of obsidian.

Greek and Roman Surgery

The Greeks practiced surgery mostly on external parts of the body. They usually used forceps, knives, and probes. Bronze Roman surgical instruments found at Pompeii include a scalpel with a steel blade, spring and scissor forceps, a sharp hook, and shears. In the first century a.d., Cel-cus described the use of ligatures. Ligatures are used to tie off blood vessels and reduce bleeding during operations. Galen (a.d. 130-200) gave detailed and sensible instructions on the use of surgical instruments.

After ancient times, medical knowledge declined, and surgeons fell to a lowly status. In the absence of knowledge about antiseptics, surgery was highly risky. As a result, only the simplest and most urgent operations (such as amputations) using the most straightforward instruments were performed. A few physicians sought to spread knowledge of surgical procedures by publishing texts that illustrated surgical instruments. Most important among these men was the great French surgeon Ambroise Paré (1517-1590). Paré revived use of ligature and invented many surgical procedures and instruments. His inventions included the "crow's beak" to hold blood vessels while tying them off. Paré also perfected an instrument for cataract removal.

The Modern Era of Surgery

The era of modern surgery began with the introduction of both anesthesia and antiseptics/antisepsis in the mid-1800s. In 1878 Louis Pasteur (1822-1895) first suggested sterilizing surgical instruments. American doctor William Halsted (1852-1922) introduced sterile rubber gloves in the 1890s. The 1895 discovery of X-rays gave surgeons an invaluable diagnostic tool.

Great Refinements

Great refinements in surgery were made possible by the introduction of the operating microscope (thus allowing microsurgery) in the mid-twentieth century. The development of laser surgery in the 1970s was another great advancement. Both of these instruments permit operations on very delicate body structures. The increasingly sophisticated technology of the twentieth century makes ever-more-precise surgical tools possible. Among the newest devices are voice-activated operating microscopes and robotic surgical hands.

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surgical instruments

surgical instruments the emblem of St Luke, and of St Cosmas and St Damian, martyrs of the early Church said in a late legend to have been twin brothers who were doctors.

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Surgical Instruments

Surgical Instruments

Definition

Surgical instruments are tools or devices that perform such functions as cutting, dissecting, grasping, holding, retracting, or suturing. Most surgical instruments are made from stainless steel. Other metals and alloys, including titanium and vitallium, are also used.

Purpose

Surgical instruments facilitate a variety of procedures and operations. Specialized surgical packs contain the most common instruments needed for particular surgeries.

Description

Basic categories of instruments include:

  • cutting and dissecting
  • clamping
  • grasping and holding
  • probing
  • dilating
  • retracting
  • suctioning

Scissors are an example of cutting instruments. Dissecting instruments are used to cut or separate tissue. Dissectors may be sharp or blunt. Scalpels are one example of sharp dissectors. Examples of blunt dissectors include the back of a knife handle; curettes and elevators can also be blunt. Grasping and holding instruments include clamps, tenacula, and forceps. Probing instruments are used to enter natural openings, for example the common bile duct, or such openings as a fistula. Dilating instruments serve to expand the size of an opening, such as the urethra or the cervical os. Retractors assist in the visualization of the operative field while preventing trauma to other tissues. Suction devices remove blood and other fluids from the surgical or dental field.

Operation

Counting

Sharps and related items should be counted prior to the beginning of the procedure; before the closure of a cavity within a cavity; before wound closure begins; and at skin closure or the end of the procedure. In addition, a count should be taken at any time when either scrub or circulating personnel are replaced. Instruments, sharps, and sponges should be counted during all procedures in which the possibility exists of leaving an item in the patient.

Cleaning and sterilizing

Surgical instruments must be kept clean during a procedure. Cleaning is done by carefully wiping instruments with a moist sponge and frequently rinsing them in sterile water. Periodic cleaning during the procedure prevents blood and other tissue from hardening and becoming trapped on the surface of an instrument. After the procedure, instruments are promptly rinsed and thoroughly cleaned and sterilized. Ultrasonic cleaning and automatic washing often follow the manual cleaning of instruments. Instruments may also be placed in an autoclave after manual cleaning. The manufacturer's instructions should be followed for each type of machine. Staff members responsible for cleaning instruments should wear protective gloves, water-proof aprons, and face shields.

Patient status

Observation of patients after surgical procedures provides the best indication that correct instrument handling and aseptic technique was followed during surgery. Postoperative patients should show no evidence of:

  • retained instruments or sponges
  • infection at the site of the incision or operation
  • excessive swelling or discoloration at the operative site

Maintenance

Inspection

The misuse of surgical instruments frequently causes alignment problems. Instruments should always be inspected before, during, and after surgical procedures. Clamps, scissors and forceps should be examined to make sure that the tips are even and in proper alignment. The instrument tips should not overlap. To test the alignment of clamps, first close the clamp. Then, hold the instrument up to a light. No light will be visible if the clamp is correctly aligned. Instruments that have teeth or serrated tips should also be checked for proper alignment. Be sure that the instrument opens and closes freely. Hinged instruments must hold firmly and close properly. To test ratchet teeth, close the instrument on the first tooth. Then, tap the ratchet part against a solid surface. The ratchet is faulty if the instrument springs open. Clamps that open when placed on blood vessels have the potential to injure patients. Scissors must be sharp and smooth, and cut easily. Inspect the edges of sharp instruments for chips, nicks, or dents. Needle holders must hold needles without slippage or twisting of the needle. To test needle holders, place a needle in the jaws of the instrument, then lock the holder in the second tooth. If the needle can be easily removed, replace the instrument. Inspection is an ongoing process that must be carried out by all members of the surgical team.

After the procedure, staff members responsible for cleaning and disinfecting the instruments should also inspect them. The instruments should be inspected again after cleaning and during packaging. Any instrument found not in good working order should be sent for repair. Depending on use, surgical instruments can last for up to ten years, given proper care.

High-risk diseases

Evidence from animal models and case reports in humans has shown that such prion diseases as Creutzfeldt-Jakob disease (CJD) can be transmitted via stainless steel instruments. British surgeons are moving toward using only disposable, single-use instruments—particularly in adenotonsillectomy procedures—to minimize the risk of transmission of CJD. Research in the United States has concluded that surgical instruments and devices contaminated with particles of brain, spinal cord, and eye tissue from high-risk patients require special treatment.

Health care team roles

Team members involved with the care and use of surgical instruments include surgeons, the first assistant, the circulator, and the scrub person. Such other personnel as medical students, orderlies, or aides may also be included in the surgical team.

The surgeon works under the policies of the facility in which the procedure is performed. The surgeon is responsible for guiding the operation. During the procedure, the surgeon may also identify instrument malfunctions not evident until the device is actually in use.

The first assistant generally acts to provide retraction, grasp tissue, perform suturing, and other duties as required by the surgeon and the procedure performed.

The person performing the scrub function is responsible for maintaining a sterile operative field. The scrub person hands instruments to the surgeon or assistant. Instruments and other materials are passed in such a way that the surgeon does not have to look away from the wound in order to receive the item. The scrub person is responsible for conducting counts of instruments, sponges, and sharps with the circulator. The scrub person should also inspect the surgical instruments prior to the procedure.

The person performing the circulating function does not undergo a surgical scrub prior to the procedure, and therefore does not enter the sterile operating field. The circulator is responsible for conducting counts of instruments, sponges, and sharps with the scrub person. The circulator positions the patient for the procedure, adjusts lighting, and assists the surgical team in carrying out functions that do not require sterile, only aseptic, techniques.

Training

Training in the use and care of surgical instruments may range from the medical training required by physicians to on-the-job training for orderlies and aides.

  • Surgeons are graduates of medical or osteopathic institutions, with additional training and education in surgical procedures.
  • First assistants. Depending on institutional policy, the first assistant may be another physician, a surgical resident, or a registered nurse.
  • Circulator. Depending on facility policy, the circulator may be a registered nurse, a licensed practical nurse, or a surgical technologist.
  • Scrub person. The scrub person may be a registered nurse, a licensed practical nurse, or a surgical technologist.
  • Other personnel. Depending on the facility, there may be surgical orderlies and aides that assist in a variety of tasks, such as patient positioning and transfers, instrument cleaning and disinfecting, and cleaning the surgical suites. No special license is required for these positions, and training may be acquired on the job.

KEY TERMS

Autoclave— A heavy vessel that uses pressurized steam for disinfecting surgical instruments.

Creutzfeldt-Jakob disease (CJD)— A degenerative disorder of the nervous system that is usually fatal within a year. CJD is transmitted by a prion.

Curette— A scoop-shaped surgical instrument for removing tissue from body cavities.

Instruments— Tools or devices that perform such functions as cutting, dissecting, grasping, holding, retracting, or suturing.

Prion— A infectious agent composed of protein and lacking a genetic component.

Sharps— Surgical implements with thin cutting edges or a fine point. Sharps include such devices as suture needles, scalpel blades, hypodermic needles, and safety pins.

Sponges— Pieces of absorbent material, usually cotton gauze, used to absorb fluids, protect tissue, or apply pressure and traction.

Tenaculum (plural, tenacula)— A small, sharppointed hook set in a handle, used to seize or pick up pieces of tissue during surgical operations.

Resources

BOOKS

Caruthers, Bob, and Paul Price. Surgical Technology for the Surgical Technologist. Albany, NY: Delmar, 2001.

Rothrock, Jane. The RN First Assistant, 3rd ed. Philadelphia: Lippincott, 1999.

Spry, Cynthia. Essentials of Perioperative Nursing, 2nd ed. Gaithersburg, MD: Aspen Publishers, 1997.

PERIODICALS

AORN Recommended Practices Committee. "Recommended Practices for Sponge, Sharp, and Instrument Counts." AORN Journal 70, no. 6 (1999): 1083-1087.

Frosh, A., R. Joyce, and A. Johnson. "Iatrogenic vCJD from surgical instruments." British Medical Journal 322 (June 30, 2001): 1558-1559.

Rutala, W. A., and D. J. Weber. "Creutzfeldt-Jakob disease: Recommendations for disinfection and sterilization." Clinical Infectious Diseases 32, no. 9 (May 1, 2001): 1348-1356.

ORGANIZATIONS

American College of Surgeons (ACS). 633 North St. Clair Street, Chicago, IL 60611. (312) 202-5000. 〈http://www.facs.org/〉

Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. 〈http://www.aorn.org/〉.

Association of Surgical Technologists (AST). 7108-C South Alton Way, Suite 100, Englewood, CO 80112-2106. (800) 637-7433.

OTHER

Sklar Instruments. 889 South Matlack St., West Chester, PA 19382. (800) 221-2166. 〈http://www.sklarcorp.com〉.

Surgical Instruments Corporation. 4575 Hudson Drive, Stow, OH 44224. (800) 444-5644. 〈http://www.spectrumsurgical.com〉.

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Surgical Instruments

Surgical Instruments

Definition
Purpose
Description
Preparation
Aftercare
Risks

Definition

Surgical instruments are tools or devices that perform functions such as cutting, dissecting, grasping, holding, retracting, or suturing. Most surgical instruments are made from stainless steel. Other metals, such as titanium, chromium, vanadium, and molybdenum, are also used.

Purpose

Surgical instruments facilitate a variety of procedures and operations. Specialized surgical packs contain the most common instruments needed for particular surgeries.

In the United States, surgical instruments are used in all hospitals, outpatient facilities, and most professional offices. Instrument users include surgeons, dentists, physicians, and many other health-care providers. Millions of new and replacement instruments are sold each year. Many modern surgical instruments have electronic or computerized components.

Description

Basic categories of surgical instruments include specialized implements for the following functions:

  • cutting, grinding, and dissecting;
  • clamping;
  • grasping and holding;
  • probing;
  • dilating or enlarging;
  • retracting; and
  • suctioning.

Scissors are an example of cutting instruments. Dissecting instruments are used to cut or separate tissue. Dissectors may be sharp or blunt. One example of a sharp dissector is a scalpel. Examples of blunt dissectors include the back of a knife handle, curettes, and elevators. Clamps, tenacula, and forceps are grasping and holding instruments. Probing instruments are used to enter natural openings, such as the common bile duct, or fistulas. Dilating instruments expand the size of an opening, such as the urethra or cervical os. Retractors assist in the visualization of the operative field while preventing trauma to other tissues. Suction devices remove blood and other fluids from a surgical or dental operative field.

Sharps and related items should be counted four times: prior to the start of the procedure, before closure of a cavity within a cavity, before wound closure

KEY TERMS

Autoclave— A heavy vessel that uses pressurized steam for disinfecting and sterilizing surgical instruments.

Curette— A scoop-shaped surgical instrument for removing tissue from body cavities.

Dilation— The process of enlarging, usually applied to relatively circular openings.

Forceps— An instrument designed to grasp or hold. Forceps usually have a locking mechanism so that they continue to hold tissue when put down by an operator.

Instruments— Tools or devices that perform such functions as cutting, dissecting, grasping, holding, retracting, or suturing.

Sharps— Surgical implements with thin cutting edges or a fine point. Sharps include suture needles, scalpel blades, hypodermic needles, and safety pins.

Sponges— Pieces of absorbent material, usually cotton gauze, used to absorb fluids, protect tissue, or apply pressure and traction.

Tenaculum (plural, tenacula)— A small, sharp-pointed hook set in a handle, used to seize or pick up pieces of tissue during surgical operations.

begins, and at skin closure or the end of the procedure. In addition, a count should be taken any time surgical personnel are replaced before, during, or after a procedure. Instruments, sharps, and sponges should be counted during all procedures in which there is a possibility of leaving an item inside a patient.

The misuse of surgical instruments frequently causes alignment problems. Instruments should always be inspected before, during, and after surgical or dental procedures. Inspection is an ongoing process that must be carried out by all members of a surgical team.

Scissors must be sharp and smooth, and must cut easily. Their edges must be inspected for chips, nicks, or dents.

After a procedure, staff members responsible for cleaning and disinfecting the instruments should also inspect them. The instruments should be inspected again after cleaning and during packaging. Any instrument that is not in good working order should be sent for repair. Depending on use, surgical instruments can last for up to 10 years given proper care.

Preparation

Instruction in the use and care of surgical instruments may range from the medical training required by physicians and dentists to on-the-job training for orderlies and aides.

Surgical instruments are prepared for use according to strict institutional and professional protocols. Instruments are maintained and sterilized prior to use.

Surgical instruments must be kept clean during a procedure. This is accomplished by carefully wiping them with a moist sponge and rinsing them frequently in sterile water. Periodic cleaning during the procedure prevents blood and other tissues from hardening and becoming trapped on the surface of an instrument.

Instruments must be promptly rinsed and thoroughly cleaned and sterilized after a procedure. Ultrasonic cleaning and automatic washing often follow the manual cleaning of instruments. Instruments may also be placed in an autoclave after manual cleaning. The manufacturer’s instructions must be followed for each type of machine. Staff members responsible for cleaning instruments should wear protective gloves, waterproof aprons, and face shields to protect themselves and maintain instrument sterility.

Aftercare

Observation of the patient after surgical or dental procedures provides the best indication that correct instrument handling and aseptic technique was followed during surgery. After an operation or dental procedure, individuals should show no evidence of the following:

  • retained instruments or sponges; or
  • infection at the site of the incision or operation.

Risks

Risks associated with surgical instruments include improper use or technique by an operator, leaving an instrument inside a person after an operation, and transmitting infection or disease due to improper cleaning and sterilization techniques. Improperly cleaned or sterilized instruments may contribute to postoperative infections or mortality. Improper use of surgical instruments may contribute to postoperative complications.

Resources

BOOKS

Brunicardi, F. C., D. K. Anderson, D. L. Dunn, J. G. Hunter, and R. E. Pollock. Schwartz’s Manual of Surgery, 8th ed. New York: McGraw Hill, 2006.

Ellis, H., R. Caine, and C. Watson. General Surgery: Lecture Notes, 11th ed. New York: Wiley, 2006.

Lawrence, P. F. Essentials of General Surgery, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.

Townsend, C.M., R. D. Beauchamp, B. M. Evers, and K. Mattox. Sabiston Textbook of Surgery, 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Downey, C. “Counting as caring.” Canadian Operating Room Nursing Journal 25, no. 3 (September 2007): 6–13.

Egorova, N. N., A. Moskowitz, A. Gelijns, A. Weinberg, et al. “Managing the Prevention of Retained Surgical Instruments: What Is the Value of Counting?” Annals of Surgery 247, no. 1 (January 2008): 13–18.

Sabrosky, P. “Spiraling instrument costs present many challenges.” Materials Management in Health Care 16, no. 7 (July 2007): 66–74.

Sroga, J., S. D. Patel, and T. Falcone. “Robotics in reproductive medicine.” Frontiers in Bioscience 13 (January 2008): 1308–1317.

OTHER

“Orange County’s 1st robotics-assisted surgery performed at UCI Medical Center.” University of California-Irvine Healthcare. May 3, 2002. http://www.ucihealth.com/News/Releases/DaVinci2.htm (January 3, 2008).

“Surgical Instruments from Ancient Rome.” University of Virginia Health System. October 30, 2007. http://www.healthsystem.virginia.edu/internet/library/wdc-lib/historical/artifacts/roman_surgical/ (January 3, 2008).

“Surgical Technologists.” Occupational Outlook Handbook. United States Bureau of Labor, Bureau of Labor Statistics. December 18, 2007. http://www.bls.gov/oco/ocos106.htm (January 3, 2008).

ORGANIZATIONS

American Board of Surgery, 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA, 19103, (215) 568-4000, (215) 563-5718, http://www.absurgery.org.

American College of Surgeons, 633 North Saint Claire Street, Chicago, IL, 60611, (312) 202-5000, http://www.facs.org/.

Association of Perioperative Registered Nurses, 2170 South Parker Road, Suite 300, Denver, CO, 80231, (800) 755-2676, (303) 750-3212, http://www.aorn.org.

Association of Surgical Technologists, 6 West Dry Creek Circle, Suite 200, Littleton, CO, 80120-8031, (303) 694-9130, (303) 694-9169, http://www.ast.org.

L. Fleming Fallon, Jr., M.D., Dr.P.H.

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