TECHNIQUES IN THE USE OF

SURGICAL TOOLSDr. Ausaf Ahmed

KhanProfessor & Head of Department

ENT / Head & Neck SurgeryHCM&D, Hamdard University

Karachi, Pakistan

2

Introduction Skilled surgical technique is facilitated by

practicing the operative techniques shown to be optimal through mechanical analysis and clinical application.

The objective of this presentation is to give you an overview and analysis of the mechanics of technical maneuvers with basic surgical tools; this analysis will give you an appreciation of the advantages and disadvantages of the various options.

In this presentation . . . Analytical approach to the use of each of the basic surgical instruments.

Alternative methods and advantages & disadvantages of several techniques are presented.

The pros and cons of a variety of motions and manipulations are pointed out.

Variety of comments about operating room behaviour and decorum.

Introduction You are encouraged to develop your surgical

techniques, to select surgical options dictated by rational mechanics rather than by loyalty to the judgement of superiors.

Your criteria for determining the best method should be accuracy and security, rather than speed and ease of performance.Speed and ease are by-products of accuracy and security (but the converse is not necessarily

true)..

Make sure your technique comes from analysis of mechanicsrather than from prejudice and ego !

Introduction Shortcuts that impairs accuracy and

security generally increase complications Many a poor operations are performed in

haste, motivated by the surgeon’s urge to be speedy.

Their purposefulness and accuracy frequently allow them to complete the procedure in less time than, that taken by hurrying, unthinking ‘technicians’….

The best surgeons appear to be deliberate - -

The scalpelScissors

Tissue forcepsSurgical clamps

Tools for providing exposure

The Needle holder Electocautery

Contents

The SCALPEL

The Scalpel – how to hold How to hold the scalpel

1. The Pencil grip,2. The finger-tip grip &3. The palmed grip.

Take advantage of all grips, No arbitrary commitment to a single

scalpel grip, Select the appropriate one by weighing

the advantages and limitations.

1 – The Pencil grip

The hand can be steadied by resting on patient to increase the precision of fine cutting

Allows fine, short, precise incisions using the intrinsic muscles of hand and muscles of forearm.

Using finger motion is more accurate for short delicate maneuvers

The pencil grip- backhand

Adaptable to backhand cutting. Allows a change in direction by

180º

Major disadvantage; the scalpel is at 30-40º greater angle than other grips, diminish cutting edge contact, decrease depth and direction control in making long incisions.

2 – The finger tip gripScalpel held in between finger tipsMaximum length of blade edge in contact with skinLong incisions can be made with arm motion

rather than finger motion

Offers most accuracy and stability in making long incisions

The finger tip gripThe greater length of blade in contact with tissues, the less

the depth variation with any change in cutting pressureWhile making long incision, direction control is enhanced

by increasing the length of blade in the wound.

3 – The Palm grip Offers power for use with special

cutting instruments, such as the periosteal elevator.

The strongest way to grasp a scalpel Useful when great pressure is needed

The Scalpel – methods of incision Four motions of the scalpel’s

cutting edge;1. Press cutting,2. Slide cutting,3. Sawing &4. Scraping.

The SCALPEL Methods of incision

1. PRESS CUTTING Direction of pressure is the same as direction of the

motion of the blade – stab With press cutting – wound are well controlled in

length and direction BUT depth control is not precise.

In making stab wound, depth control can be improved by exposing a limited amount of knife blade, by using a finger (middle finger) as a ‘bumper’ and by resting the knife hand against the patient

Press cut can also be made by an inverted blade.

Press cutting

Slide cutting

SawingScraping

1 – Press cutting Figure 5, pg 6

Direction of pressure is the same as direction of the motion of blade.Wound are well controlled in length and direction BUT depth control is not precise.

Press cutting

Slide cutting

SawingScraping

2. SLIDE CUTTING A slide cut is made by sliding the knife blade on its

cutting edge while exerting a sub-bursting pressure on the tissues; The motion is at the right angle to the direction of scalpel pressure

Depth control is precise, since bursting pressure is never exceed. The depth is determined by the amount of sub-bursting pressure exerted, length of blade distributing the pressure, and the resistance to cutting of the tissue being incised.

The lighter the pressure and the more knife edge in contact with the tissue, the shallower is the cut.

Accuracy of depth control, associated with precise direction and length control makes the sliding cut the most applicable of the scalpel motions

The SCALPEL Methods of incision

Press cutting

Slide cutting

SawingScraping

Slide cuttingIn slide cutting, blade motion (d) is at right angle to the scalpel pressure (p)

p

d

Accuracy of depth control, associated with precise direction and length control

makes the sliding cut the most applicable of the scalpel motions..

Press cutting

Slide cutting

SawingScraping

3. SAWING It’s merely “to-fro” or push-pull slide cutting It allows the cut to be continued deeper

than a single slide cut, without the need for removing and reinserting the blade into the wound

The SCALPEL Methods of incision

Press cutting

Slide cutting

SawingScraping

The SCALPEL Methods of incision

Press cutting

Slide cutting

SawingScraping4. SCRAPING

4. SCRAPING Scraping is the cutting motion done by exerting a sub-

bursting pressure while moving the scalpel perpendicular to both the edge of the blade and the direction of pressure.

Scraping will not cut the layer beneath the knife edge, it is a precise way to separate layers of tissues without the hazard of “buttonholing” that easily occurs with push cutting or slide cutting.

Accuracy of tissue layer separation. Security from perforation. Uses;

Preparation of skin flaps. Separation of facial planes in reconstructive surgery.

The SCALPEL Methods of incision

Press cutting

Slide cutting

SawingScraping

Use of The Scalpel to make incisions

1. Plan before cutting2. Stabilize the skin during execution of an incision3. Depth control of the incision4. Where to watch5. Direction6. Attitude of the knife blade during skin incision

1 – Plan before cut

Establish starting and stopping landmarks with the patient in neutral position

Landmarks are established using natural skin crease

Mark the skin with skin marking pen Cross hatch marks may leave a permanent

unsightly or ugly scars or keloids.

2 – Stabilize the skin during execution of an incision

To cut in desired direction, smooth out the surface by stretching the skin tightly.

In most of the cases, the surgeon should be the one touching and stretching the skin during incision. If surgeons uses an assistant to help place tension, neither person has any accurate measurement of the tension being exerted by other.

The surgeon can accurately know that his incision is going straight when he exerts tension with his thumb on one side and his other fingers opposite.

Don’t use your assistant to distort the skin

The surgeon’s assisting left hand, with thumb and the other fingers on

opposite sides, provides a stretched, undistorted surface for

incision.

ac

b

de

d‘e‘

If you cant see the cutting

edge of

the scalpel,

you are operating by Braille…

This figure shows position of the assisting left hand. Tension is exerted in directions c-e and c-e’, resulting in longitudinal vector forces d-e and d’-e’ and lateral vector forces c-d and c’-d’, so that the cutting surface can be stretched and the incision separated with the force c-e and c’-e’.

During the incision, as the knife blade moves farther and farther from the assisting hand, the vector forces c-d and c’-d’ becomes smaller, while d-e and d’-e’ becomes greater.

At a certain distance, forces c-d and c’-d’ which have been separating the skin edges to allow visualization of the depth of the incision, are so small that the knife blade edge is no longer seen.

At this point cutting should be stopped and the assisting hand should be repositioned closer to the scalpel, so that vector c-d and c’-d’ again become great enough to expose the depth of the parting tissue.

Do not advance the assisting hand beyond the knife’s edge, as the vector forces d-e and d’-e’ will be reversed in such a way as to wrinkle the skin beneath the knife and eliminate the benefit of longitudinal tension.

3 – Depth control of the skin incision

Cut completely through the skin in first pass of knife blade assures best possible perpendicular skin edges for closure.

To assure proper depth control, use a slide cut.

Starting an incision with a press cut results in uncontrolled depth.

Continue the incision while increasing or decreasing the pressure necessary to keep the blade at a proper level

Half to one centimeter of incision at each edge end will not be full thickness, complete these two areas by holding the scalpel in pencil position.

Be bold in all sure things

4 – Where to watch Focus your attention on the incision

behind the scalpel blade to determine the amount of pressure adjustment needed to continue at the proper depth.

To continue in a straight line, focus your attention upon the segment already cut, rather than on the destination.While driving a car, watch where you are going ; while making an incision, watch

where have you been .

5 – Direction When a minor deviation from the

preconceived direction of the first part of incision occurs, deviating the opposite way to correct it may compound the problem

When you discover that the incision is slightly off the course, continue on it in a straight line (to point ‘c’ in photograph) to achieve a satisfactory cosmetic scar.

Though the incision A-B was planned, once the cut is off course, continue to (C) to avoid a ‘hockey-stick’ correction

c ab

6 – Attitude of knife blade during skin incision

Keep the scalpel blade perpendicular to the skin surface.

When the surface is curved, there is a tendency to keep the knife blade perpendicular to the floor instead of to the skin surface where the incision is being made.

While making a neck contour incision, 180º change in attitude of the knife blade must occur gradually in order to make a perpendicular incision throughout the length of the wound.

Keep the scalpel face perpendicular to the patient, Not perpendicular to

the floor .

The SCISSORS

The ScissorsA common surgical tool for Cutting and

Dissecting tissues Used to cut loose tissues, the blades stabilize

the tissues during cutting. Provides very good control of depth and

direction of cutting.  More traumatic than scalpel because they

crush during cutting.Two advantages of Scissors over Scalpel in cutting

1. Precisely cut flaccid tissues2. Excellent depth control

The Scissors – basic mechanics

Scissors are designed so that three force vectors are used in cutting... (These forces are transmitted from the hand to the shanks and then through a fulcrum to the cutting edges.)a. Closing force : is the force which causes

the blades to come togetherb. Shearing : is the force that pushes on

blade flat against the other while closingc. Torque : is the force that rolls the leading

edge of each blade inward to touch the other

The gripping motion of the hand transfers three forces to the scissors blades:a. Closing force. b. Torque, c. Shearing force

a

b

c

The Scissors – Basic principles of use

Cutting nearer the scissor’s tip less closing force on the tissue but more tissue stabilization btw blades.

Wider the scissors opened & nearer the tissues to the fulcrum the more the blades tend to push the tissue away bunching of tissue ahead.

Scissors stabilize tissue between the blade and hence cut flaccid tissue more accurately than

scalpel– Stability of tissues between the blades &– Security of the operator’s grip on scissors.

During cutting, direction control & accuracy depends upon;

The more obtuse the angle between the blades : less the scissors stabilize the tissue : less accurate the cut

The more obtuse the angle between the blades : less the scissors stabilize the tissue : less accurate

the cut

Scissors wide opened & tissues nearer to the fulcrum: the blades

tend to push the tissue away.

Cutting nearer the scissor’s tip:more tissue stabilization

1. The Thumb and Ring finger grip

2. The Thumb and Middle finger grip

3. The thumb – Index finger grip

4. The Backhand grip

Gripping the Scissors

Gripping the Scissors1- The Thumb and Ring finger grip

Provides the largest “tripod” Best stability for direction control This grip motion applies maximum shear, torque

and closing force : gives best direction control.

(index finger resting on shank near the fulcrum)

Creates a smaller tripod Less stable

Gripping the Scissors2- The Thumb and Middle finger

grip

Less direction control, less stability, lack precision.

Less shearing and torque forces chew rather than cut the thick tissues.

Gripping the Scissors3- The Thumb and Index finger

grip

The Thumb-Index finger grip is good for reverse cutting

A slight variation in thumb-ring finger grip Useful in cutting towards right

Gripping the Scissors4- The Backhand grip

A Surgical Stunt or affectation is any manoeuvre

that accomplishes nothing except to show

how ‘‘cool’’ the surgeon is !

Hand, arm and body attitude

while using scissors

Scissors held in pronated hand with the palm down allows greatest maneuverability; can be supinated to almost 180 and further pronated to 90 by abducting the arm.

When forearm is completely supinated there is no further supination unless some adjustments are made…

For vertical cutting forearm is positioned midway

Scissors can be held in- Pronation- Supination

- Any position between above

Fig 24, 25

Scissors held inPronated hand

Forearm is completely

Supinated

Types of Scissors Scissors are available in various configurations

Blunt/blunt blades Blunt/sharp blades Sharp/sharp blades

Basic 2 types with Straight blade with Curved blades

Some famous scissors METZENBAUM Scissors MAYO Scissors STITCH Scissors

IRIS Scissors BANDAGE Scissors

Curved Scissors have 30-40 more

mobility and visibility than straight ones

Use of Scissors Scissors can be used to

makeA. Two types of cuts

1. Scissor-cuts 2. Push-cuts

B. Blunt dissectionScalpel can cut through an intact surface

Scissors need an opening to insert

the lower blade

Use of Scissors1. SCISSORS CUTTING

More traumatic than scalpel but gives excellent control

Blades partially closed over tissue and elevated slightly (stabilizes tissues).

Tips closed to cut the tissue; only use the tips.

More crushing trauma and jagged edges if entire blade used.

Scissors cuttingPush cuttingBlunt dissection

Movie of scissor cut

Use of Scissors2. PUSH CUTTING

Efficient cutting method, used for longer incisions in light fascia

Begins with a scissor blades partially closed (tip still open)

Continue by pushing the nearly closed blade forward through the tissue

Tissue is cut in one continuous motion without further opening/closing of the blades

Scissors should advance easily without tearing the tissue or technique is abandoned

Scissors cuttingPush cuttingBlunt dissection

Movie of push cutting

Use of Scissors3. BLUNT DISSECTION separate fine tissue attachments between

anatomic tissue planes and isolate delicate structures nice for separating muscles, fat and fine fascial planes more traumatic than sharp dissection (scalpel) not for dividing strong fascial attachments Advantage over hemostat; alternate sharp and blunt

dissections can be made without changing instruments ‘Blind’ scissors cutting and dissection can sometime

be safe and advantageous.

Scissors cuttingPush cuttingBlunt dissection

TISSUE FORCEPS

TISSUE FORCEPS Forceps are nonlocking grasping

tools. Generally used with left hand to assist

maneuvers with the right.

They are almost in constant use as an adjunct to needle holder, scalpel, hemostat, scissors or others.Extensive practice to develop facility

with thismost-used instrument will be time well

spent.

Tissue Forceps – uses / types

Hold tissue during cutting Retract for exposure Stabilize during suturing Grasp vessels for cautery Pass ligature around

hemostat Pack sponges Grasp free objects for

extraction

Types of tissue forceps

Uses of tissue forceps

Adson tissue forceps

De’bakey forceps Plain forceps Forceps with tooth

How to hold Tissue Forceps

Hold the forceps so that one blade function as an extension of the thumb, and the other blade as a extension of the opposing fingers.

Grasp with the forceps, using the same motion as grasping with the empty hand

The pencil position with the shanks against the index finger metacarpal-phalangeal joint gives the widest range of maneuverability

When forceps is not in use, palming the forceps can save time. (Hold forceps with middle & little fingers) (pg-67 Flexor digitorum profundus role)

The pencil position with the shanks against the

index finger metacarpal-phalangeal joint gives the widest range of maneuverability

Holding the shank in the palmhas very little role in surgery

When not in active use, forceps may be palmed and supported by

flexed fingers

Changing from ‘hold’ to a ‘use’ position can be done with one motion without climbing up and down the forceps.

Smooth and efficient transfer of forceps from

‘use’ to the ‘hold’ position and back again

becomes automatic, secure and comfortable

with practice.

Changing forceps from ‘use’ to ‘hold’ position

Tissue Forceps approach to a wound

There is maximum mobility in the use of forceps if the wound from opposite sides by the two hands.

To improve mobility, Forceps maneuvers requiring wrist flexion

should be started in wrist extension, and vice versa.

Maneuvers that require supination should be started in pronation, and vice versa.

Tissue forceps approach to the wound that forces

elbows close to the body unduly restricts mobility

With elbows wide, both hands are

afforded maximum maneuverability

Tissue forcepsapproach to the

wound that forces

elbows close tothe body undulyrestricts mobility

With elbows wide, both hands are

afforded maximum maneuverability

SURGICAL CLAMPS

SURGICAL CLAMPS Surgical clamps have a great

variety of uses; Hemostasis by clamping of blood

vessels Dissection Retraction Tissue holding Ligature passing Suture tagging Occluding of tubular structures

Curved artery forceps

Straight artery forceps

Allis forcepsDuvall forceps

Kelly clampDebaky forceps

Babcock forcepsTowel clamp

Types of clamps Allis Duvall Kelly Debaky Curved artery

forceps Straight artery

forceps Babcock towel clamp

Curved and straight Artery forceps / Hemostats

Correct and incorrect uses of artery forceps

Curved Hemostat application

In non critical situation; ‘palming’ several tools save time

A curved hemostat can be conveniently held in palm while using other instruments.

For greatest accuracy & security in applying a hemostat, grasp a single instrument in your dominant hand with thumb & ring finger grip and

index finger on the shafts

Curved hemostat : HandlingA curved hemostat is an excellent tool for

dissection and hemostasis.

Curved hemostat : Handling

Curved Hemostat application

A curved hemostat is an excellent tool for hemostasis

Two clamping techniques;1. TIP technique

- Tip is pointed towards vessel cauterized or ligated.- Clamp the open vessel while including the minimum

of surrounding tissues Minimum devitalized tissues.

- Needs more coordination between the two persons minor inconvenience.

2. JAW technique- Clamp the open vessel in greater curvature of jaw - Tip pointing away from the vessel: trap the ligature- Includes more tissues in the hemostat sacrificing

viable tissues.

Don’t destroy tissues to save time

The ‘TIP’ and ‘JAW’ techniques of holding a Hemostat

Control of hemorrhagesome important concepts;

Arterial system is a low-pressure hydraulic system; normal pressure is 3p.s.i.

You can control bleeding in any major vessel with very gentle pressure. A heavy hand applying enough pressure may further lacerate the vessel.

To control massive hemorrhage; Put finger on bleeding point, exert minimal pressure Analyze the situation, make preparation for definitive

control, Don’t panic Improve the exposure Clamp the bleeding vessel on either sides Repair or ligate the vessel

Hysteria is not a useful adjunct for control of hemorrhage

Surgical clamps as Blunt Dissectors

Smooth tip clamp is a VERY USEFUL instrument for blunt dissection.

Can be used as a probe, as a rake or as a spreader.

Best for dissection around vessels, nerves, vital structures.

Clamps and diathermy are used together frequently.

Clamps and scissors can also be used in concert by two operators

Clamps as tissue holders

Can hold tissues securely, Very effective retracting instruments, Useful in moving layers of tissues or in

maneuvering a mass to allow dissection around it.

Kocher, Alice, Babcock's, Duval

Tools for providing exposure

Retractors One of the basic secret of good surgery

is good exposure Adequate exposure requires accessibility

as well as visibility.If an operation was difficult for you, your exposure was poorly

planned..A skilfully performed operation can be done

only with superior exposure that is well planned and continuously

maintained….

1. The basic exposure retractors Provide unchanging, long-term retraction for a

major portion of surgery, Should usually be self retaining, Avoid fatigue, allows both free hands, prevent

clutter of unnecessary retracting hands and arms,

Major hazard ; ischemia at the pressure points – release periodically to avoid it.

TYPES; Weitlaner, jolls,

Two categories of retractors

1. The basic exposure retractors

2. Minor variation retractors

Types of Retractors

2. Minor variation retractors Can be used by assistants to fine tune the

exposure, once the basic self-retaining retraction is provided

Hand retractors, sponges, clamps, peanut sponges, etc.

TYPES; Langenback, catspaw, army-navy.

Retractors A great hazard in use of retraction of all

types is tissue laceration (due to inappropriate retraction or excessive pull)

Only one person should pull at one time

If two persons pull, neither can sense the amount of tug applied by the other

Assistant should release the tension whenever surgeon takes it for repositioning

If you want to tear a liver or lacerate an organ, two can pull harder than one

Traction and countertraction: An aid to dissection

Accurate secure dissection depends upon continuing exposure and stabilization of the tissue being dissected.

The surgeon sets up countertraction by placing his assistant’s hooks, rakes, clamps or other devices and exerting traction in direction opposite to the assistant.Directed traction and countertraction keep

the operation moving while enhancing the accuracy and security of the dissection.

The NEEDLE HOLDER

The NEEDLE HOLDER

The Needle holder

Sewing with the needle holder is a succession of maneuvers with opportunity

to waste time at each step !

(Inefficient use of the needle holder by surgeons

accounts for more wasted time than poor

technique with any other instrument.)

The Needle holder Two common mechanisms of time lost

are;1. Stuttering: non productive repetition

of steps needed to be done once.2. Stammering: interruption during a

step that can be done with one motion.Stuttering and stammering in surgery

are done with the needle holder.Self-discipline is needed to force

oneself to do each step in suturing once ;

Get tough with yourself .

10 steps in taking a stitch1. Positioning the needle in the NH2. Grasping the needle holder3. Positioning the free end of the suture4. Placement of the needle point5. Putting the needle through the tissue6. Needle release 7. Re-grasping the needle for extraction8. Needle extraction9. Puling the desired length of suture through the

wound10. Reposition the needle on the NH for the next stitch

Grasping the Needle holder1. The PALMED grip

2. The THENAR grip

3. The THUMB-RING FINGER grip

4. The PENCIL grip

(Pg; 46-49)

Because of the advantage of each grip in specific application, skill should be

developed in using each.

Grasping the Needle holder1 – The PALMED grip

Thumb and index finger grasp the holder near the needle,

Grasping the Needle holder1 – The PALMED grip

Thumb and index finger grasp the holder near the needle, give maximal control of needle movements.

Strongest grip + needle can be rotated in any direction. Provides greatest pressure in driving a needle through

tough material such as thick scar, periosteum, cartilage.

Disadvantage; The needle can not be released & regrasped after a stitch is

taken without readjusting to another grip. Changing the grip in mid of stitch always moves and stresses

the tissue in the needle bite and may dislodge the needle unacceptable with fragile structures where tears might occur.

Grasping the Needle holder2 – The THENAR grip

NH is grasped between the ball of the thumband either ring finger or little finger.

Grasping the Needle holder2 – The THENAR grip

NH is grasped between the ball of the thumb and either ring finger or little finger.

Greatest advantage; time saved during continuous stitching, the needle can be released and regrasped for extraction without changing grips.

Disadvantage; lack of precision when releasing the needle pg-48

Grasping the Needle holder3 – The THUMB-RING FINGER grip

Thumb and ring fingers are in the ring of Needle Holder.

Grasping the Needle holder3 – The THUMB-RING FINGER grip

Thumb and ring fingers are in the ring of NH

Advantage; it allows precision when releasing the a needle. Needle can be released without stressing the tissue by inadvertent motion of the needle holder.

Regrasping is also precise In critically important sutures; small BV

suturing, this grip is a better alternate method

Grasping the Needle holder4 – The PENCIL grip

Most delicate and accurate method for very fine suturing.

Best used with spring opening NH with finger pressure release locks or no locks at all.

Applicable to eye surgery, microvascular anastamosis, nerve repair etc…

ELECTROCAUTERY

ELECTROCAUTERY

Its current has an alternating sine wave configuration at a radio frequency of approx. 20,000 cps.

2 modesCUTTING mode :

continuous current(Produces more intense

heat)COAGULATION mode :

alternating current(Heats more slowly)

Electrocautery is the modern refinement of the ancient

practice of searing a wound to stop bleeding .

Unipolar/Bovie Needs ground plate, Can CUT and COAGULATE

Bipolar Forceps – tips act as electrodes, Precise Coagulation, Poor Cutting tool, Even effective in a wet field.

Electrocautery – Unipolar vs. Bipolar

Electrocautery – Technique of Application

Modified pencil grip between the thumb, middle and ring finger tips.

The index finger is free as a “trigger finger”. Coagulation is done with the tip of

instruments perpendicular to the wound Cutting is done with the tip and edge Repeated cleaning of the tip is essential to

prevent build up of char and disperse the current

Modified pencil grip between the thumb,

middle & ring finger tips.The index finger is free as

a “trigger finger”.An alternate grip; The Thumb act as “trigger finger”.

Electrocautery – Technique of Application

With a unipolar electrode; the drier the wound the more localized the current, and the more effective the coagulation. Mild to mod. bleed ; pressure dry it

cauterize Brisk bleeding ; apply clamp cauterize Large bleeders ; clamp and tie with sutures

When depth control is critical ; use the open end of a clamp to elevate the layer and cut.

Avoid touching skin with the coagulating current.

Electrocautery – Technique of Application

While cutting with diathermy, the current should be allowed to do the cutting without exerting undue pressure on the tissues. Progress should be slow enough that vessels be coagulated before cut. Let the electric current do cutting .

Trying to cut with pressure will decrease depth control

Two special requirements for use of bipolar electrodes;1. There must be continuity of electrolyte fluid (water,

electrolyte, tissue) between the tips2. There must b a gap between the two tips

Electrocautery Advantages

Economy of blood loss Drier field Speed

Disadvantages Poor depth control Cauterized vessel more liable to rebleed No mechanical feel of tissue tension If inappropriately used – leaves large amount

of devitalized tissues and deter healing

Thank you