Section 5-a

Instruments, Sutures and Needles for Hand Transplantation Giovanna Lucchini, Francesca Magni, Marco Lanzetta

Introduction A complete range of instruments to face any possible situation during a hand transplantation procedure is mandatory. The material and instruments needed for hand transplantation should be carefully selected and prepared in advance. Their division into practical and readyto-use sets is essential in a scenario where wasting time must be minimised. Our list of instruments and materials as well as the additional items to be used in the operating theatre is as follows: - Surgical instruments trays - Suture stitches tray - One table with sterile sheets - Two tables, one of which prepared with a tray for harvesting an iliac crest bone graft - Two squared tables: one for the osteosynthesis set; one for the harvested limb (including iced solution) - Operating microscope with videocamera and monitor - Portable image intensifier.

- One power drill - One saw blade (size 1-2-3) - One electric dermotome + blade + 10-cc syringe with Vaseline - Two Lambottes, large size - Two bowls, large and medium size - One basin - One preset colour-tagged mosquito for each individual flexor/extensor tendon (Fig. 1).

A. Surgical instruments trays: - Two basic hand trays - One iliac crest bone graft tray - One bone tray - One tendon tray - One microsurgical tray. B. Additional individually stored instruments/ items:

Fig. 1. Preset coloured tags for each individual flexor/extensor tendon

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- Two Kilner skin retractors, double ended, medium size - Two Kilner skin retractors, double ended, large size - One lead hand - One osteosynthesis (forearm) set - One elastic bandage (Esmarch). C. Complementary items: - Six scalpel blades, no. 15 - One beaver scalpel blade - Two marking pens - One electric scalpel - Various towels TNT repellent - One operating microscope towel - Bone wax - Aspirator - Cannulated needles of various sizes - One 20-cc syringe with local anaesthetic and adrenalin 1% (for skin preparation in iliac crest bone graft harvesting) - One hypodermic needle

- Four 10-cc syringes: two with NaCl 0.9%, one with heparin, one with local anaesthetic Suction drains Silicon drains Skin stapler, small and medium size Tapes of various sizes Three plaster splints, sponge-cloth and elastic bandages. D. Sutures (Fig. 2): - Subcutaneous and muscles: Polysorb 1/0, 2/0; Monocryl 3/0, 4/0 - Skin: Dafilon or Ethilon 3/0, 4/0 - Ligaments: Ethibond 3/0 - Flexor tendons: Ti-Cron 3/0, 4/0; Prolene 4/0, 5/0 - Extensor tendons: Prolene 4/0, 6/0 - Microsurgery: Ethilon or Monosoft 8/0, 9/0 - Safil loops: 3/0

Fig. 2. Sutures: 1 Monocryl 3/0, 4/0; 2 Ethilon 8/0, 9/0; 3 Ti-Cron 3/0, 4/0; 4 Polysorb 1/0, 2/0; 5 Ethibond 3/0; 6 Safil 3/0; 7 Dafilon 3/0, 4/0; 8 Prolene 4/0, 5/0, 6/0

Instruments, Sutures and Needles for Hand Transplantation E. Basic hand tray (Fig. 3): - Marking pen - 10-cc syringe for irrigation - Scalpel with no. 15 blade - Beaver blade handle with no. 64 blade - Adson dressing forceps, 12 cm plain - Stevens tenotomy dissecting scissors, 11 and 13 cm - Sutures scissors, sharp/sharp, 12 cm - Adson tissue forceps, 12 cm with 1?2 teeth - Tendon hook, blunt - Gillies skin hooks, 17.5 cm - Farabeuf skin retractors, double ended, small size - Freer dissector sharp/blunt, 15 cm - Kleinert-Kutz periosteal elevator

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Curette, soluble ended, small Ruler Hegar needle holder Towel clips Self-retaining retractor Bone/synovium rongeur, double action, 15 cm Dressing scissors, sharp/blunt, 15 cm Dressing scissors, sharp/blunt, 15 cm Metzenbaum scissors Mosquito forceps, straight, 12.5 cm O’Shaugnessy forceps Mosquito forceps, curved 12.5 cm Bipolar coagulation forceps Needle holder with fine, smooth jaws Small bowl for irrigating saline.

Fig. 3. Basic hand tray: 1 marking pen; 2 10-cc syringe for irrigation; 3 scalpel with no. 15 blade; 4 beaver blade handle with no. 64 blade; 5 Adson dressing forceps, 12 cm plain; 6 Stevens tenotomy dissecting scissors, 11 cm; 7 Stevens tenotomy dissecting scissors 13 cm; 8 suture scissors, sharp/sharp, 12 cm; 9 two Adson tissue forceps, 12 cm, with teeth; 10 tendon hook, blunt; 11 two Gillies skin hooks, 17.5 cm; 12 Farabeuf skin retractors, double ended, small size; 13 Freer dissector, sharp/blunt, 15 cm; 14 Kleinert-Kutz periosteal elevator; 15 curette, soluble ended, small; 16 ruler; 17 Hegar needle holder; 18 towel clips; 19 selfretaining retractor; 20 bone/synovium rongeur, double action, 15 cm; 21 dressing scissors, sharp/blunt, 15 cm; 22 dressing scissors, sharp/blunt, 15 cm; 23 Metzenbaum scissors; 24 mosquito forceps, straight, 12.5 cm; 25 O’Shaugnessy forceps; 26 mosquito forceps, curved, 12.5 cm; 27 bipolar coagulation forceps; 28 needle holder with fine, smooth jaws; 29 small bowl for irrigating saline

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F. Tendon tray (Fig. 4): - Button with straight needles eyelet - Link forceps - Tunneler - Tendon-pulling forceps - Kocher clamp - Tendon stripper - Tendon hook, blunt, 10 and 12 cm. G. Bone tray (Fig. 5): - Bone spreader - Metzenbaum scissors - Bone curettes, double ended - Bone hook, sharp - Kleinert-Kutz periosteal elevator - Freer dissector sharp/blunt, 15 cm - Two small Hohmann retractors - Set of small straight osteotomes, 2- to 15mm diameter - Mallet - Bone compression/distraction device - Goniometer - Awl

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Bone rongeur, double action Liston bone cutters Bone-holding forceps Bone-reduction forceps Metallic wire, various sizes Wire cutters Wire pliers.

H. Microsurgical tray (Fig. 6): - Fine-toothed forceps, Pierce design, 10 and 12 cm - Fine, nontoothed forceps, Vicker’s design - Fine jewellers forceps, nontoothed - Straight suture-cutting scissors,Vicker’s design - Curved dissecting scissors - Needle holder, Vicker’s design - Needle holder - Microvascular clamps, double and single - Background material - Ikuta approximator - Clamp holder.

Fig. 4. Tendon tray:1 button with straight needles, eyelet; 2 tendon hook, blunt, 12 cm; 3 tendon hook, blunt, 10 cm; 4 link forceps; 5 tendon stripper; 6 Kocher clamp; 7 tendon-pulling forceps; 8 tunneler

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Fig. 5. Bone tray: 1 bone spreader; 2 Metzenbaum scissors; 3 bone curettes, double ended; 4 bone hook, sharp; 5 Kleinert-Kutz periosteal elevator; 6 Freer dissector, sharp/blunt, 15 cm; 7 two small Hohmann retractors; 8 set of small straight osteotomes, 2to 15-mm diameter; 9 mallet; 10 bone compression/distraction device; 11 goniometer; 12 awl; 13 bone rongeur, double action; 14 Liston bone cutters; 15 bone-holding forceps; 16 bone-reduction forceps; 17 metallic wire,various size; 18 wire cutters; 19 wire pliers; 20 wire pliers

Fig. 6. Microsurgical tray:1 Ikuta approximator; 2 microvascular clamps,double and single; 3 background material; 4 curved dissecting scissors; 5 fine, nontoothed forceps, Vicker’s design; 6 needle holder, Vicker’s design; 7 straight-suture cutting scissors, Vicker’s design; 8 fine-toothed forceps, Pierce design, 10 cm; 9 fine-toothed forceps, Pierce design, 12 cm; 10 fine jewellers forceps, nontoothed, 10 cm; 11 clamp holder; 12 needle holder

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I. Iliac crest bone graft tray (Fig. 7): - Needle holder - O’Shaugnessy forceps - Self-retaining retractor - Mayo scissors - Scalpel with no. 15 blade - Fine-toothed forceps - Heavy-toothed forceps, Gillies

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Suture scissors Metzenbaum scissors Bristow periosteal elevator Set of large osteotomes Heavy mallet Large curette Farabeuf retractors, medium and large size.

Fig. 7. Iliac crest bone graft tray: 1 needle holder; 2 O’Shaugnessy forceps; 3 self-retaining retractor; 4 Mayo scissors; 5 scalpel with no. 15 blade; 6 fine-toothed forceps; 7 heavy-toothed forceps, Gillies; 8 suture scissors; 9 Metzenbaum scissors; 10 Bristow periosteal elevator;11 set of large osteotomes;12 heavy mallet;13 large curette; 14 Farabeuf retractors,medium size;15 Farabeuf retractors, large size