Thursday, August 2, 2018

The Grooved Director Surgical Instrument Mystery Explained

The function of a surgical instrument is usually obvious; retractors retract, clamps clamp, cutting instruments cut and forceps hold things. I made a comment about a lovely grooved director instrument on Instagram and was asked, "What is that thing used for?"  When I was a novice scrub nurse grooved directors were widely called for and  used for a hodge-podge of probing, directing of suture and guides for  cutting tasks. As I approached retirement they  remained in the instrument tray on the back table and finally disappeared forever.

Grooved directors always reminded me of Mickey Mouse. The end of the instrument with the ears was called the spoon or saddle. Dr. Slambow, my favorite general surgeon liked to sing Home on the Range while working so I took a  liking to the "saddle" reference. The curved shaft extending from the saddle was called the shank.

 Surgeons are big fans of devices that restrict their view to the work at hand and use drapes and devices like grooved directors to frame their field just like a movie director with  a view finder.  The tiny, circular opening in the saddle was often centered over the opening of a duct or anything else that might require exploring with a probe. The grooved director was positioned at a right angle to the wound or duct and served as a fulcrum for manipulating the probing. Imaging techniques were few and far between in days past. Probes  were a crude but effective tool for exploring. When ducts and wound tracts could be evaluated without probes grooved directors fell out of use as guides for probes.

Grooved directors could also be used as protective shielding tools. The shaft had a horseshoe or curved profile and could be placed over nerves, arteries or anything else that should not be cut. The rare illustration of a grooved director in action shows it placed over a tendon while cutting from above. The surgeon must be an early specialist as general surgeons almost never hold a scalpel like a pencil. He must really be an old-timer. Is he actually performing surgery bare handed? That lovely scalpel is way before my time. BD disposable scalpel blades have been in use since the 1950s.
Surgical residents are very familiar with 3 rules of survival:  eat when you can, sleep when you can, and don't monkey with the pancreas. Grooved directors were frequently used to guide suture away from the pancreas when working on the duodenum. They functioned much like a clothes line prop with the suture strand guided by the groove in the spoon away from the friable pancreas. If left alone, suture assumes a caternary  curve and the grooved director straightened things out.

I managed to put my blowhard nature on the back burner and seek outside input for grooved director information. When I Googled the instrument  I discovered uses like a pediatric tongue depressor or elevator during surgery on the frenulum. That's a new one on me.

I emailed Dr. Sid Schwab from Surgeonsblog fame and he exclaimed, "That's a trip down memory lane!" He used the instrument once or twice on pancreatic duct procedures. Dr. Skeptical Scalpel (on my blog roll) almost never used a grooved director.

Grooved directors fell from disuse like open drop ether anesthesia and Operay lighting systems. Almost everything has a shelf life and I often what modern devices will be extinct in 30 years. Maybe the grossly overpriced, unproven surgical robots?

16 comments:

  1. Love the surgical 3 rules of survival! To these I'd add the ones we used to tell them - never, ever mess with the Charge Sister or the Professor of Surgery's Personal Assistant. Getting on the wrong side of either of these esteemed figures could mean your residency would be Pure Hell.

    Getting the Scrub Nurse off-side was of course career suicide which goes without saying really...

    Cheers! Sue

    ReplyDelete
  2. I usually tried to avoid conflict in the OR and pretty much kept my mouth shut. One day an older, more experienced scrub nurse advised me of one of her rules. "When they yell at you..holler right back, keeping your mouth shut is bad for the soul." Over time, I could see her point although I was never one that indulged in much hollering.

    ReplyDelete
  3. So is it the case that these rather nifty looking little instruments went out of use largely due to improved imaging techniques OFRN?

    I was impressed when varicose vein surgical stripping was largely done by laser treatment, but that was about the time I retreated out of nursing altogether... I'm feeling distinctly out of my depth around hospitals these days & generally just do my best to stay away from them! Sue

    ReplyDelete
  4. Sue, improved imaging and diagnostics are part of the reason grooved directors lost favor. Surgeons almost always know what they are dealing with without resorting to probing around and making an on the fly diagnosis.

    One of the other game changers in the OR was the introduction of swadged or atraumatic sutures in the late 1960s. I think there is a post somewhere on this blog about these sutures. When suture was threaded onto needles there was quite a bit of fiddling around with the strands to prevent pulling the suture off the needle. Grooved directors were very popular with guiding and securing loose sutures.
    Anyhow, as swadged sutures became common, grooved director use markedly declined.

    New surgeons rarely used grooved directors in their training so less were familiar with the instrument.

    ReplyDelete
    Replies
    1. Thanks for that info OFRN I think atraumatic sutures were all I remember coming across in the 1970s when I trained. A friend of mine went back to nursing after taking a few years out to have her children - she had trained in the 1980s at the same hospital as me - she told me she left after a few weeks feeling that the technology had changed so much she would have to start her training all over again. I remember her exclaiming to me "We didn't have central lines when I was training!" She said she felt overwhelmed - and she had been voted best midwife at our leading maternity hospital when she completed her midwifery after general nurse training, so she was a smart lady.


      I learn quite a bit from posts like this one, thanks and cheers, Sue.

      Delete
  5. I love learning the history of instruments like this! I actually just passed a grove director to a surgeon yesterday, he used it to protect the tissue and direct the needle as the fellow closed the incisions from a laparoscopic procedure. And this particular surgeon always refers to it as "Mickey Mouse ears"

    ReplyDelete
  6. Emily, I like surgical instruments too, especially the odd-ball, little used ones. We always had a grooved director in a tray on the back table until it's triumphant return for a unique situation. A grooved director was the perfect tool to filet a duct...oops I almost said duck.


    Whenever a GSW presented itself. old school surgeons almost always used the grooved director to guide a probe.


    Thanks for your readership and taking time to comment

    ReplyDelete
  7. Great things you’ve always shared with us. Just keep writing this kind of posts.The time which was wasted in traveling for tuition now it can be used for studies.Thanks เครื่องเชื่อมhdpe

    ReplyDelete
  8. Thank you!!! Finally an answer to this question...I have never seen it in the field and most information lists it as a dental instrument.

    ReplyDelete
    Replies
    1. Yep...Grooved directors were on their way out decades ago. When I was a novice scrub nurse they were used quite a bit as guides for probes. Some older grooved directors had 2 guide holes-one at the base of the saddle and one further down near the sheath. I never saw both holes used as guides at the same time, but I had the feeling that was their purpose or maybe it was just for overkill. You can't be too careful in the OR.

      Thanks for perusing one of my older posts!

      Delete
  9. An upper endoscopy usually takes 20 to 30 minutes to finish. When the procedure is over then, the doctor will firmly remove the endoscope. After that, you will go to a recovery room and an endoscopy procedure includes entering a long, flexible tube down your throat and into your esophagus. A small camera that appears on the end of the endoscope allows your doctor to identify the esophagus stomach and the starting of your small intestine.
    surgical instruments

    ReplyDelete
  10. Thanks for sharing such important information regarding surgical instruments.

    ReplyDelete
  11. We still use these in ENT to help perform lingual frenulectomy for ankyloglossia. Everyone calls them "the Mickey Mouse"

    ReplyDelete
  12. Amazing to read that kind of blog. Useful Information about the instruments for knowing about the Veterinary and Surgical Instrument

    ReplyDelete
  13. I'm not a medical professional. I just upon your site after googling what is a grooved director used for? I ordered a cheap student dissection kit on amazon because it was a good way to get some tools that I needed for completely non-medical projects. Think crafting, fishing, small electronics repair, general hobbies type stuff, not Silence of the Lambs type stuff. It came with a grooved director and my curiosity got the best of me. I didn't need to look far into your entry to find the answer, but your writing is so inviting and your stories so interesting that I kept going. Thanks for the time you take to do this and your years of service as a nurse (this is coming from a retired female police officer who's seen firsthand alot of abuse heaped on nurses [by patients, families, and doctors] and appreciates the strength and commitment it takes to push through that to provide care for those who need it).
    Not only was my curiosity satisfied but your explanation sparked some ideas about how it can help me out. I can use it to protect the stitching of buttonholes while cutting them with the scalpel from my kit. I can use it in tufting upholstery by holding down the fabric and padding with it and adjusting the tuft before using the guide and piercing the fabric and pulling the tufting cord tight (with my kits forceps of course). So many uses inspired by your article. Thanks for taking the time.

    ReplyDelete
  14. Your wonderful comment made my day! Grooved directors were included in just about every tray of surgical instruments back in the day. I think with modern surgical techniques of repair and replace (I'm having a knee joint replaced August 3rd) there is less needs for grooved directors. There was something almost magical the way grooved directors routed suture lines around friable organs like the pancreas. Thankfully modern laparoscopic techniques have made big open surgeries less common. The good old days were not that great when it came to invasive procedures. Cheers!

    ReplyDelete