All the Wrong Instruments

When you lack, get creative.

I cautiously sewed the mesh into place, leading the needle down into the tissue and out again with the curved hemostat, careful to avoid locking it. The angle of the instrument in combination with the angle of the needle made this simple action a challenge, but unfortunately, we had no needle drivers. No DeBakey forceps, no retractors, no knife handle, and of course, no needle drivers.

img_5609We were in a small clinic in rural Guatemala, and through the metal bars of the operating room window I could see the bountiful cornfield that surrounded us. Stalks of corn stretched higher than the roof of our building, occasionally tapping the walls to alert us of afternoon rain.

In the sterilizing room next door, time in the autoclave was precious. We alternated between two sets of surgical instruments, and when that morning a hernia repair had been delayed to await sterilization, we had decided to modify the sets. Fewer instruments in each set meant less time needed to hand-wash, and faster overall turnaround.

We evaluated each item: could we ever imagine using this for an inguinal hernia repair? No? Then it was pulled from the set.

Lahey traction forceps? We would never use those; out of the set they went.

Long metal hook that looked suspiciously like a dental instrument? Out of the set.

Hemostats #5 and 6? No need for so many. Out of the set.

Before long we had two groups of instruments— one with every item we needed for a hernia surgery, and one with every item we didn’t.

The following operation was uneventful, and before long we were ready for the next case. The patient was anesthetized, shaved, cleaned, and draped. The inguinal canal was palpated and the site of the incision decided. And soon it was noticed that there was no knife handle.

What set does not have a knife handle? We looked through it in dismay. None of the next several instruments we would use were present— no Adson, no Gelpi, no DeBakey. Instead, we saw Lahey traction forceps, a weird dental hook, and some hemostats.

We soon realized that the table was stocked with “never” instruments, while every item we considered to be useful lay in the next room, unsterilized.


If we delayed for better instruments, the patient on the table would receive unnecessary anesthesia and other patients who had traveled so many hours for surgery might not receive care. As we considered our options, the anesthetist’s precious tank of gas became steadily emptier. We assessed, and began.

Grasping a knife blade with a hemostat, the incision was made. I dissected down to the inguinal canal with gloved fingers and the scrub tech passed a dental hook to the assisting surgeon for retraction. The surgery proceeded; every action requiring strategy, nothing routine. Soon the hernia was reduced and the mesh painstakingly sewn into place. Before long I was gently using one hemostat as an Adson and one as a needle driver to close the skin. We never did find a use for the Laheys.

Surgeons are eternal optimists. To operate, they must believe that there is a way to use whatever they have to fix the problem, and that their team can meet the challenge. They must strategize, calculate, assess, and believe. They must hope in the success of the procedure and the future of the patient; for if there is no hope, there is nothing worth investing in. In settings with limited resources and options, sometimes operating requires that much more strategy and that much more hope.

The patient did very well, both that day and at the follow-up clinic visit. But I will not forget to be grateful when I palm a smooth, perfectly weighted needle driver, well designed for its task. And even if operating in difficult circumstances may mean facing equipment failure, limited supplies, and unexpected instrument selection, we must continue to problem solve and work outside of our routine to meet the tremendous global burden of surgical disease.

Antigua, Guatemala

4 Comments on All the Wrong Instruments

  1. Every day in surgery comes with unexpected challenges. In the developing world, those challenges often occur at the most basic level (like availability of electricity, or in this case knife handles and forceps). the point of surgical training is to learn principles,, but also to think and problem solve. And a key to being a problem solver and innovator is to question assumptions…for instance the assumption that those instrument sets had to stay together as assembled) Your story above demonstrates that problem solving mindset. I congratulate you on a successful case, and successful day with limited resources to help as many as possible.

  2. Rachel, I am so thrilled to read about the work you are going and to see the dream of an international track coming true! I think back to some of our earliest conversations and find myself grateful to have had the chance to know you.

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