If you control your overhead costs, then you would do well to select high-quality instruments and maintain them for long use. You'll spend far less in the long run if you buy top-of-the-line instruments. You'll also save time and enjoy your work more.

For thorough debridement and precision suturing, you will need the following:

1. Tissue forceps
2. Delicate scissors
3. Needle holder

You may also need the following:

4. Mosquito clamp
5. Scalpel handle and blade
6. Suture-cutting scissors
7. Skin hook or small retractor

A complete soft-tissue-repair instrument tray should contain all of the above. Here are a few facts about each instrument:

a. Tissue Forceps

Pick an Adson forceps with teeth. Contrary to popular belief, forceps with teeth should be less traumatic than forceps without teeth. Think for a moment: with teeth you'll likely need to squeeze less to hold the wound edge; without teeth, you'll have to squeeze harder, thus damaging more cells.

As you develop increased skill, you should never have to squeeze a forceps more than a little - forceps only need to hold a wound edge immobile to facilitate needle passage during suturing. This should require very little force. If possible, hold the dermis of the wound edge rather than the epidermis.

b. Dissecting Scissors

Most commonly, Iris scissors are a poor choice for emergency room trays. The blades are pointed and loosen quickly. Iris scissors are designed for eye surgery (thus the name), not for skin surgery.

A better choice is strabismus scissors, or the tenotomy scissors. These can cut skin or muscle. Both are excellent for fine debridement of devitalized tissue fragments prior to closure.

c. Needle Holder

The wrong needle holder will slow you down no matter how skilled you are. Blunt-nosed, groove-jawed examples turn up on ER trays looking like operating room rejects. What you need is a smooth-jaw or tungsten-jaw Webster or Halsey needle holder.

You may prefer the short version (4 1/4 - 4 3/4") or the longer variety (5 1/2 - 6 1/2"). This can be your choice if you are able to pick the instruments you will use each day.

d. Mosquito Clamp

A delicate vascular (mosquito) clamp will be useful for clamping small bleeders. A fine tip is preferable to a blunt one. You may even want two or three on your soft tissue tray.

e. Scalpel Handle and Blade

A #3 scalpel handle and #15 blade are appropriate for elective incisions or for debridement.

f. Suture-cutting Scissors

You might wish to have on your instrument tray a small but heavier duty straight scissors for suture removal.

g. Skin Hook or Small Retractor

You might want one or the other or both depending on the scope of your needs. Skin hooks are relatively atraumatic when sharp and when placed firmly. The Joseph hook with a single prong is durable and performs nicely. Don't select very delicate hooks for emergency room or office use. They don't last. Small retractors suitable for this use are the Senn (rake at one end, long right-angle blade at the other) or the Ragnell (double right angle).

Finally, remember that buying quality instruments pays in the long run. Ask your operating room staff to tell you which are the best products. Send your office nurse to a hospital operating room for a half day to learn proper maintenance from the instrument-room staff.

If you must deal with a purchasing agent at the institution you work for, remind him or her that the main operating room is spending thousands for high technology it doesn't keep in constant use. You are asking for an investment of a few hundred dollars for instruments used around the clock. A $100 needle holder is a cost-effective purchase. Buying a $30 needle holder may be like throwing money away!