Instrument Handling: Scalpels

Authors: Andrew S Wright MD, Aaron Jensen MD, Sara Kim PhD, Karen Horvath MD

The scalpel is the most precise tool for tissue dissection and, in comparison to scissors or blunt dissection, causes the least trauma to surrounding tissue. The scalpel usually consists of a disposable scalpel blade and a reusable handle, but may be a disposable one-piece unit. There are several different scalpel blades available, of which three are the most commonly used.

#10 Blade

The #10 blade is commonly used for large, straight incisions. It is held like a violin bow, allowing the most efficient use of largest cutting surface of the blade.  This also allows the surgeon to modulate the depth of incision by feel as well as by vision. Finally, this grasp encourages straight incisions, as the arm moves as a unit from the shoulder.

 

 

When making a skin incision, it is best to use one smooth stroke, rather than multiple small strokes, causing less trauma to the tissue. The scalpel should be perpendicular to the skin and equal tension should be applied to both edges of the skin to prevent beveling of the skin edges.

A common error is to hold the #10 blade like a pencil. This forces the tip of the blade against the skin, instead of using the belly of the blade to make the incision, making harder to cut in a straight, even line.

15 Blade

The #15 blade is most often used for short or curved incisions. In contrast to the #10 blade, the #15 blade is held like a pencil, allowing the curve of the blade to come in contact with the skin.  In this grasp, control of the scalpel is with the wrist, allowing more precise cutting. In order to stabilize the scalpel, the heel of the hand may be rested on the patient.

 

When making a curved incision, it is especially important to keep the scalpel perpendicular to the skin, as it is easy to inadvertently bevel the skin edges in this setting. In making an elliptical incision, make sure to draw the scalpel away from the corners in order to prevent cross-hatching of the incision.

 

11 Blade

The #11 blade is most often used to make stab incisions. It is held like a pencil and is often held upside down. If the wound needs to be extended, the scalpel is moved in a sawing motion. The blade has a back bevel which may be placed against a guide, such as the guidewire used in central venous catheterization, to ensure accurate placement of a stab incision. The #11 blade is extremely sharp and may inadvertently be passed too deep. To prevent this, the hand may be stabilized with the heel of the hand on the skin, preventing undue advance of the scalpel.

There are a number of other specialty blades that are used in unusual situations. Use of these blades is outside the scope of this tutorial.

How to Practice This Skill: 

Using a tissue pad make three incisions using the appropriate scalpel blade, using the self-assessment criteria below.