Biopsy Punches & Their Critical Application In Surgery


A punch biopsy is a minimally invasive diagnostic or surgical procedure performed with the goal of obtaining a tissue sample for the purpose of microscopic examination or, less commonly, removal of certain tissue parts.

Biopsy punches, as they are often referred to, are one of several skin tissue biopsy techniques currently in use in modern medicine, the other ones being: incisional biopsy, excisional biopsy, shave biopsy, curettage biopsy, saucerization biopsy and needle aspiration biopsy or fine needle aspirate.

This biopsy technique is most often used in dermatology as a diagnostic method. The sample is collected from the patient under local anesthesia and sent to the pathologist for microscopic examination. Samples collected using biopsy punches can be very helpful when decision is being made about a proper treatment for number of conditions ranging from different infections and inflammation types to cancer. Some unwanted or cosmetically unacceptable skin lesions, small tattoos, corns, acne, nail tumors, etc. can be completely removed using biopsy punches.

So, how exactly are biopsy punches performed? A small, usually round or elliptical shape, sample of tissue is extracted using a circular blade mounted on a handle roughly resembling a pencil. Also, some other punch biopsy instruments can be in the form of biopsy forceps, like in the case of cervical biopsy punches. The size of the sample varies from 0.5 to 10 millimeters in diameter, while the thickness can be anywhere from 1 mm (cosmetic procedures) to 4mm (inflammatory skin conditions).

Instruments used for biopsy punches can be reusable, disposable or automated and they can also be hand held or hand-machine mounted, the so called power punches. All of these can be used for diagnostic, cosmetic and therapeutic purposes.

Biopsy punches are considered to be a simple diagnostic or surgical procedure and for this reason they are often performed by physicians. The infection risk is very low with this procedure while the bleeding is minimal and the incision rarely requires suturing. All of this makes biopsy punches the most useful of all biopsy techniques.

Diagnostic use

As it was mentioned before, biopsy punches are used for collecting tissue samples intended for histology examination. Skin tissue samples as well as nail and mucous membrane tissue samples can be collected using biopsy punches but in combination with some other biopsy techniques, such as needle aspiration biopsy, samples of solid organs tumor tissues can be obtained as well, for example in the case of breast tumors.

Biopsy punches are commonly used for diagnosis of abnormal tissue developments in the cervix or cervix cancer. This procedure is known as cervical biopsy punches and it enables collection of one or more cervical tissue samples with the use of instruments such as, Gellhorn Biopsy Forceps, Kevorkian Biopsy Forceps,  Tischler Morgan Biopsy Forceps, Tischler Baby Biopsy Forceps etc. When a biopsy sample is taken with a punch biopsy forceps it is essential to ensure the tip has a sharp and perfectly aligned cutting edge. This would result in a traumatic cut for the patient and minimize discomfort. Surtex Instruments Cervical Biopsy Punches are considered the industry leading standard for precision and reliability by surgeons worldwide.

Quality and usability of tissue samples collected through the application of diagnostic punch surgery can also be enhanced by deploying different techniques of harvesting the samples.

For example, the split-punch technique enables for the sample to remain undamaged, when the division of it is necessary for different examinations.

Double-trephine punch biopsy is a technique used for collecting samples of subcutaneous tissue without making large excisions of the above tissue layers. This is done by using two punches of different diameter, with the second, smaller punch being deployed in the center of the larger initial punch to obtain the deeper, subcutaneous tissue sample.

In the case when the dissection of tissue samples is undesirable, “the string of beads” punch biopsy technique is used with the string of small neighboring punches being made to provide the sample.

Biopsy punches in the form of diagnostic punch surgery significantly improve diagnosis in a number of dermatological and non-dermatological (eyelid tumors, arteriosclerosis, nerve pathology, etc.) conditions.

Cosmetic use

Biopsy punches or reconstructive punch surgery is often used in cosmetic purposes for a whole variety of reasons. Good examples of this are vitiligo treatments (with the use of punch grafting), removal of moles and acne scars through punch excision, small tattoo removal, earlobe repair as well as eyelash implantation and eyebrow and hair transplant with micro-punches intended for follicular unit extraction (FUE). In liposuction, micro-punches are used to open holes for cannulas to be inserted.

When compared to other reconstructive surgical techniques available, punch surgery, when applicable, provides great results due to simplicity of procedures, low risk of complications such as infections and amazing cosmetic value (very small or non-existing scars).

Therapeutic use

Punch excisions of corns, acne, nail tumors, scrotal calcinosis, warts and cysts are some very common examples of biopsy punches being used for therapeutic purposes. Cartilage and bone pathologic tissues can also be removed using biopsy punches.

Punch grafts can be used to assist in wound healing by enhancing and speeding up the process, good example of which are non-healing ulcers. The punch grafts used for this are usually thick (3mm) and taken from a donor site (most commonly thighs and buttocks) and placed inside recipient punch holes made in the wound tissue.

All of the above mentioned diagnostic, reconstructive (cosmetic) and therapeutic uses of biopsy punches are in fact small and simple surgical procedures whose major significance is in the fact that they very effectively replace other far more invasive and complicated ones, with many of them actually being completely new and most efficient solutions for problems caused by certain medical conditions.


The Evolution & Modern Applications of Surgical Forceps

Evolution of Surgical Forceps

The word Forcep is derived from “Forca,” a Latin term which means to grip or grab onto an object. Forceps are primarily used when fingers are unable to grasp small objects or when an object needs to be held in place while the other hand is used to perform a task.  Illustrated forceps can be found in writings of Hippocrates that covered the Greek and Roman era over the period between 500 BC and 500 AD. These instruments were primarily used to help deliver babies.

Back then, surgical instruments and kitchen utensils were used to remove the dead fetus. This would prevent maternal mortality. However, this practice was kept a secret for several centuries by its inventors.

16th Century

After the ban on Protestant physicians, Huguenot William Chamberlen, French physician was forced to flee England in the 16the century. The use of forceps as a way to deliver live infants began with his two sons who were both named Peter Chamberlen but were referred to as, ‘Peter the elder and Peter the younger.’  Both of his sons played a significant role in ‘man-midwifery’ which was later termed Obstetrics.

While it is unclear who the real inventor of the forceps is, it is usually attributed to Peter, the elder who later worked as a surgeon for the Queen. Peter the younger’s eldest son continued the tradition of using forceps for midwifery. However, the family took extensive measures to conceal the instrument from others. To ensure the instrument remained a secret, the forceps were carried in a gilded chest. In some cases, the women were blindfolded while only the Chamberlens were present during the delivery. The Chamberlens used elaborate means to keep the forceps a secret for nearly a century.

However, in 1670, Hugh Chamberlen decided to sell the secret to the French government. However, his secret remained intact as he was unable to deliver a patient successfully.

18th Century

William Smellie was among the most skilled obstetrician during the 18th century. He created his forceps to prevent loss of children. His forceps also includes an ‘English lock’ with special blades covered in leather. The material was lubricated using hogs lard to prevent the transmission of infections.

Smellie developed the rules of using forceps. His work was published in 1752 in a book called ‘Treatise on the Theory and Practice of Midwifery.’

19th Century

When the Duchess of Kent became pregnant in 1819, her obstetrician David Davis started to develop new instruments to aid the delivery of babies. Davis was particularly interested in finding a way to reduce injury to babies. He thus altered the design of forceps to minimize the chances of maternal trauma. This led to the development of forceps featuring axis traction. He developed long forceps that later became popular in England.

20th Century

A lot of emphases was put on improving fetal well-being throughout the 20th century thus high-quality forceps were developed to aid delivery. Special designs were developed for deep arrest in the mid-pelvic cavity as a result of malposition. The Kielland’s forceps particularly gained popularity in 1916. This designed featured a straight structure along with a slight pelvic curve. These forceps also included a sliding lock to ensure better performance.

New materials such as titanium, stainless steel, vanadium, and chrome were then introduced to manufacture these instruments. At present, the Caesarean section is a common solution to tackle difficult birth. While the use of forceps has changed significantly, obstetrician forceps are now used as a last resort to delivering babies when there are no chances of risks that can threaten the life of the mother and baby. Today, these instruments are used for a variety of medical purposes.

Modern Applications of Surgical Forceps

Some of the most modern types of surgical forceps include:

  • Splinter Forceps: Splinter forceps are designed to handle sutures and remove pieces of bones. Splinter forceps can also be inserted in the body.
  • Sponge Forceps: Sponge forceps are excellent for holding sponges during medical procedures. It can also be used to grip gauzes.
  • Tumor Forceps: Tumor forceps are commonly used in neurosurgical procedures that involve tumor removal.
  • Micro Suturing Forceps: Micro Suturing Forceps are typically used for suturing cataract procedures.
  • Tissue Grasping Forceps: As the name indicates, Tissue Grasping Forceps primarily aid surgeons in holding tissues during medical procedures. Surtex Instruments offer a plethora of tissue grasping forceps that you can choose from.
  • Jeweler Forceps: Jeweler forceps are designed to aid micro-surgical procedures. They typically feature micro or fine types to handle fine tissues.
  • Micro Ophthalmic Forceps: Micro Ophthalmic Forceps are specifically used for Micro Ophthalmic procedures. They can be used for holding on to the tiniest of components.
  • Dressing Forceps: As the name indicates, dressing forceps are used for removing dressings and for wounds.

The types mentioned above are among the most common surgical forceps used for modern day medical applications. Also, dental forceps are also used to aid dental procedures.

Basic types of surgical instruments and their applications

General Surgical Instruments

With the variety and complexity of surgical techniques, surgeons use different instruments to optimize their performance. To date, thousands of surgical instruments were developed to assist professional surgeons to perform their operations. Some surgical instruments are designed for general use in different types of surgery, whereas others are highly-specific and used for particular surgeries. Given the high number of surgical instruments employed, young surgeons may find a challenge in identifying and acquiring adequate knowledge about all instruments. However, a simple classification of surgical instruments helps in facilitating this process. Surgical instruments are basically classified according to their function. They are used for cutting, dissecting, holding, grasping, occluding, clamping, retracting, suturing, dilating, …. etc. This article will review the basic types of surgical instruments and their clinical applications. Surgical instruments are classified according to their functional usage into the following categories:

  • Cutting and dissecting surgical instruments:

    Many surgical instruments are used for cutting skin, soft tissue, and even bones, or dissecting tissues through their anatomical planes. Some of these instruments are disposable such as scalpels and blades, whereas others are reusable such as knives. Blades of different sizes are used for particular operations. For instance, vascular surgeons commonly use blade 11 to puncture large arteries e.g., aorta, ENT surgeons use blade 12 for tonsillectomy, and plastic surgeons use blade 15 for their operations. Some instruments are designed for dissecting tough tissues such as Mayo scissors commonly utilized by obstetricians and gynecologists for cutting ligaments, while others are designed for dissecting delicate tissues such as Metzenbaum scissors used by plastic surgeons for dissecting intestinal mesentery. Bone curette exemplifies a common instrument in this group that is used by neurosurgeons and orthopedic surgeons for laminectomy in intervertebral disc surgeries. Other examples of surgical instruments used for cutting or dissecting are bone cutters, snares, blunt dissectors, biopsy forceps and bunches.

  • Grasping and handling surgical instruments:

    Surgeons use certain instruments to grasp or hold tissues to help to have a closer view of their surgical field. The most common surgical instruments used for this purpose are forceps (including tissue forceps, smoothed forceps, toothed forceps, Allis forceps, Babcock forceps, and stone forceps), tenaculum and bone holders. Rat toothed forceps is a common surgical instrument used by general surgeons to grasp skin. Babcock forceps is used for grasping intestine and towels, and Allis forceps is used by obstetricians for colporrhaphy (anterior and posterior repair).

  • Clamping and occluding surgical instruments:

    Those instruments are mainly used for clamping blood vessels and/or other tissue to get them away from the field during surgical procedures. They include hemostatic forceps, hemostats, crushing clamps, and non-crushing vascular cramps.

  • Retracting and exposing instruments:

    Retractors assist surgeons to have a better visualization of the surgical field. Surgeons retract tissues away without traumatizing them through using those instruments. Balfour abdominal retractor is a common example of surgical instruments used in laparotomy for this purpose. Other examples include Army navy and Farabeuf retractor. Some retractors, such as GELPI perineal retractor, are self-retaining, thus facilitating operative field visualization. Finochietto is a bone retractor used for sternotomy operations. Hooks, such as skin, bone or spay hooks, are used to retract skin edges in wide-flap dissection in mastectomy or face-lift operations. Some of these hooks are designed with rounded tips to minimize tissue trauma.

  • Instruments for improving visualization:

    Special instruments are designed to view deep structures that cannot be seen externally. Speculums, endoscopes (hollow and lens endoscopes), anoscopes (for visualizing anus) and proctoscopes (for viewing anus and rectum) exemplify instruments of this category.

  • Suturing and stapling surgical instruments:

    Suturing, as well as stapling, instruments are designed to bring the edges of the skin and/or soft tissue adjacent together. The typical suturing kit is composed of a suturing material, a needle, a needle holder, a toothed forceps, and a fine suturing scissor. Instruments with tungsten carbide jaws are used to eliminate turning and twisting of the needle, enhance instrument life and enable a better grip and balance. Crosshatched serrations provide a smooth surface for the needle to prevent damage, and smooth jaws are used with small needles such as those used for plastic surgeries. Staplers and clip appliers are other instruments that can be included in this category. Staplers can be used for stapling terminal end, internal anastomosis, and ends to ends.

  • Suctioning and aspiration instruments:

    Surgical and dental fields may be filled with blood and copious amount of fluids that obscure the underlying structures. Surgeons, thus, use particular instruments to remove these fluids from their filed, for instance, Poole abdominal tips used in laparotomy, Frazier tip used in brain and orthopedic operations, and Yankauer suction tip used for oropharyngeal procedures.

  • Dilating and probing instruments:

    Dilating instruments are used to expand the size of an orifice such as the cervical os or the urethra. Dilators have different calibers ranging from small to large; surgeons start to use small dilators and gradually increase the size of the dilator inserted to expand the orifice. Probes, on the other hand, are inserted into natural openings, such as urethra, vagina, and common bile ducts, to explore these cavities. Urethral and uterine sounds are examples of surgical probes.

Other more advanced surgical instruments are used particularly in ophthalmic surgeries, for instance, corneal section scissors, Piere micro scissors and others. Powered surgical instruments, either electrically or air-powered, are also used during surgery.