3.3 Tissue & Thumb Forceps

The Spring Form

A thumb forceps (called "pick-ups" at the field) is two arms joined at a proximal spring. There is no box lock and no ratchet; the instrument opens by its own spring tension and closes under the surgeon's thumb and index finger. Identification therefore rests almost entirely on tip pattern and on overall shape.

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Tip Patterns

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The Named Patterns

Adson. A short forceps (usually 4¾ in) with a broad proximal grip that narrows sharply to a fine tip. That taper is the identifying silhouette. Adson comes as Adson with teeth (1x2, used on skin closure) and Adson dressing/tissue forceps without teeth. The Adson-Brown variant carries multiple fine intermeshing teeth (typically 7x7 or 9x9) in a broad tip and is a plastics and delicate-tissue favourite.

DeBakey. Long, slim, with the characteristic fine double row of atraumatic teeth and a central groove. Available from about 6 to 12 inches. Any set involving a vessel or bowel anastomosis will carry them. The rows are shallow and easily flattened, so DeBakeys must never be used as a general grasper and never used to hold a needle.

Russian. Distinctive round, star-shaped serrated tip that flares outward. Used to grasp tissue with a broad, non-slip grip in GYN and general work.

Ferris-Smith. Heavy, broad, toothed tissue forceps used on fascia and dense tissue.

Gerald. Fine, long, slender forceps with either serrated or toothed tips, common in neuro and cardiovascular sets.

Cushing. Long forceps, straight or bayonet, with or without teeth, standard in neurosurgery.

Bayonet. Not a tip pattern but a shape: the shafts step laterally out of the line of the tips so the surgeon's hand does not block the view down a nasal cavity, an ear canal, or a craniotomy corridor. Bayonet forceps appear across ENT and neuro sets and are often also bipolar electrosurgical forceps.

Bipolar forceps. A bayonet or straight forceps wired as an electrode pair; the current passes only between the two tips. Identified by the insulated shafts and the cord connector. These are inspected as insulated instruments (Chapter 7), and their tips are checked for char build-up and non-stick coating loss.

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Choosing By Tissue

The governing rule: the more delicate and the more it must survive, the fewer teeth.

• Skin being closed → toothed (Adson with teeth): the teeth grip the dermis without crushing a wide area.
• Vessel or bowel → DeBakey: atraumatic rows distribute pressure.
• Dressings and packing → smooth dressing forceps.
• Fascia → Ferris-Smith or heavy toothed.
• Cornea or nerve → micro/jeweler's with a specified tip number.

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Inspecting Thumb Forceps

The standard test is quick and is expected knowledge:

1. Hold the forceps up to a light source and close the tips gently with the fingers.
2. Toothed patterns: the teeth must interdigitate, meshing fully with no gap and no tooth riding over its neighbour.
3. Smooth and serrated patterns: the tip faces must meet flush with no light visible between them and no lateral overlap.
4. DeBakey patterns: examine the double rows under magnification — flattened, polished, or missing rows mean the forceps has been misused and no longer holds tissue.
5. Spring: release and confirm the arms return fully open. A forceps that stays closed or opens weakly has a fatigued or bent spring.
6. Alignment: sight down the length; the arms must be in the same plane, with tips neither crossed nor splayed.

A forceps that fails alignment is a repair item — tips can usually be realigned and re-teethed by a vendor — but it must be removed from the set at inspection, not sent back to the OR to "see if the surgeon minds."

Tooth Notation and What the Numbers Mean

Thumb forceps are catalogued using a notation that appears verbatim on count sheets, and misreading it produces a genuine assembly error. The notation 1x2 means one tooth on one jaw meeting two teeth on the opposing jaw; the single tooth seats between the pair, interlocking to hold tissue securely. 2x3 follows the same logic with more teeth and a broader hold. A designation such as 9x9 describes multiple fine interdigitating teeth across the tip, as found on Adson-Brown forceps, which spread grip across many small points and are correspondingly gentler on skin edges.

"With teeth" and "without teeth" are therefore not interchangeable descriptions of the same item — they are separate catalogue numbers. A tray calling for Adson with teeth and one calling for Adson without teeth (dressing pattern, with serrations only) are different instruments, and substituting one for the other is precisely the kind of error the Ethics domain asks about.

Dressing, Tissue and Specialty Patterns

The plain dressing forceps has serrated but untoothed tips and is used to handle dressings, packing, and sponges rather than to grasp living tissue. Tissue forceps carry teeth. The distinction matters clinically because a toothed forceps used on a dressing is wasteful, and an untoothed forceps used on skin requires crushing pressure to hold, which damages the wound edge.

Among the named patterns, Adson forceps are short with a wide, comfortable thumb platform narrowing to a fine tip, designed for skin closure. DeBakey forceps carry the distinctive fine longitudinal serrations with a central ridge that grips vessels without crushing them, and are the definitive atraumatic vascular pattern. Russian forceps end in a broad, round, star-patterned tip that grips over a wide area. Bonney and Ferris-Smith are heavy toothed forceps for fascia. Gerald forceps are long and delicate for fine work, and Cushing forceps appear on neurosurgical trays with fine teeth and a bayonet shape.

Bayonet Shape and Why It Exists

Several patterns — Cushing, Jansen, and many ENT and neurosurgical forceps — are made in a bayonet configuration, where the shafts step laterally before running out to the tips. This is not decoration: the offset moves the surgeon's hand out of the line of sight and out of the path of a microscope or speculum, so the tips remain visible in a deep, narrow field. When inspecting bayonet forceps, sight down the instrument to confirm the tips still meet, because the offset makes misalignment easy to miss from directly above.