Surgical Essentials: Scalpel Blades and Handles

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It’s been a while since we did a surgically-focused episode - we’ve previously done a series on laparoscopy and hysteroscopy, as well as on sutures and needles. Today, let’s focus in on an essential surgical instrument - the scalpel!

Additional reading: British Journal of Surgery Oct. 2022 review (also, the author Dr. Ron Barbosa is on Twitter and does some great surgical tweetorials!) 

History of the modern scalpel

  • Morgan Parker, a 22 year old engineer at the time, patented a locking scalpel handle and blade system in 1915 to replace what previously were often single-piece instruments without a replaceable blade.

    • His original design (slightly modified) is still what we use today!

  • Parker initially numbered handles 1-9 and blades 10-20; while this has been somewhat modified/expanded, the nomenclature largely remains the same.

    • We’ll talk about the most common handles and blade types today.

Scalpel handles

  • You’ve probably never had to ask for these in a surgical tray – so let’s review!

  • The number three handle is most commonly used in surgical specialties:

    • Flat shape

    • Some serrations near the blade attachment area to provide better grip for surgeon

    • Fits blade numbers 10-19

    • Modifications include the 3L (long-handle scalpel) and 3L angled (long-handle with a slight angulation).

  • The number four handle fits larger blades (#20 and above), but otherwise is very similar to the #3. 

  • The number seven handle is very narrow and meant for precise, fine work – not typically used in OB/GYN or subsepcialties – more common in head/neck/ENT, plastics, neurosurgery, and dentistry.

Barbosa, BJS, 10/2022

Scalpel blades

  • You may be more familiar with these, but likewise may not have had to ask for them before!

  • The number ten blade is used to make longer skin incisions for laparotomy, or for shorter cuts where a wide blade is ideal (i.e., hysterotomy). 

    • This is probably what you’re most familiar with in OB/GYN applications. 

    • You may also encounter a number 22 blade, which is essentially a larger version of the #10.

  • The number eleven blade is triangular, long, and has a sharp point with an edge on one side. 

    • Its shape is best suited for a stab incision - for instance, for laparoscopic port incisions, Bartholin’s gland cruciate incisions, and the like.

    • Its shape is not great though for excising anything - it’s really pointy!

  • The number fifteen has a small, curved cutting surface as well as a pointed tip.

    • You can use this for a stab incision at the point, and a more controlled incision for excising tissue with the curved portion.

    • Great for working in tight spaces versus a 10 blade for excision (i.e., oncology cases or urogyn cases – think about sharply cutting on your cardinal ligament bites – a 15 blade on a 3L handle is great for this!)

    • Also great for stab incisions, and many folks may prefer a 15 to an 11 blade for Bartholin’s or laparoscopy incisions.

10 blade (top), 11 blade (middle), 15 blade (bottom)

Scalpel blade materials, and disposables versus regular blade/handles

  • Disposables are great and often very available for outpatient procedures or for emergencies

  • The blades between disposable and regular blades are the same shape/size/nomenclature, so there’s no difference in that regard.

    • However, the regular blades tend to be a bit thicker on the back, non-cutting surface of the blade, which gives a bit more structure and may feel sturdier when cutting.

  • In terms of materials, the vast majority of scalpels we use will be made of carbon steel or stainless steel.

    • Steel blades can also have other compositions or coatings that can help with retaining sharpness and/or resisting rusting/corrosion.

  • Other materials used in modern blades include ceramic, titanium, diamond, sapphire, and obsidian.

    • Many of these - especially ceramic and obsidian - are extremely sharp, and can be chosen because they are non-magnetic – so for MRI-guided procedures, they are preferred. However, they are so sharp that they can be very dangerous in poorly trained hands - so we wouldn’t use these unless you have a great reason to do so! 

How do I hold a scalpel?

  • Intern struggle – and the truth is that it depends!!! 

    • For larger blades - i.e., a #10 blade or a #20 or above - the best grip is a “palmar” or “violin grip,” in which you have your index finger atop the handle, and use your other fingers to hold the body of the handle, with the back part of the handle under your palm.

      • This allows for precision with the long, wide cuts you would typically make with this blade.

    • For smaller, pointier blades – a #11 or #15 - the “pencil grip” is preferred.

      • This allows for precision with your “stab” incision or for those tight/deeper spaces. 

Barbosa, BJS 10/22: Palmar/”Violin” grip, for larger blades (#10, #20 and above)

Barbosa, BJS 10/22: Pencil grip, for smaller blades (#11, #15)

Popular Birthing Trends and the OB/GYN

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What are some birthing trends that we have seen rise in the United States?

  • Obviously, there are many, but unfortunately, we don’t have time to address all of them, and not all of them have robust scientific literature. Therefore, we will focus on some that are more controversial and may come up more often to help our colleagues navigate these trends with their patients that might desire them. 

  • Please see our other episode on limiting interventions in birth to look at some other trends that we fully support, like having a doula or other support person in labor and nonpharmacologic methods for coping. 

  • Today, we will discuss: 

    • Lotus Birth 

    • Vaginal seeding 

    • Placentophagy (ie. eating the placenta)

Lotus Birth 

  • What is a lotus birth? 

    • Practice of leaving the placenta attached to the umbilical cord and baby until the cord falls off on its own 

    • Anecdotally, this can take up to 3-10 days 

    • Conventional practice, as we know, is for delayed cord clamping for 30-60 seconds 

  • What are the perceived benefits? 

    • Modern resurgence is thought to be credited to Claire Lotus Day in 1974 

    • She observed that apes don’t sever their infants from placenta 

    • Delayed cord clamping does have many benefits, as we reviewed in previous episode Delayed Cord Clamping 

      • Increased hemoglobin levels, improved iron stores in first few months of live, increased red blood cell volume, decreased need for blood transfusion, and decreased risk of NEC and IVH 

    • There isn’t a lot of research about the benefits of lotus birth, but those that practice it believe it can: 

      • Increase blood and nourishment from the placenta 

      • Decrease injury to the belly button 

      • Be a gentle, less-invasive transition for the baby to the world 

      • Be a ritual to honor the placenta (though there does not appear to be written record of cultures that leave the cord uncut), and gives patients autonomy on their desires for delivery

    • The way it is done: 

      • The cord is not detached during birth and the placenta is usually kept in a cotton bag with a drawstring that contains herbs or salt to dry and preserve the placenta  

  • What are the risks? 

    • Qualitative studies show that many patients who practice lotus birth view the placenta as belonging to the baby and that it is something the baby should release when they are ready. They also discuss it in spiritual and ritualistic terms, but medical benefit and cleanliness were often secondary concerns 

    • Overall, very little data about lotus birth 

      • However, there is currently no evidence regarding effects on cognitive or emotional development of infants or possible benefit

      • There are case reports suggesting potential for infection, such as endocarditis from staphylococcus lugdenensis and omphalitis 

      • No data available regarding late-onset sepsis 

  • How should we counsel our patients regarding umbilical cord nonseverance? 

    • First of all, we should always respect the wishes and decision of patients 

    • It is important to review patient’s beliefs and why they desire lotus birth 

    • Discuss current evidence (very little) and society recommendations 

      • Important to realize that right now, there are no formal recommendations available from professional societies.

      • From the American Academy of Pediatrics:

        • Providers should conduct routine assessment and management of ill-appearing neonate 

        • Any placenta and umbilical cord attached to affected child should be immediately removed if child is ill appearing (esp if necrotic tissue is evident) 

        • Tissues should be cultured 

        • Antimicrobial coverage with anaerobic bacteria and vanc may be needed to be included to usual regimens 

    • Ultimately, the biggest risk is infection and patients should be counseled by us and pediatrics about signs of neonatal infection

    • Overall, there does not appear to be significant medical benefit to lotus birth and there are possible risks, but if it is highly desired by your patient, it is not unreasonable to achieve 

    • Things to consider: 

      • Cesarean delivery - it is possible to do lotus birth with cesarean 

      • Postpartum hemorrhage - if there is hemorrhage, in order to save the woman’s life, lotus birth may not be possible 

      • Non-vigorous infant or preterm infant - there is not a lot of data in these cases, but should review with patient that in order for expeditious pediatric evaluation, the cord may need to be clamped and cut

      • Placental pathology (ie. accreta, vasa previa) - lotus birth is likely not possible 

      • Review placenta disposal - placenta should not be flushed down the toilet or buried close to the surface of the ground; if it is buried, then it should be disposed of in a location that adheres to local laws and sanitation guidelines 

      • Be careful of buying placenta bags – not sure what the material is made from, not sure what the herbs that are included are, and realistically, not sure if what is included can actually harm babies

Vaginal Seeding 

  • What is vaginal seeding?

    • For babies who are born via C-section, inoculation using cotton gauze or swab with maternal vaginal fluid applied to the newborn’s mouth, nose, and/or skin 

  • What are the purported benefits? 

    • Thought is that it can restore the newborn’s microbiome that is more typical of vaginal delivery 

    • Epidemiologic studies show that there is a relationship between cesarean sections and increased risks for various conditions such as allergies 

    • Nonvaginal delivery may be associated wit changes in the infant’s microbiome (though changes do not appear to persist) 

  • What are the risks? 

    • Vaginal seeding has potential to transfer pathogens to newborns that are associated with vertical transmission (ie. GBS, HIV, HBV, syphilis, etc) 

    • There are other factors that may be related to initial colonization beyond the mode of delivery (ie. gestational age, transfer via breastfeeding) 

    • Of note, both AAP and ACOG recommend against vaginal seeding outside of research settings: 

      • Families should be counseled regarding the risk of exposure to pathogens that may occur despite negative screening because of possible false negative results or acquisition of the pathogen after the screening is done  

      • Concerns are compounded by increased risk of infections in preterm infants 

  • How do I counsel my patient? 

    • Again, it is important to discuss the patient’s beliefs and motivations 

    • We should review that currently, there is no data to suggest that vaginal seeding leads to benefits, but there is data about possible harm 

    • Of course, we can’t control what patients will do when we get home, but would recommend against vaginal seeding per ACOG and AAP 

Placentophagy 

  • What is placentophagy? 

    • Eating the placenta, usually prepared by steaming, followed by dehydration and then grinding to a powder and then encapsulated 

    • However, there are also practices of eating the placenta raw, cooked, or blended in liquid extracts

  • What are the purported benefits? 

    • For spiritual reasons 

    • Claims that it will increase milk supply or improve energy and decrease postpartum depression, though these results have not been substantiated 

  • What are the risks?

  • How do I counsel my patients?

    • As always, review the patient’s beliefs and motivations 

    • Discuss the current literature and data with the patient and that we ultimately don’t recommend eating the placenta 

    • If someone really wants to do it: 

      • Review that the placenta should be professional prepped if possible - do not do it at home 

      • The process should ensure that the placental tissue gets to high enough temperatures to kill viruses and bacterias 

      • Really recommend against it if there is infection of certain things that can be vertically transmitted (ie. GBS, HIV, Hep B, etc.) 

      • Monitor yourself and your baby closely - if either one gets sick, please seek professional help 

      • Similarly, if patient begins to have symptoms of PPD, don’t wait for the purported benefits of the placenta to kick in; should seek medical help 

Microscopic Hematuria

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Committee Opinion 703 serves for additional reading today!

Defining Microscopic Hematuria

  • 2012 American Urologic Association (AUA) criteria - 3+ RBC/high power field

  • The AUA guidelines also noted that if found, recommendation for evaluation for all patients older than age 35 years

    • This evaluation includes cystoscopy and upper urinary tract imaging with CT, with the primary concern being urothelial malignancy

  • The data supporting this approach was largely based on male patients - so ACOG and AUGS put together this series of recommendations thinking about the female patient 

    • As an example of how this can be so different: the CO points to a large study where 20% of urinalyses performed had microscopic hematuria, and other studies pointing to incidences between 2% and 31% – that would be a lot of studies!

  • These studies do carry risks – radiation and malignancy risk, particularly for young patients.

Differential Diagnosis and Risk Factors

  • ACOG points to specimen collection being potentially more challenging in women:

    • Hematuria might result from true hematuria, but also from

      • Menstruation

      • Urogenital tract atrophy

      • Pelvic organ prolapse

      • Other non-threatening urogenital diagnosis (prostatic hypertrophy in men, urethral stricture, etc). – these are much less common in women as well.

    • The primary concern with microscopic hematuria: urothelial malignancy.

      • Risk factors:

        • Male sex

        • Age over 50

        • Previous or current smoker

        • Gross hematuria

        • HIstory of pelvic radiation

      • Male sex specifically has 3.3x more new cases of bladder cancer than female sex

        • 4th most common cancer in men, while not in the top 10 cancers for women

      • Renal cancer is also 1.7x more likely in men.

When is reasonable to consider screening in women?

  • Studies looking at women have found:

    • Urologic malignancy rate in women under 40 years with any microscopic hematuria was 0.02%, and older than 40 years was 0.4%

    • Urologic malignancy rate is higher in women with 25 RBCs / hpf or greater

    • Smoking also increases risk.

  • Bottom line: women older than 60, with gross hematuria, and history of smoking have highest risk of urologic cancer.

    • Low risk, never smoking women, younger than 50 and fewer than 25 RBC/hpf - risk of urologic malignancy is less than 0.5%. 

  • In 2020, the AUA updated their guidelines to incorporate these gender-specific screening pathways, which are helpful to recognize and be  aware of:

    • Low risk women can undergo repeat urinalysis within 6 months, or cystoscopy/renal ultrasound

    • Intermediate risk women should undergo cystoscopy and renal ultrasound

    • High risk should undergo cystoscopy and CT urogram

  • Of course, keep your local urogyn / urologist aware of any patient for whom you have concern based on risk factors to discuss evaluation for urothelial cancers.

AUA/SUFU 2020 Microhematuria Algorithm

Menstrual Suppression

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Read the new ACOG Clinical Consensus! – General Approaches to Medical Management of Menstrual Suppression

Why menstrual suppression?

  • As an OB/GYN that might sound like a silly question – but for our patients, this is a serious concern!

    • A holdover of understanding (even with the design of OCPs) that a “natural cycle” is necessary for health – it’s not. 

  • Goal overall is to:

    • Reduce menstrual flow, by amount and total days while

    • Find a strategy based on patients preferences and goals, balancing any risk factors.

Which method is best?

  • Combined Hormonal Contraception

    • Can achieve menstrual suppression by skipping the placebo week.

      • Some packs designed for this - 84/7 regimens, 24/4 regimens.

      • This can be done indefinitely!

        • Studies have found these extended cycle and continuous use regimens to be safe and effective

    • Patients should be counseled that over time, breakthrough bleeding is more likely to occur. In a recent RCT comparing OCPs to an LNG-IUD for menstrual suppression, folks in the OCP group had BTB:

      • 50% at pill pack 3;

      • 69% at pill pack 7;

      • 79% at pill pack 13.

    • Bleeding overall tends to decrease with successive cycles.

    • Breakthrough happens less with higher doses of estrogen (i.e., more bleeding on a 20mcg pill than a 30mcg pill).

    • BTB will decrease with each successive cycle – so it’s not unreasonable to consider monthly cycles for 3-6 months, then transition to more extended cycles. 

      • Intermittent estrogen can also be used to help prevent BTB.

    • The patch and vaginal ring can also be used for menstrual suppression, and have advantage of not requiring daily medication.

      • Patch has no difference in frequency of BTB compared to pills.

      • Ring is well tolerated for extended cycles and seems to be effective in reducing/minimizing bleeding.

  • Progestin-Only Methods

    • These can be of particular importance to patients where estrogen is contraindicated (cardiovascular disease, migraine with aura, hypertension, hypercoagulability) or undesired (trans-men, patient preference).

  • POPs

    • The mini-pill (norethindrone 0.35mg) has to be taken in a tight window, and has low rates of amenorrhea, so is generally not a great choice for menstrual suppression.

    • Norethindrone acetate 5mg can be used for menstrual suppression with better success compared to the minipill, with amenorrhea rates of up to 76% at 2 years of use.

      • However, this formulation is not approved as a contraceptive so can’t be used for this.

    • Drosperinone 4mg is a new progestin only pill on the market; data is limited, but it is likely more promising than the minipill for menstrual suppression and also has contraceptive effect. 

      • That said, likely not a first line choice for this indication specifically.

  • DMPA (depot medroxyprogesterone acetate)

    • The DMPA shot is given roughly every 3 months.

    • Amenorrhea rates are good, especially with more prolonged use – 68-71% at 2 years.

      • However, unscheduled bleeding is a common side effect.

      • Loss of bone mineral density and weight gain are other common concerns; the loss of BMD is reversible with discontinuation. 

  • LNG-IUD

    • Excellent at amenorrhea - 50% at 1 year, 60% at 5 years; highest with the 52mg varieties.

    • BTB can be managed by offering a trial of NSAIDs, POPs/OCPs, or doxycycline before discontinuing the IUD.

    • Not a good choice for patients where ovulation suppression is also desired (ie, PCOS) – the IUD has unclear/unpredictable effects on ovulation suppression.

  • Etonogestrel implant (nexplanon)

    • Can be continued up to 5 years for contraception, FDA approved for 3 years.

    • For menstrual suppression, use past 3 years may not be effective. 

    • 22% achieve amenorrhea, but breakthrough bleeding and spotting are common, especially shortly after insertion.

      • BTB can be managed with OCPs or norethindrone.

  • The ACOG document contains a very helpful but large table on the different types of hormonal contraception and their relative success, advantages, and disadvantages with menstrual suppression. Definitely worth keeping a bookmark on or a snapshot on your phone!

How do I go about selecting a method?

  • Counsel your patient with shared-decision making in mind:

    • Be aware of inequities in provision of menstrual suppression methods and your own biases

    • Share with patients realistic expectations of what each method might offer in the way of menstrual suppression

      • No method can guarantee amenorrhea

    • Take into account patient’s preferences and values

    • Be aware of medical history / medical eligibility criteria that might contraindicate certain methods

By patient population:

  • Adolescents:

    • Hormone therapies are safe for adolescents

    • Initiation of menstrual suppression is safe anytime after menarche!

      • Need to have at least one menstrual period to be certain of normal pubertal development.

    • Pelvic exam is not needed for routine prescription of contraception, unless needed for the actual insertion (i.e., IUD)

      • IUD insertion has been shown to not be any more difficult in adolescents compared to older individuals, nor more difficult in nulliparas compared to parous patients.

    • Other tenets of adolescent reproductive healthcare counseling should be applied:

      • Discuss concerns about any side effects that are common / common concerns - fertility, weight, development, bone health, STIs

      • Use the opportunity to establish healthy alignment with adolescent at the OB/GYN office to establish as a safe place for current & future care

  • Transgender / Gender Diverse Patients

    • Menstrual suppression can help reduce feelings of gender dysphoria associated with menstruation

    • Testosterone use for gender-affirming care is associated with amenorrhea, often within a few months of starting therapy.

    • GnRH is also capable of pubertal blockade and suppression of menses for gender-affirming therapy, with amenorrhea rates nearing 100%.

      • Testosterone and GnRH are not contraceptives, though - so if they are at risk of pregnancy, contraception should be discussed

      • GnRH also cannot be used long term given concerns for bone density effects.

  • Patients with physical or cognitive disabilities, or both

    • Particularly for patients with cognitive disability, menstruation is a significant source of anxiety for caregivers and is a common reason for visit for pediatric gynecology clinics, even among premenarchal patients

    • Adolescents and adults with disabilities are also often assumed (erroneously) to be asexual and do not receive sexuality and contraceptive counseling on par with their peers

      • These individuals are also at increased risk of sexual abuse and unintended pregnancy

    • Assist families with developmentally-appropriate education and family assistance with hygiene concerns, contraception, STIs, and abuse prevention

    • Menstrual suppression methods can follow the patient’s needs, preferences, and values. 

      • Consider in these patients their mobility and presence of contractures; swallowing ability for pills; and presence of other interacting drugs (i.e., antiepileptics).

      • If plan for LARC and anesthesia required, it can be considered to “bundle” together services like dental work to minimize patient exposures to anesthetics

    • If patient doesn’t have capacity to make independent decision, menstrual suppression discussions should be made with the caregiver in patient’s best insterest.

      • Ethical and prudent choice is reversible and low-risk options.

  • Populations with challenges affecting hygiene/privacy

    • Military deployment

    • Incarceration

    • Houselessness

    • Patients in war zones or difficulty with care access

    • Athletes

      • Obviously hard to think about all of the potentials here, but consider patient access to medical services, sanitary products, restrooms or private areas, in making shared-decision making on menstrual suppression

How do I manage breakthrough bleeding?

  • One of the most common challenges in menstrual suppression

  • Anticipatory counseling that this is common is helpful in reducing method discontinuation rates and improving method satisfaction, as well as reassuring that BTB is benign and common.

    • Reassure that with some methods BTB decreases or ceases after some time period of initial use

Student Loans: The Saga Continues! An Update with Michael Foley.

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Two major updates

$10k or $20k forgiveness (Pell grant recipients)

  • Qualify if you make less than 125k single or 250k married

  • Likely what they already have on file for you- automatic or app coming in October

  • Is it going to be taxed?

    • Not federally but maybe in some states- check with your CPA

  • Is it going to be challenged legally?

    • Likely

    • Will take a long time to reach the Supreme Court

    • Also hard to sue without being able to show harm.

Forbearance extension through end of the year

  • No interest accrual or payments due

  • Also means the deadline for REFUNDs has been extended

  • Likely further extensions on Recertification dates.

Opportunities that have presented themselves with these extensions

Income reporting

  • Typically, must report income every 12 months – different during COVID

  • Paystubs or Most recently completed tax return

    • Presented opportunity to get on track for reporting your income from two years ago.

    • Some may be able to keep their incomes from 2019 for another year or more!

      • Huge for those seeking PSLF

      • Even helpful for folks paying down loans aggressively – REPAYE example- bulk payments.

      • Don’t forget about filing your taxes separately from your spouse and community property rules

PSLF Program and Waiver Action Items

  • Make sure all your loans qualify

  • Employer Certification form submitted to Mohela

  • Call current loan servicer and let them know you want to enroll in PSLF and move to Mohela

    • Don’t write this off even if you have a high income and not a lot left.

  • Income contingent repayment could be helpful for you

    • Lesser of 20% of income OR 12yr repayment times factor based off income (max 200%)

  • If you are unsure if you could qualify or not, request the refund of payments now

    • Worst case scenario, you pay that money right back towards your loans

    • Still no interest until January.

Proposals announced:

  • New repayment plan with a 5% discretionary income payment

    • Only for undergrad loans

  • Raising discretionary income amount to 225% instead of 150%\

  • No accrual of unpaid interest

Major takeaways

  • If you have Federal loans, everyone should be reassessing their gameplan. Lots of new strategies at play.

  • Don’t leave any money on the table.

  • Get your ducks in a row for PSLF even if there is a glimmer of possibility that you go for it.

  • Seek professional counsel on this by advisors trained on the Federal loan system. Let them help guide you through this.

    • This is not a simple system.

    • Lots of content going around that are either politically charged or financially charged that are offering tainted advice for borrowers – Beware!

Michael is a comprehensive financial advisor who runs his practice out of Scottsdale, Arizona, under North Star Resource Group. Michael was trained at Duke University and holds his Certified Financial Planner designation alongside his Certified Student Loan Professional designation. Although Michael serves a diverse group of clients with their financial and student loan needs, with two physician parents, Michael has found a specialty in working with those in the healthcare space. 

North Star Resource Group is independently owned and operated. 6720 N Scottsdale Rd Ste 290, Scottsdale, AZ 85253.

Separate from the financial plan and his role as financial planner, Michael may recommend the purchase of specific investment or insurance products or accounts. These product recommendations are not part of the financial plan and you are under no obligation to follow them. Financial Professionals do not provide specific tax/legal advice and this information should not be considered as such. You should always consult your tax/legal advisor regarding your own specific tax/legal situation.

To schedule an initial consultation with Michael click here.