Mixter Right-Angle Clamp
The Mixter is a ring-handled dissecting and grasping instrument used to pass a tie or vessel loop around an identified structure in an exposed plane. Right-angle models have angled, serrated jaws and a ratchet; the broader Mixter family includes different curves, jaw patterns and lengths.[1][2]
It is the standard right-angle instrument on open pelvic trays and the usual tool for the pass-around-and-tie step that precedes vessel ligation.
Uses in reconstructive surgery
The Mixter is used whenever a structure must be encircled before it is divided, ligated or tagged. Common examples in open pelvic and reconstructive work:
- Dorsal venous complex. Passing around the complex and puboprostatic ligaments during open retropubic prostatectomy and cystectomy. The Broglia modification was designed for this maneuver.[3]
- Internal iliac branches. Ligature placement during deep pelvic dissection, hostile pelvic re-entry and complex fistula repair.
- Mesenteric vessels. Passing ties around arcades during ileal conduit, neobladder and continent reservoir construction.
- Ureter. Passing a vessel loop around the ureter during reimplantation, ureteroureterostomy, ileal ureter interposition and ureterolysis, so that the ureter can be tagged and retracted without crushing it.
- Spermatic cord and vas. Encircling the cord or vas during open orchiectomy, orchiopexy and vasal procedures.
- Pedicles. Broad-ligament, uterine and cardinal pedicles during hysterectomy performed with sacrocolpopexy or other reconstruction.
Identify the Actual Instrument
Compare jaw angle, tip width, serration pattern, shaft length and stiffness. For example, Sklar's 55-2892 is a heavy 90° pattern, whereas Teleflex catalogs multiple curved and dissecting patterns. The name alone does not define a delicate clamp or a fixed length range.[1][2] Fine, standard and long lengths are stocked for superficial, mid-pelvic and deep retropubic work. Use the smallest instrument that reaches: a large clamp in a small space deflects off the target plane and tears tissue, whereas a short one cannot reach a deep structure.
| Task | Selection principle |
|---|---|
| Passing a ligature around a vessel planned for division | Choose jaws that fit the dissected space and allow the tip and returning tie to be controlled. |
| Passing a loose loop around a ureter or other structure to preserve | Protect surrounding blood supply and avoid constriction, crushing or using the metal jaws as a retractor. |
| Temporary vascular occlusion | Select a suitable vascular-control instrument or technique; a serrated right-angle dissector is not automatically an atraumatic occlusion clamp. |
| Fine nerve, lymphatic or microvascular work | Select dedicated instruments and magnification appropriate to the structure. A small Mixter or Gemini is not a substitute for a microsurgical set. |
Controlled Pass-Around Technique
- Identify the target and adjacent anatomy, and develop the intended passage under direct visualization. In scarred or irradiated tissue, an easy avascular cleft may not exist.
- Select a clamp with sufficient reach and a jaw profile that fits without forcing the space. Advance the closed tip only through the prepared plane; stop if it catches, meets resistance or cannot be followed safely.
- Once the tip is visible and clear of adjacent tissue, open enough to accept the tie or loop. Avoid spreading blindly against a vessel, nerve or ureter. If the tip is not visible after passage, do not open the jaws; advance again carefully or back out.
- Grasp the suture, tie or vessel loop, which the assistant feeds into the open jaws in a tight or deep space, and withdraw along the same path without trapping adjacent tissue.
- Confirm what the loop surrounds and whether it is intended for gentle identification, vascular control or ligation before tightening anything, then pass the tie to the surgeon.
For deep pelvic vascular control and unexpected bleeding, see Vascular Management & Damage Control. A narrow passage suitable for a tie does not establish an adequate tunnel for a vascularized flap.
Comparison with adjacent instruments
| Instrument | Geometry | Typical use |
|---|---|---|
| Mixter | Right-angle jaws | General pass-around-and-tie; isolating vessels, ducts and the ureter |
| Gemini | Right-angle, finer | Small or delicate structures in confined spaces |
| Lahey right-angle | Right-angle, broader jaw | Sturdier purchase; thyroid and bile-duct dissection |
| Mixter-Broglia modification | Angled, curved tip | Retropubic passage beneath the pubis[3] |
| Maryland dissector | Angled or curved, laparoscopic | Laparoscopic and robotic equivalent |
| Schnidt | Long, curved | Reach-and-grasp hemostasis at depth; not a right-angle instrument |
| Kelly / Crile / Péan | Straight or curved | Clamping rather than pass-around |
Evidence and Specialized Variants
Broglia's 1994 report described a modified clamp intended to reach beneath the pubis for open prostatectomy/cystectomy. It is a technical description, not evidence that all right-angle clamps safely encircle the dorsal venous complex.[3]
Clamp contact can injure vessels even when a device is described as atraumatic. Manship's study examined endothelial injury in atherosclerotic femoropopliteal segments; its findings do not prove that pelvic veins tolerate spreading or that a particular Mixter is safer than another.[4]
Inspect jaw alignment, serrations, hinge and ratchet. Remove damaged instruments from use and follow the exact model's reprocessing instructions.
Historical note
The clamp is named for Samuel Jason Mixter (1855–1926), a Boston surgeon who was chief of a surgical service at the Massachusetts General Hospital and took over its brain surgery in 1911. His son, William Jason Mixter, became the hospital's first chief of neurosurgery in 1939.[5] In operating-room usage, "a Mixter" often stands for any right-angle clamp. The instrument belongs to the lineage of hemostatic and dissecting clamps that descends from Péan, Halsted, Kelly and Crile.[6]
See also: Kelly, Péan, Gemini, Schnidt, and DeBakey forceps.
References
1. Sklar. Mixter Right Angle Forceps, 55-2892. Manufacturer specifications. Accessed September 12, 2026.
2. Teleflex. Surgical Instruments Catalog: Mixter and Gemini forceps, Right Angle Clamps section. Manufacturer model descriptions; accessed September 12, 2026.
3. Broglia L, Scattoni V, da Pozzo L, Rigatti P. A modified right angle clamp for radical retropubic prostatectomy and cystectomy. Eur Urol. 1994;26(3):262–263. doi:10.1159/000475391.
4. Manship LL, Moore WM, Bynoe R, Bunt TJ. Differential endothelial injury caused by vascular clamps and vessel loops. II. Atherosclerotic vessels. Am Surg. 1985;51(7):401–406. PubMed.
5. Barker FG 2nd. The Massachusetts General Hospital. Early history and neurosurgery to 1939. J Neurosurg. 1993;79(6):948–959. doi:10.3171/jns.1993.79.6.0948.
6. Sachs M, Auth M, Encke A. Historical development of surgical instruments exemplified by hemostatic forceps. World J Surg. 1998;22(5):499–504. doi:10.1007/s002689900424.