Bonney Tissue Forceps
Heavy-duty, non-locking, spring-action thumb forceps with broad tips and prominent 1×2 interlocking teeth, designed for grasping thick, tough tissues — particularly fascia and skin — during closure of deep surgical wounds. Named after the British gynecologic surgeon Victor Bonney (1872–1953), Bonneys are among the most widely used toothed forceps in open surgery across general surgery, urology, gynecology, and orthopedics.[1][2]
Design
- Tip width: ~ 3–4 mm; broad and flat.
- Teeth: 1×2 interlock — one large tooth on one jaw fits between two on the opposing jaw. The teeth are substantially larger and deeper than the Adson- or Gerald-toothed variants.
- Shaft: heavier than DeBakey, Adson, or Gerald; transverse cross-hatched serrations along the inner proximal shaft for finger grip.
- Spring tension: firm — stiffer than Gerald or DeBakey, matching the forces needed to grip thick tissue and providing tactile feedback on fascial thickness.
- Length: typically 17.5 cm (7"); 15 cm and 20 cm variants exist.
- Material: surgical-grade stainless steel; reusable autoclavable and disposable variants.
Why Heavy Teeth — The Grip-Trauma Trade-Off
Bonney's design maximizes grip security at the cost of surface trauma. Biomechanical work on the instrument–tissue interface shows that larger teeth raise grip security but also raise focal tissue damage.[3] For fascia and thick skin this trade is acceptable because:
- Fascia is mechanically robust — it tolerates tooth penetration without functional compromise. The maximum acceptable tractive force for fascia (~ 11.4 N) is nearly tenfold higher than for delicate structures like the fallopian tube (~ 1.25 N).[4]
- Secure grip prevents re-grasping — each re-grasp causes cumulative trauma; a single secure grip with toothed forceps often causes less total damage than multiple smooth-forceps attempts.[3][5]
- Fascial closure requires significant traction — particularly during mass closure of laparotomy. Smooth or lightly serrated forceps cannot maintain grip under those forces without excessive compressive squeeze.[3]
Bonney vs Adson-Toothed — The Frequently-Confused Distinction
| Feature | Bonney | Adson-Toothed |
|---|---|---|
| Tooth size | Large, deep | Moderate |
| Tip width | ~ 3–4 mm | ~ 3 mm |
| Shaft | Heavy with cross-hatched grip | Lighter, delicate |
| Spring tension | Stiff | Moderate |
| Clinical niche | Deep fascial closure | Skin / superficial fascial handling |
Comparison Across the Forceps Family
| Feature | Bonney (1×2) | Adson-Toothed (1×2) | Gerald-Toothed (1×2) | Russian | DeBakey |
|---|---|---|---|---|---|
| Tip width | ~ 3–4 mm | ~ 3 mm | ~ 1.0–1.5 mm | ~ 5 mm (round) | ~ 2 mm |
| Tooth size | Large, deep | Moderate | Fine, shallow | None (serrations) | None (serrations) |
| Tissue trauma | High | Moderate | Low–moderate | Low–moderate | Lowest |
| Grip security | Excellent | Good–excellent | Moderate | Good | Moderate |
| Best tissue | Thick fascia, heavy skin | Skin, moderate fascia | Tunica, adventitia, graft | Bladder, ureter, broad grasp | Vascular, delicate |
| Typical suture pairing | 0 to 2-0 (fascial closure) | 2-0 to 4-0 | 5-0 to 8-0 | 2-0 to 4-0 | 3-0 to 6-0 |
| Primary use | Fascial closure, laparotomy | Skin / fascia closure | Microsurgery, fine reconstruction | General tissue handling | Vascular, delicate tissue |
See also: Adson, Gerald, Russian, DeBakey.
Primary Applications
Fascial Closure After Laparotomy — The Quintessential Use
During midline-laparotomy closure, the surgeon uses Bonney in the non-dominant hand to grasp and evert the fascial edges while placing sutures with the dominant hand. Contemporary evidence supports continuous closure with slowly absorbable monofilament suture using the small-bites technique (5 mm × 5 mm), which reduced 13-year cumulative incidence of incisional hernia from 49% → 34% vs large bites in the STITCH trial, with smaller hernias when they did develop (mean 25 vs 43 mm).[6] The European and American Hernia Societies recommend this approach with a suture-length-to-wound-length ratio ≥ 4:1.[7] Bonney provides the secure fascial grip and edge eversion the small-bites technique demands.
Skin Closure (Thick Skin)
Trunk and extremity skin where thick dermis benefits from tooth grip without the need for excessive squeeze.
Abdominal Wall / Hernia Surgery
- Primary fascial closure or mesh placement in ventral / incisional hernia repair.
- Component-separation handling of the external oblique aponeurosis, rectus sheath, transversalis fascia.
Urologic Applications
- Open radical or partial nephrectomy — flank and midline fascial closure.
- Open radical prostatectomy — lower-midline / Pfannenstiel fascial closure.
- Open cystectomy with urinary diversion — large midline laparotomy closure.
- Renal transplantation — handling the thick fascia of the Gibson iliac-fossa incision.
- Gerota's fascia — secure grasp during open renal surgery.
- Vaginal cuff and dense pelvic scar during redo prolapse / fistula surgery (the original gynecologic-tradition use).
- Pubovaginal sling harvest — rectus-sheath fascial grasp during strip retrieval.
Gynecologic Surgery
Open hysterectomy and cesarean fascial closure — the original Bonney indications.
Victor Bonney — Historical Note
Victor Bonney (1872–1953) was a British gynecologic surgeon at the Middlesex Hospital and the Chelsea Hospital for Women in London. He advanced radical surgical techniques for gynecologic malignancies — the Wertheim-Bonney radical hysterectomy bears his name — and pioneered modern myomectomy.[1][2] He designed the eponymous forceps to address the need for a robust instrument that could securely grasp the thick fascial and peritoneal layers of major abdominal gynecologic surgery in an era before modern suture materials and closure techniques.
Advantages
- Maximum grip security on thick tissue — the standard for fascial closure under traction.[3]
- Reduced need for re-grasping — secure initial purchase lowers cumulative tissue trauma.
- Tissue-edge eversion — broad flat tips facilitate edge-to-edge fascial approximation, the workflow at the heart of the small-bites STITCH technique.[6][7]
- Tactile feedback — heavy construction and stiff spring let the surgeon gauge tissue thickness and tension.
- Durability — robust construction tolerates repeated sterilization and heavy use.
- Ergonomics for forceful grasping — broad shaft and cross-hatching prevent slippage in the surgeon's hand.
Limitations
The large teeth create puncture wounds — acceptable for fascia, not acceptable for:
- Bowel serosa / mesentery — risk of perforation or serosal tear.
- Vascular structures — risk of intimal injury.
- Ureteral or bladder mucosa — risk of mucosal disruption / leak.
- Any tissue incorporated into a watertight or tension-free anastomosis — tooth marks become weak points.
- Cosmetically sensitive skin — tooth marks may leave visible scars (use Adson-toothed or finer instead).
- Microsurgical tissues — vas, nerve, fine vessels (use Gerald or jeweler's).
The wide tip also obscures the field in confined spaces, and Bonney has no role in laparoscopic / robotic surgery (open-only instrument).
Excessive squeeze still causes crush injury beyond what the teeth alone produce — engage the teeth, then stop. Gentle tissue handling is part of contemporary SSI-prevention practice.[8][9][10]
Variants and Related Instruments
- Bonney (standard) — 17.5 cm, 1×2 teeth; the workhorse.
- Lane forceps — Bonney-like but with 2×3 teeth; even more aggressive grip for very thick / obese-patient fascia. Rarely used today.
- Ferris-Smith — heavy multi-toothed (3×4 or 4×5) for orthopedic and neurosurgical use on periosteum, dura.
- DeBakey-Brown — hybrid serrated-but-broader-tip design bridging atraumatic and toothed.
- Cushing toothed — fine neurosurgical toothed variant; far more delicate than Bonney.
Practical Tips
- Palm grip, not pencil grip — palm grip provides the squeezing force and stability fascial work demands.
- Engage teeth perpendicular to the tissue surface so both teeth of the 1×2 fully interlock; angled engagement leaves only partial penetration and slippage.
- Rotate to evert the fascial edge toward the surgeon after grasping — this is the signature workflow advantage of Bonney during closure.
- Stop squeezing once the teeth engage — the teeth provide the grip; additional compression only crushes the tissue between the jaws.
- Pair with a heavy needle driver (Mayo-Hegar) for 0 or 1 looped PDS on a large needle; smaller needle drivers and 2-0 PDS on a 31-mm needle are appropriate for small-bites technique.[6]
- Instrument passing — present tips down, hoop toward the surgeon's hand.
Role in Modern Practice
Despite minimally invasive surgery's dominance, Bonney forceps remain indispensable for open procedures requiring fascial closure. The secure grip and edge eversion they provide are exactly what the STITCH small-bites technique demands[6] and what the EHS / AHS 2022 closure guidelines assume the surgeon can deliver.[7] In reconstructive urology specifically, Bonney remains standard during fascial closure of any open flank, midline, Pfannenstiel, Gibson, or perineal-extension incision, and during rectus-fascia harvest for pubovaginal slings.
Summary — When to Use, When to Avoid
| Use Bonney for | Avoid Bonney for |
|---|---|
| Midline fascial closure (linea alba) | Bowel serosa, mesentery |
| Pfannenstiel fascial closure | Vascular structures |
| Flank-incision fascial closure | Ureteral / bladder mucosa |
| Thick trunk or extremity skin | Cosmetically sensitive skin |
| Hernia-repair fascial edges | Microsurgical tissue (vas, nerve, fine vessels) |
| Gerota's fascia | Renal parenchyma |
| Rectus sheath / external oblique aponeurosis | Peritoneum (tears easily) |
| Pubovaginal-sling fascial harvest | Watertight / tension-free anastomoses |
References
1. Kirkup J. "The history and evolution of surgical instruments. VII. Spring forceps (tweezers), hooks and simple retractors." Ann R Coll Surg Engl. 1996;78(6):544–52.
2. El-Sedfy A, Chamberlain RS. "Surgeons and their tools: a history of surgical instruments and their innovators. Part IV: pass me the forceps." Am Surg. 2015;81(2):124–7.
3. Marucci DD, Cartmill JA, Walsh WR, Martin CJ. "Patterns of failure at the instrument-tissue interface." J Surg Res. 2000;93(1):16–20. doi:10.1006/jsre.2000.5906
4. Rodrigues SP, Horeman T, Dankelman J, van den Dobbelsteen JJ, Jansen FW. "Suturing intraabdominal organs: when do we cause tissue damage?" Surg Endosc. 2012;26(4):1005–9. doi:10.1007/s00464-011-1986-5
5. Cheng L, Hannaford B. "Evaluation of liver tissue damage and grasp stability using finite element analysis." Comput Methods Biomech Biomed Engin. 2016;19(1):31–40. doi:10.1080/10255842.2014.981166
6. van den Berg R, van Egmond S, Smits F, et al. "Small bites vs large bites for closure of abdominal midline incisions." JAMA Surg. 2026. doi:10.1001/jamasurg.2026.0618
7. Deerenberg EB, Henriksen NA, Antoniou GA, et al. "Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies." Br J Surg. 2022;109(12):1239–50. doi:10.1093/bjs/znac302
8. McHugh SM, Hill AD, Humphreys H. "Intraoperative technique as a factor in the prevention of surgical site infection." J Hosp Infect. 2011;78(1):1–4. doi:10.1016/j.jhin.2011.01.011
9. Chauveaux D. "Preventing surgical-site infections: measures other than antibiotics." Orthop Traumatol Surg Res. 2015;101(1 Suppl):S77–83. doi:10.1016/j.otsr.2014.07.028
10. Seidelman JL, Mantyh CR, Anderson DJ. "Surgical site infection prevention: a review." JAMA. 2023;329(3):244–52. doi:10.1001/jama.2022.24075