Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Checklist of Requirements on Equipment/Instruments for

Thoracic Ambulatory Surgery
The following equipment/instruments shall be required for the specified procedure. Place a check (/) if
the ASC is compliant and x mark (X) if not compliant.

PROCEDURE AVAILABILITY ADDITIONAL COMPLIANCE REMARKS

(/ if available) EQUIPMENT/INSTRUMENTS
1. A-V Fistula Plastic set consisting of:
•Blade handle
•Towel clips
•Adson forceps
•Mosquito forceps
•Vein retractor
•Scissors (Mayo/Metz/Iris)
•Needle holder
•Weitlainer
2. Pleural Biopsy Standard Throracostomy set:
•Forceps (thumb/tissue)
•Blade handle
•Kelly forceps
•Towel clips
3. Bronchoscopy Alligator biopsy forceps
a. Rigid Biopsy forceps & brush
b. Fiberoptic Bowl
Fiberoptic bronchoscopes
4. Esophagoscopy
Rigid ventilating bronschosopes
a. Rigid
Fiberoptic esophagoscopes
b. Fiberoptic
Rigid esophagoscopes
5. Biopsy Cautery pencil
a.Core Needle
Biopsy (CNB)
b.Sentinel Node
Biopsy (SNB)
6. Percutaneous Needle, gauge 16-22, long Fine
Needle Lung Standard thoracostomy set
Biopsy (PNLB)
7. Thoracentesis Needle, gauge 19, short
8. Vascular Access Cutdown set consisting of:
•Blade handle
•Adson forceps
•Needle holder
•Mosquito forceps
•Scissors (Mayo)
•Needle (cutting)
Towel clips (4)

DOH-ASC-LTO-AT Checklist Thoracic

Revision:01
01/26/2015
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