Complex Surgical Instruments

Chapter 12

Objectives:As a result of successfully completing this chapter,

students will be able to:

Provide an overview of and discuss procedures to care for and effectively process powered surgical instruments.

Explain basic concerns important when handling and processing endoscopic instruments.

Discuss detailed information about flexible endoscopes. Review general processing and inspection requirements for

rigid and semi-rigid endoscopes and laparoscopic instruments.

Identify basic protocols important at each step in the loaner instrumentation process.

Powered Surgical Instruments (PSI’s)

What We See and Don’t See

Powered Surgical Instruments

Look Simple – Are Complex

Look Durable – Are Delicate

Look Plain – Are Expensive

Look Easy to Clean – Are Difficult to Clean

Electrically Powered Instruments

Cable attached to a motorized hand piece

Require a cable that can be sterilized (One end attached to the instrument handpiece and the other to a motor or adapter that is connected to a 110 volt outlet)

Pneumatic Powered Instruments

Powered by Compressed Gas

Powered by compressed gas. They require a hose that can be sterilized (One end attaches to the instrument handpiece and the other to a stand alone cylinder tank or a wall or column mounted regulator panel)

Battery Powered Instruments

Least cumbersome because there is no cord or cable

Requires batteries and a battery charger

Example of a Battery Powered PSI and Two Styles of Batteries

PSI Processing Concerns

PSIs are complex instruments that are difficult to clean and easy to damage

Central Service Technicians should follow manufacturer’s processing instructions carefully

Fluid Invasion

Occurs when water or cleaning solution is allowed to enter PSIs

Fluid invasion can severely damage a PSI

Decontamination of Batteries and Cords can protect PSIs from

Fluid Invasion

Attachments are Complex Instruments Too!

PSI Accessories

Chucks Keys Burr Guards Cords Batteries…and much, much more!

Common PSIs Dermatomes/Dermabraiders – used to harvest skin

grafts or reshape skin surfaces Cebatomes – used to remove cement Sternal Saws – used to split the sternum for open

heart surgery Dental Drills – used for teeth and jawbones Micro Drills – used for middle ear bones and to drive

very small wires Wire Drivers, Drills and Saws – come in various

sizes and are used to work on small to large bones. Saws - designed to perform specific cutting actions

such as reciprocating or oscillating

PSI Instrument Cleaning

PSI’s must be processed manually.

Care MUST be taken to prevent Fluid Invasion.

Basic PSI Processing Procedure(You MUST Follow Manufacturer’s Specific Instructions)

Remove all bits, burrs and blades from the unit, disconnect from the power source

Disassemble and remove debris at point of use, keep the instrument moist

Separate devices with internal mechanisms from simple devices. Generally, simple components can be soaked

Attach handpiece to a hose of specialized cleaning attachment to reduce the risk of fluid invasion during cleaning

Clean the exterior with an approved germicidal detergent

Pay special attention to recessed areas, moving levers, switches, etc.

Clean recessions and cannulas using a stiff bristle brush

Clean, rinse and inspect the hose, cable or battery pack. Look for signs of damage or excessive wear

Lubricate and test as required by the manufacturer

Dry all components

Package and sterilize as recommended by the manufacturer

Endoscopy Instruments

Endoscopes greatly reduce patient trauma when physicians perform minimally invasive surgery.

Endoscopeman**with permission from Lighthouse Imaging Corporation

Rigid Endoscopes

Provide an optical view and in some cases minimal access through a rigid instrument. The scope is inserted through a sheath inserted via a small incision.

Flexible Fiberoptic Endoscope

Provides optical access using a flexible, maneuverable scope most commonly inserted through a mucous membrane opening.

Regulations and Guidelines

Several regulatory agencies and professional associations provide input into proper scope handling and processing practices.

For a list, please refer to pages 207-209 in the text.

Infection Control Concerns

Flexible endoscopes pose significant infection control challenges. Their configuration makes them difficult to clean and dry and they can harbor bacteria.

Infection Control Issues

Inadequate training of employees who clean and handle scopes

Adequate time for thorough processing Commitment of employees (and policy writers) to safely

reprocess scopes Failure to adequate inspect scopes prior to processing Failure to follow manufacturer’s instructions for

reprocessing Failure to follow label direction on processing chemicals Using the scope without a leak test Poor manual cleaning habits Failure to use automatic endoscope reprocessors in

accordance with manufacturer’s instructions Improper drying and storing procedures

Additional Concerns:

Failure to leak test correctly Failure to manually clean all channels Failure to flush all channels with disinfectant solution Failure to fully immerse Failure to adequately time the length of disinfectant contact Use of disinfectant solutions after their expiration date Failure to process all scopes in the same manner (Standard

Precautions) Failure to sterilize biopsy forceps Inaccessible manufacturer’s instructions Variations in staff training Improper reprocessing of reusable cleaning supplies.

Additional Concerns:

Inadequately trained personnel Lack of competence reviews for scope processing and

procedures Improper storage and transport Pressure from physicians to process scopes more quickly so

they can perform more procedures on more patients Difficulties processing these complex instruments Space constraints Absence of, or an inadequate quality control program. Poor water quality Facility processing equipment In order for endoscope processing to be successful, each of

these concerns must be addressed

Liquid Chemical Processing Systems

Glutaraldehyde

High Level Disinfectant Can be used manually or in automatic

processors Must be tested Takes Time Employee Safety Concerns (ventilation a must!)

Ortho-Phthaladehyde (OPA)

High Level Disinfectant May be used manually or in an

automatic processor Must be tested

Automatic Endoscope Reprocessors (AERs)

Automated equipment designed to clean, disinfect, and rinse flexible endoscopes

Advantages of AERs Process consistency Reduced staff exposure to

chemicals Timed cleaning Consistent exposure to the

cleaning agent Timed contact with liquid

disinfectants An air flush cycle to remove

excess moisture Use of copious and

consistent amounts of rinse water

When using AERs:

Follow manufacturer’s instructions to connect the scope to the AER

Place removable parts in the AER if possible

Attach channel cleaning connectors to all channels

Follow manufacturer’s instructions for using disinfectants

Set the machine for the recommended time

Staff Education All staff must be

thoroughly educated in the proper cleaning, processing, and handling of endoscopes

Page 215 in the text contains a sample competency checklist for endoscope training

A Closer Look at Endoscopes

Although they look similar, endoscopes vary greatly in configuration

Some scopes are only used to visualize and do not have channels, while others have internal channels

Endoscope Channels

Instrument Channel

OpticalChannel

Air/WaterChannel*Suction

Channel

*Some Flexible Scopes have separate Air and Water Channels

Distal Tip

Flexible FiberopticEndoscope

Video Monitor

Water Bottle Light Source

Suction Canister

Common FFE’s

Bronchoscope

Used for the direct visualization of the tracheobronchial tree

CystoscopeUreteroscope

Used to visualize the urethra and bladder (cystoscope) and to look for obstructions such as kidney stones

(ureteroscope)

Gastroscope Esophagoscope

Used for the visual inspection of the upper GI tract (gastroscope) and for

the direct visualization of the esophagus and the cardia of the

stomach (esophagoscope)

Colonoscope Sigmoidoscope

Used for the visual inspection of the entire large intestine (colonoscope)

and the visual inspection of the lower part of the large intestine

(sigmoidoscope)

Care & Handling

Steps in Endoscope Processing

1. Preclean2. Leak Test3. Clean4. High-Level Disinfect or

Sterilize5. Dry6. Store

Fluid Invasion

Fluid invasion can cause damage to flexible fiberoptic endoscopes

Leak Testing Detects leaks that

can compromise the safety of the scope

Scopes that fail a leak test must be removed from service and repaired

Storage

Scopes must be dry when stored

Do not kink or bend

Endoscope Accessories

Diagnostic Accessories

Therapeutic Accessories

Follow manufacturer’s instructions for the proper processing of each type of accessory

Rigid and Semi-Rigid Endoscopes

An Important Note:

The term “Rigid” is misleading! Rigid Endoscopes are VERY DELICATE and can be easily damaged

Rigid Endoscope Guidelines

Always follow manufacturers’ recommendations Never soak instruments for cleaning or high level disinfection in

a metal soak pan Instruments may need to be soaked in a vertical position Utilize flush ports when available to circulate (under pressure)

enzymatic detergent through the channels Lenses must never be placed in an ultrasonic cleaner Gently brush clean the exterior and accessible lumens with the

appropriate brush Thoroughly rinse with distilled water and rough dry Inspect instruments for cleanliness, missing parts, and damage. Thoroughly air-dry instruments Remember that these instruments are fragile and must be

handled carefully

Clean carefully and check for missing parts

Inspection

Check surfaces of the telescope for visible damage

Inspect for clarity using white paper with writing on it

Check the eyepiece seal for visible damage

Laparoscopic InstrumentsMinimally Invasive Instrumentation

Inspect Insulation for Damage or Wear

Insulation Testers are available

Loaner Instrumentation

Owned by the vendor and brought in for a specific case

Can have a significant impact on Central Service workload

Loaner Instrument Processes

Log Receipt of Loaner Instruments and Implants. Include the following information: Date Time Signature of delivery person Initials of receiving person Doctor’s name Patient’s last name Number of trays Inventory check of tray(s) for completeness Inventory check of tray(s) for damaged items.

Loaner Instrument Processes

ALL Loaner instruments must be decontaminated by the receiving facility before use

After cleaning and decontamination, inspect and assemble instruments for sterilization. Defective instruments should be documented

Sterilize according to manufacturer’s instructions

After sterilization, place in a low traffic area and handle as little as possible before use

As technology advances, instruments (and the Central Service Technician’s

job) become more complex...