CH 11: Complex Surgical Instruments

Electric-Powered Surgical Instruments

Procedures where access is limited (maxiofacial, dental, small bones.) Most Common Problems: 1) Damage to electrical parts during cleaning / sterilization. 2) Condensation that enters the equipment when seals wear out. 3) Electrical contacts that become worn and affect equipment handling. General Guidelines: Don't use solvents or lubricants unless specified by the equipment manufacturer.  Can be operated with a foot switch.

Pneumatic-Powered (Air-Powered)

Small, medium, and large bones. Require a hose that can be sterilized.  Compressed Gas: From a tank or regulator. They must be pressurized for proper inspection; therefore, an air source is required in the processing area. Never immerse in any solution including water unless IFU permits it. Decontamintion Hose: Made from damaged pneumatic hoses and marked nonfunctional (red tape usually.) Air Hoses: Fail because of sterilization heat breaks down rubber and O-rings causing air leakage. Clean with mild detergent. Proper coil size is 9-12 in.

Battery-Powered Instruments

Procedures performed on larger, denser bones. Batteries/chargers are not interchangeable. Common Instruments: Dermatome/Dermabraders (harvesting skin grafts or reshaping skin surfaces.) Cebatomes (removing bone cement.) Sternal Saws (split the sternum and allow access for open heart surgery.) Dental Drills. Micro Drills (reshaping middle ear bones or driving very small wires through bone.) Wire Drivers, Drills, and Saws. Saws for specific cutting actions (reciprocating, oscillating, etc.) Clean with mild detergent. Use a decontamination battery to protect electrical components from moisture.

Continued..

How to Create a Decontamination Battery: Mark red X with marking tape/keep the batteries in decon. 

Reasons for Powered Equipment Repairs

Corrosion of internal components. Physical damage. Lack of or improper preventive maintenance.

Endoscopes/Endoscope Classification

Endoscopic Procedures: Minimally invasive (no large incision.) Some endoscopes also provide a working channel, allowing the surgeon to perform surgical procedures (operative endoscopes.) Fiber optics + LED. Types: Rigid, semi rigid, and flexible. Video or non-video for rigid and flexible. 

Endoscope Use and Selection

Rigid: Viewing anatomy where there is a straight line access to the site. Semi-Rigid: Some slight bending of the scope shaft needed to access the site. (Bladder Surgery.) Flexible: Straight line access is not possible. (Esophagus, lung, kidney, or large intestine.)

Rigid/Semi Rigid: Guidelines for Decon

Remove light source adaptors from the light post. Use a neutral-pH enzymatic cleaning solution. Hand wash (soft cloth.) Wash the working channel.  Rinse/flush with treated water. Clean with a lint-free cloth.

Laparoscopic Instruments

Very slender: 3mm to 10mm in width. Tips are the same design as general instruments with the same name. Laparoscopic insulation (for cutting/cauterizing) protects patients from electrical current that flows through the instruments / is susceptible to pin holes, cracks, tears and overall loosening = electricity leaks and burns tissue/organs. If insulation moves from the metal collar when sliding it back then repair it. Electronic testing with an approved testing device should be done prior to set assembly on the clean side of the CS department. Remove/discard disposable tips prior to cleaning.

Robotic Instruments

Heavier and more difficult to clean than standard laparoscopic instruments. Mechanical/Electrical Components: Located in the proximal end. Do not come apart for cleaning. Clean the rotating distal end and flush lumens.

Arthroscopy Instruments

Because joints are small, enclosed areas, the instruments used for arthroscopy surgery are smaller. Shavers can become clogged with debris during surgery.

Flexible Endoscope Components

Small-Diameter Flexible Endoscopes Direction: Up and down. Large-Diameter Flexible Endoscopes Direction: Up, down, left, and right. Fiber Optic or Video. External Sheath: Contains internal components/ withstands exposure to bodily fluids. Diagnostic or Operative. Reprocessing: Use protective water caps on endoscopes that come with them. Venting Cap: Allows sterilants to enter and exit the scope channels. Never use when scope will be exposed to fluids (damage.)

Types of Flexible Endoscopes

Bronchoscope: Bronchus. Gastroscope: Upper digestive tract (esophagus, stomach, and duodenum.) Esophoscope: Esophagus. Colonoscope: Large intestine. Sigmoidoscope: Lower part of the large intestine. Cystoscope: Urethra and bladder. Ureteroscope: Ureter and kidney. Rhino-Laryngoscopes: Nose, sinus cavity, or upper gastro intestinal (GI) tract.

Cleaning/Processing Flexible Endoscopes

CDC, Society of Gastroenterology Nurses and Associates Inc. (SGNA), and AAMI protocols. Basic steps required to reprocess flexible endoscopes: 1) Precleaning, 2) Leak Testing, 3) Cleaning, 4) High-Level Disinfecting (HLD/sterilizing, 5) Drying, 6) Storing.

Leak Testing

Dry Leak Testing: Attach the leak tester and pressurize the scope. Manipulate and hold the parts in each direction for 15 sec minimum. Pressure drops on the gauge = leak & send for repair. Wet Leak Testing: Pressurize scope and submerge distal end under clear water (with no chemicals), so air bubbles will be easily seen. No air bubbles when rotating distal end = fully submerged. Use syringe to flush. If air bubbles are observed exiting the endoscope after previously flushing all air out of the channel, a leak has occurred. Common Leak Areas: Bending rubber at the distal tip of the insertion tube. Drain, release pressure, verify deflation of the endoscope. Never disconnect the leak tester while submerged (water enters the leak tester.) Leaking Endoscopes: Send to manufacturer or repair.

Cleaning Steps: Flexible Endoscopes

External Components: Dried with a soft , lint-free cloth. Internal Channels: Dried with an alcohol flush or particle-free, low-pressure (-5 psi) compressed air.

General Guideline AER

Automatic Endoscope Reprocessors are machines that clean, disinfect and rinse flexible endoscopes.

Storing

With the insertion tube hanging vertically (not coiled.) With the weight of the control body supported, and angulation locks off. In a dry dust-free cabinet with good ventilation. Without removable parts but stored with the scope. Remove water-resistant cap from video scopes. Scopes stored in the same cabinet should not touch eachother.

Scope Transport

Transport loosely coiled and with their distal tip protected.

Carrying Cases/Accessories/Water Bottle

Carrying Cases: Should not be used to store an endoscope or transport the instrument within the facility. Place contaminated endoscopes in a bag prior to placing them in the carrying case. Flexible Endoscope Accessories: Diagnostic and/or Therapeutic. Water Bottle: Sprays organs, sterilize at least once a day (ideally after each use), use sterile water to fill it, never leave water in a bottle overnight.

Flexible Endoscope Instruments

Biopsy Forceps, Brush for Cytology, Cannulas for Opacification, Measuring Device, Electro-Coagulating ("Hot Biopsy") Forcep, Polypectomy Snares, Polyp Retriever, Foreign Body Forceps, Stone Management Instrument, Electrodes for Electroagulation, Injection Needle, Laser Probe.

Flexible Endoscopes: Regulations/Guidelines

OSHA Department of Transportation CDC FDA EPA AAMI, SGNA, APIC, AORN: Have written standards or guidelines.

Flexible & Rigid Endoscope Care & Handling

$750,000: Yearly repair expenses (large hospitals.) $200,00: Yearly repair expenses (community hospitals.) 60%-75%: Scope damage caused by improper care and handling. 

Storage/Transport/Procedural Use/Prep & Pack

Storage: Don't leave scopes in basins (flexible scopes will be coiled too tightly, rigid scopes will fall out of the basin.) Transport: When carrying by hand, hold rigid scopes by the housing body and not the shaft. Flexible scopes should be carried by the handle, while holding onto the distal end of the shaft and umbilical cable (if present.) Procedural Use: 50% of damage to endoscope/accessories occurs during procedures. Prep & Pack: Wipe off the distal and proximal windows with 70% isopropyl alcohol. Non Video Rigid Scopes Image Quality (typewritten print): Check from a distance of about 1 inch. 

Loaner Receipt and Inventory Procedures

Date/Time Signature of delivery person Initials of receiving person Surgeon's name  Patient's name or identifier Number of trays Number of implants Inspect instruments with a vendor representative. Verify IFUs are received and are up to date.