INTRODUCTION TYPES OF SURGICAL INSTRUMENTS

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1 Sterile Processing University, LLC Module 21: Types of Surgical Instruments and Specialty Devices Part I [Technician] Copyright Sterile Processing University, LLC 2016 All Rights Reserved. This material may not be copied or used without permission of SPU. LEARNING OBJECTIVES: 1. Discuss the materials used to manufacture surgical instruments. 2. Describe the classes and categories of surgical instruments. 3. Understand the structure and grades of surgical instruments. 4. Understand the various types of equipment available to test devices. 5. Describe the various inspections needed to ensure proper working order of surgical instruments. 6. Discuss special considerations associated with orthopedic and spinal sets, powered instruments, endoscopic equipment, dental instruments, and other specialty items. INTRODUCTION Reprocessing surgical instruments and devices is the direct responsibility of the SPD technician. It is important that SPD technicians understand instrument materials, categories, structure, and grades to help ensure patient safety and surgeon satisfaction and to help prolong the life of instruments. Each instrument is designed for a specific purpose and should never be used for any other purpose. The manufacturers of surgical instruments must provide processing instructions with each instrument manufactured. For the safety of the patient and the satisfaction of the surgeon and to help prolong the life of the instrument, it is imperative that these instructions be followed. Specific training is required for surgical instrumentation and devices because of their high cost and the implications for patient safety. Instruments that are not tested or assembled correctly can cause harm to a patient and/or delay the surgical procedure. Staff should be trained in all surgical instruments in use, according to the specific set (see the section on count sheets). Competencies in the identification, care, handling, and testing of surgical instruments should be determined initially and verified annually. This chapter provides general guidelines to help SPD technicians do the best possible job when handling and caring for surgical instruments. MANUFACTURING MATERIALS TYPES OF SURGICAL INSTRUMENTS Stainless steel is the material of choice in the manufacture of surgical instruments. Two types of stainless steel are used: 300 series ( austenitic ) stainless steel and 400 series ( martensitic ) stainless steel. The 300 series stainless steel is used to manufacture basins, bowls, malleable retractors, and the like. (The word malleable means capable of being shaped or formed, as by hammering or pressure.) Ribbon retractors are surgical instruments made of malleable metal 1

2 molded into various shapes to assist the physician in holding back tissue during surgery. (See Figure 9-1.) Stainless steel in the 300 series is very corrosion-resistant. The 400 series stainless steel is used for such instruments as scissors, forceps, osteotomes, and chisels; this type of stainless steel is hardened with extreme heat and can become magnetic. It can be brought to a very sharp cutting edge and will hold the edge during continuous use. However, it might be more prone to corrosion than 300 series stainless steel. Whether the stainless steel is of the 300 series or the 400 series, it is only stain-resistant and will pit and corrode when improperly handled. Some surgical instruments are made from titanium, a very strong and non-magnetic metal that can be recognized by its blue color. It is much stronger than stainless steel and very light in weight (an important factor in preventing surgeon fatigue). In general, titanium instruments are found in microsurgical instruments such as cardiovascular and ophthalmology (eye) sets. Figure 9-1 Malleable ribbon retractors CLASSIFICATION OF SURGICAL INSTRUMENTS There are five basic categories of surgical instruments: Hand-held Microsurgical Powered Endoscopic Laparoscopic (including robotic instruments) Microsurgical instruments are usually classified as hand-held instruments, but they require special care and handling. CATEGORIES HAND-HELD INSTRUMENTS There are seven basic categories of hand-held instruments: 2

3 Hemostats, which are primarily used to clamp arteries to stop the flow of blood but might also be used to dissect tissue Scissors, which are used to cut and dissect tissue and to cut dressings and sutures Needle holders, which are used to hold suture needles Forceps (tissue and dressing), which are used to manipulate and grasp tissue, sponges, and dressings Retractors, which are used to hold back tissue and organs Laparoscopic instruments, which are used in minimally invasive surgery (MIS) Miscellaneous instruments (e.g., knife handles, towel clamps, sponge sticks) Surgical instruments can be generally categorized according to the following uses: Instruments used to cut or incise are usually referred to as sharps. They include scissors, knives, scalpels, chisels (Figure 9-2), and osteotomes (Figure 9-3), among others. Hand-held and self-retaining retractors are used to retract tissue or organs. Examples are instruments such as skin and bone hooks (Figure 9-4). Instruments used to grasp, hold, or occlude tissue include hemostats and dressing, tissue, and bone-holding forceps. Instruments can be used to dilate or enlarge openings or to find an area or foreign object. This category includes probes, catheters, drains, and cannulas. Instruments that aspirate, inject, or infuse are used to remove unwanted fluids from a patient or to inject needed fluids into a patient. They include certain needles, trocars, and cannulas. To close or rejoin a wound or an area (e.g., a blood vessel, nerve, or tissue), a variety of products can be used, including staples, ligating clips, suture, and suture needles. 3

4 Figure 9-2 Chisels Figure 9-3 Osteotomes 4

5 Figure 9-4 Skin hooks STRUCTURE Hand-held instruments are generally composed of the following parts: Jaws, the part that comes into contact with the patient A box lock, the weakest part of the instrument and the part most difficult to clean Shanks, which provide the closing force A ratchet, which holds the instrument closed and which is difficult to clean Finger rings, which are used to grasp the instrument and control the action of the jaw and which can be open or closed, round or oval 5

6 JAWS BOX LOCK SHANK RATCHET FINGER RING Figure 9-5 Anatomy of an instrument GRADES AND OTHER CHARACTERISTICS OF HAND-HELD INSTRUMENTS There are three grades of surgical instruments: Surgical grade: Surgical-grade instruments are the instruments of highest quality and are reusable. Although other countries manufacture surgical instruments, the steel from the United States and Germany is considered to be of the highest quality. Therefore, it is important to know the origin of the base steel used to manufacture an instrument. The country of origin, the catalog number, and the name of the manufacturer are usually etched on the instrument. Today, some surgical instruments are manufactured in Malaysia, Hungary, Poland, and Pakistan. The FDA requires that the country of origin of the stainless steel be stamped on the surgical instrument. Therefore, it is possible to be using surgical-grade instruments that are stamped Pakistan or some other country. It is important to differentiate these instruments from floor-grade instruments. Floor grade: Floor-grade reusable surgical instruments are made from a lower grade of stainless steel. They are usually referred to as Pakistani because that is where they originated. The majority of Pakistani instruments are manufactured to be single-use or limited-use. To identify them, it is necessary to read the marking or etching on the instruments. Such instruments usually have a mirror or shiny finish, and the serrations are not as finely filed as those of surgical-grade instruments. Because of their lower quality and their tendency to rust quickly, floor-grade instruments should not be used in OR sets. Disposable: Disposable instruments, which are intended to be used only once, are stamped single use and should never be reprocessed. One of the biggest differences between surgical-grade instruments and floor-grade instruments is the manufacturing process. The final stage in manufacturing surgical-grade instruments is 6

7 passivation, a process in which a chemical dip (usually nitric acid) removes all debris and creates a layer of chromium oxide. The chromium oxide layer makes the instrument more resistant to corrosion, rust, and stains. Steam sterilization and the regular use of a water-soluble lubricant reinforce this protective coating. Rust and corrosion can occur if the passivation layer is damaged (Figure 9-6). Figure 9-6 Rust on scissors blades and needle holders Some brass or non-stainless steel ( carbon steel) instruments are manufactured with chrome plating. However, most instruments are now stainless steel because of the tendency of chromeplated instruments to chip. Chipping exposes the carbon layer underneath, which can contaminate stainless steel instruments. In addition, stainless steel can be resharpened, but chrome-plated instruments cannot. Hand-held instruments also vary in other characteristics. Some have gold or black finger rings. Instruments with gold finger rings have tungsten carbide edges or inserts. Tungsten carbide is a very strong metal that keeps scissors sharp longer and prevents the jaws of needle holders from wearing out quickly. Tungsten carbide needle holder inserts can be replaced when they are worn or broken; the entire needle holder need not be replaced. Microsurgical scissors do not have tungsten carbide blades because the blades are too small. Scissors with black finger rings are often referred to as supersharps. These scissors are very sharp, and one edge may be slightly serrated; they must be sharpened with great care to prevent permanent damage. Hand-held instruments have shiny, satin, or black (ebonized) finishes. Instruments with a shiny finish do not show stains as quickly; but, because they reflect the bright light in the operating room, they can cause the surgeon and OR staff to experience eye fatigue. For this reason, a satin finish is preferred. Instruments intended for use in laser procedures often have a black coating to help absorb the light; seen under a microscope, this surface is very irregular. LUBRICATION Most surgical instrument manufacturers recommend regular lubrication of surgical instruments to keep them in good working order. Instruments that require lubrication should be treated with the type of lubricant that is recommended by the instrument manufacturer and that is compatible with the subsequent sterilization process. Water-soluble lubricants are compatible with steam sterilization (AORN, 2016). 7

8 The lubricant should always be prepared according to the lubricant manufacturer s instructions. The recommended quality of the water used to dilute the lubricant varies with the lubricant manufacturer, but critical water (distilled, deionized, or RO water) is usually recommended. Diluting with tap water might leave crystals that could interfere with sterilization (Bartnett, 2008). Instruments should be cleaned before the lubricant is applied. Cleaning, particularly ultrasonic cleaning, removes lubricants from instruments. Lubricants decrease friction between working surfaces. (Bartnett, 2008) When carefully selected, lubricants can do much more than reduce friction and wear; they can lengthen the useful life of an instrument. Lubricants for medical equipment and invasive surgeries have obvious health and safety requirements. For example, hygiene and environmental regulations require lubricants to be discrete, non-toxic and effective. (Bartnett, 2008) The lubricant should be water-soluble and should be recommended for use on instruments. An oil- or grease-based lubricant should never be used, because it will interfere with the sterilization process. Steam, for example, cannot penetrate oil or grease; only waterbased surgical lubricants are steam-penetrable. Using an inappropriate lubricant can thus lead to inadequate sterilization of surgical instruments and, ultimately, adversely affect surgical outcomes. Sometimes the lubricant is referred to as instrument milk because most of these products are white in color. Some lubricants are available pre-mixed, whereas others are concentrated and must be diluted. It is important to read the lubricant manufacturer s IFU to determine the quality and quantity of water that should be used for dilution. If the lubricant is over-diluted, it will not be effective. Conversely, if a lubricant is too concentrated or too heavily applied, it will result in slippery instruments that are difficult to handle. Devices may also be mistakenly identified as being wet after sterilization if they have concentrated lubricant on them. (Bartnett, 2008) Because most instrument lubricants are not microbicidal, they might have a use-by date (expiration date) to limit the use of the product (microorganisms can grow in the solution and then be deposited on the instruments). The lubricant manufacturer s instructions for use and expiration dating should always be followed. Instruments can be lubricated manually, or the lubricant can be applied mechanically in an instrument washer. When lubrication is performed manually, the instrument milk bath should be located in the preparation and packaging area, not in the decontamination area where it could become contaminated. For manual lubrication, the instruments should be opened and dipped into the lubricant solution, not allowed to soak. If too much lubrication is used, it can build up and cause instrument joints to stick. The instruments should be placed in the lubricant solution for the length of time specified by the lubricant manufacturer and then allowed to air dry. The lubricant should not be wiped or rinsed off. The container should be washed and thoroughly rinsed before it is reused. For convenience, some automated washers have a preprogrammed lubrication cycle to facilitate routine lubrication. (Bartnett, 2008) When a container is used to lubricate instruments manually, the lid must be kept on the container and the container must be marked with the lubricant s expiration date (if one is specified by the lubricant manufacturer). It is important to see the lubrication step not merely as an add-on but as a proactive step in the instrument care process that provides a film of protection against wear from metal-on-metal 8

9 friction of moving joints. If carefully selected, lubricants can lengthen the life of surgical instruments by: 1. Reducing wear and friction 2. Preventing staining and rusting during sterilization and storage 3. Contributing to ease of use 4. Preventing corrosion due to friction (Bartnett, 2008) Do not assume that all instruments should be lubricated. It is important to verify that the instrument manufacturer recommends lubrication; some implant manufacturers, for example, do not recommend that the screws or plates be placed in instrument milk. (See Chapter 5.) It is also important to verify in the IFU that the lubricant is compatible with the sterilization process to be used. For example, not all instrument lubricants are compatible with low-temperature sterilization methods. Some lubricants will react with the EO and cause the instrument to freeze. Some manufacturers do not recommend lubrication of ophthalmic instruments. This is why reading the lubricant and instrument manufacturer s IFU is critical. SPOTTING, STAINING, PITTING, AND MARKING OF INSTRUMENTS As noted earlier, one way in which high-quality instruments are protected from corrosion is passivation, the final manufacturing step. In the passivation process, a shielding outer layer or shell is applied (usually by means of chemicals), creating a microcoating of chromium oxide that hardens the steel and makes it less prone to corrosion and rusting. The passivation layer can be damaged by improper handling (e.g., dumping instruments, scratching instrument surfaces, using certain metal brushes for cleaning), by the use of improper cleaning agents or chemicals (e.g., saline, bleach), by residues from reusable textiles, by hard-water deposits, and even by immediate-use steam sterilization (because of the rapid temperature changes). Ultrasonic cleaning can also remove the passivation layer. The passivation layer is less affected by environmental factors such as air or water. Blood, pus, and other secretions contain chloride ions that can lead to instrument corrosion, most often appearing as dark spots. If blood is left on instruments for more than 20 minutes, the instrument will be marked and stained, especially if the blood is allowed to dry. Therefore, every instrument should always be cleaned and dried thoroughly after use. Only a clean instrument should be sterilized. The most damaging procedure is to allow dried-on debris to become baked-on in the steam sterilizer. The temperature of a steam sterilization cycle (250 F to 275 F [121 C to 135 C]) will cause chemical reactions that can make staining permanent and cause instrument corrosion. Unlike stains, spots can usually be removed from instruments by wiping the instrument with a cloth or using a pencil eraser (it is important to wash the instrument afterwards to remove eraser marks and residues). Spots can result from improper water quality, from steam residues, and from poor cleaning. Spotting associated with steam residues usually can be prevented by the installation of steam filters in steam lines. The filters should be installed and maintained according to the filter manufacturer s instructions. Tap water can also cause staining of instruments. Tap water contains a high concentration of minerals, including chlorine, which can be seen as a fine deposit (water spot) on the instrument surface. Rinsing with critical water (distilled, deionized, or RO water) eliminates such deposits. If water with high mineral counts is left on an instrument, there can be severe staining. Therefore, 9

10 it is important to dry instruments immediately and thoroughly and never to allow them to air dry. Air drying also increases spotting and rusting. Instead, instruments should either be dried using instrument air or placed on a clean, lint-free towel and gently blotted with another towel. A stain is part of the surface of an instrument and usually cannot be removed. One of the most common causes of staining is electrolysis, which occurs when dissimilar metals are exposed to a solution at the same time (see Chapter 5). The cleansers and cleaning agents used in SPD can also cause instrument corrosion. Black or rust-colored stains can be caused by highly alkaline detergents; the black stains are a result of under-neutralization of the alkalinity of the detergent, whereas the rust-colored stains result from over-neutralization of the alkalinity (Kaiser, et al., 2000). The use of strong substances, such as acid- or alkaline-based solutions, can lead to pitting and staining. (See Chapter 5.) As noted earlier, rusting of instruments can occur when floor-grade instruments (which tend to rust quickly) and surgical-grade instruments are mixed together. Rusting can also be caused by high rust content in the water. Although some stains can be removed, rust will leave permanent damage, compromising the integrity of the instrument. INSPECTION OF HAND-HELD INSTRUMENTS Each and every time an instrument is handled, it should be inspected for cleanliness and proper working order. Instruments should be inspected by SPD personnel when the instruments are received new in the department, whenever they enter the decontamination area, and when they are being assembled and packaged for sterilization. In the OR, before use, they should be inspected by the OR staff. The best means of performing a thorough inspection is to use a lighted magnifying lamp (Figure 9-7). Each instrument must be checked for cleanliness, function, alignment, tension of ratchets, stiffness, cracks, loose screws, and burrs. The plating of chrome-plated instruments should be checked to ensure that it is not cracked or missing. Instruments with missing or cracked plating cannot be effectively cleaned or sterilized because the surface of the instrument is no longer intact (Figure 9-8). It should be noted in Figure 9-8 that the finish of the handle of the retractor at top has been removed. Such an instrument should not be used, but rather sent for repair.) Figure 9-7 Lighted magnifying lamp 10

11 Figure 9-8 Handles of surgical instruments (top: handle s plating has been removed; bottom: handle s plating is intact) The inspection of instruments using a lighted magnifying lamp should not be seen as an additional step in the assembly process but rather as a part of the routine. In addition to making it easier to identify defects and improper cleaning, use of lighted magnification reduces eye fatigue and enhances visualization of the manufacturer s catalog number etched on the instrument. Each type of instrument has its particular quality check that needs to be performed. Microsurgical instruments (e.g., eye instruments) should be inspected under a microscope to detect defects that might not be visible even with a lighted magnifying lamp. If an instrument is found to be soiled, it should immediately be sent back to the decontamination area for re-cleaning. At no time should any cleaning be performed in the preparation and packaging area, which is a clean area where personnel are not wearing PPE. Instruments should also be checked to determine if the surface is intact. If there are any signs of pitting (dark black craters on the surface of the instrument), rust, chipped or missing plating, or cracks in the box lock, the instrument must be removed from service and replaced because any defects in the surface of the instrument will interfere with proper cleaning and sterilization. When new instruments are purchased and received, they should be inspected for damage, and it should be verified that they are the correct instruments (as ordered). The instruments should then be unpackaged and washed. Cleaning new instruments before use is important because instrument manufacturers coat the instruments with an oily material to protect the instruments during shipment and storage. This residue can be toxic to patients if not removed. NOTE: After new instruments are washed, they cannot be returned to the manufacturer. New instruments that will not be used immediately should be cleaned, dried, and stored in an area that will protect them from dust and damage. During storage, ratchets should be kept open to avoid excessive pressure on the box lock, which can damage the instrument. Inadequate cleaning can result in the buildup of debris in the box lock, which can cause the instrument to freeze or stiffen. Lubrication does not solve this problem. The instrument needs to be returned to the decontamination area for thorough cleaning, including the use of an instrument-safe paste applied directly into the box lock and a small brush to work the paste into the joint. Manual cleaning should be followed by thorough rinsing, ultrasonic cleaning, and another rinsing. 11

12 MEASURING GUIDELINES It is important to measure instruments to ensure that the correct instrument is placed in the set or package. The overall length of hinged instruments is determined by measuring from the tip of the finger rings to the end of the jaws. For retractors, several measurements are needed; the distance from the tip of the handle to the tip of the blade (the depth) is measured, then the length and width of the retractor blade. For scissors, the blade length is measured from the screw point to the tip of the blades. It is helpful to keep instrument catalogs in the preparation and packaging area as a reference for verifying catalog numbers and checking instrument sizes and other characteristics. SPECIAL CONSIDERATIONS FOR SPECIFIC TYPES OF HAND-HELD INSTRUMENTS Hemostats: Hemostats must be inspected for cleanliness at the jaws, in the box lock, and in the ratchet. The jaws should align correctly, with no gaps. As stated previously in this chapter, the box lock is the weakest part of an instrument; a great deal of pressure is exerted there, and it is there that most cracks will be noticed. Debris often builds up in this area, and two things can occur. First, the debris can lead to corrosion. Second, the debris can cause sufficient pressure on the box lock to cause a fracture (cracked box lock). If the box lock cracks, the instrument is usually not repairable. A cracked box lock weakens the instrument, which can then fail (break) while in use, and also permits blood and body fluids to enter, making effective cleaning and sterilization virtually impossible. Cracked box locks can be detected by the appearance of a fine black line across the box lock of the instrument (Figure 9-9). Figure 9-9 Cracked box lock The function of the ratchet can be checked by closing on the first ratchet, holding the instrument by the tips, and gently tapping the handle on a table; the instrument should not open. This test need not be performed each time the hemostat is processed; it is mainly done when OR personnel complain that the hemostat does not feel right when handled. Hemostat jaws have various patterns, depending on the intended use of the hemostat. The serrations can be horizontal (the lines are straight across), longitudinal (the serrations are placed lengthwise from the tip of the jaws), or criss-crossed (similar to a diamond design). Scissors: Many types of scissors are used in the operating room. They vary in length and style and can be curved or straight, sharp or blunt. In general, curved scissors are used to cut and dissect tissue, whereas straight scissors are used to cut sutures and to cut tissue when a smooth, straight cut is desired (e.g., to cut a damaged nerve or blood vessel). Scissors can be 12

13 used for probing, dissecting, or spreading tissue. These types of scissors should never be used to cut paper or tubing; bandage scissors should be used for this purpose. Commonly used types of surgical scissors include Mayo scissors, which have heavy curved or straight blades with rounded tips; Metzenbaum (Metz) scissors, which are similar to Mayo scissors, but lighter and more delicate; and Iris (dissecting) scissors, which resemble cuticle scissors but are more delicate in style. Operating or general-use scissors can be used to cut sutures and gauze. The heavier types, also known as wire-cutting scissors, are used to cut fine wire sutures and can be identified by their angular blades with serrated edges and a groove to hold the wire as it is being cut. Scissors must be checked for sharpness, according to the manufacturer s instructions, each time they are processed. In general, the best way to check sharpness is to cut through a product made to simulate tissue. These testing products are available in two thicknesses and latex or latex-free. The thicker product should be used to test large scissors (scissors 4.5 inches [11.4 cm] or longer in length); the thinner product should be used to test smaller scissors (scissors 3 to 4 inches [7.6 to 10 cm] in length). Two or three cuts should be made through the testing product, using the distal third of the blade of the scissors. If the scissors cannot cleanly cut through the material or if it snags the material, the scissors should be removed from the instrument set and repaired. The final test is how the scissors feel. Scissors should open and close smoothly and should not jump, grind, or feel loose (Integrated Medical Systems, 2015). The blades should be inspected for correct alignment each time the scissors are processed. Incorrect alignment of the blades will affect the functionality of the scissors and will have an impact on sharpness testing. The screw that holds the two blades together should be checked to ensure that it is not too loose, which can affect the scissors alignment. Figure 9-10 Testing scissors for sharpness A lighted magnifying lamp should be used to inspect the tips of scissors for cracks, cuts, or missing tips serious problems if not noticed until they are being used in surgery. The screw of the scissors (located in the box joint) also needs close attention; this screw can be loose or missing and soil can become trapped there. For scissors with tungsten carbide blade inserts (the inserts cannot be replaced in this type of scissors), the entire blade surface should be inspected for pitting or cracking, especially along the insert line. Dissecting scissors should never be used to cut suture, dressings, or wire. Such misuse can result in dullness and permanent damage to the scissors. Damaged scissors can cause tearing of tissue and delayed healing. 13

14 Needle Holders: Some needle holders have stainless steel jaws; and, as noted earlier, others have tungsten carbide inserts (these instruments have gold handles). When stainless steel jaws become worn, the needle holder must be discarded. Tungsten carbide inserts are usually soldered or welded to the jaws or working ends of the needle holders. Soldered tungsten carbide inserts can be separated from the instrument and replaced when they become worn. However, welded tungsten carbide inserts cannot be separated and therefore are not replaceable. Tungsten carbide inserts hold the suture needle better and prolong the use life of the needle holder. It is important to inspect the tungsten carbide inserts each time to ensure that they are intact. If part or all of the tungsten carbide jaw is missing, the needle holder should be sent for repair. Figure 9-11 Tungsten carbide jaws When inspecting needle holders for wear, close attention should be paid to the upper half of the jaw, where the needle is actually held. One way to inspect the jaws of the needle holder for wear is to close the needle holder tightly and hold it up to a light. If the jaws are worn, light will be seen through the top part of the jaw. (The jaws of needle holders must close tightly so that little or no light shines through the tips of the closed jaws; they must be able to hold suture material.) Wear on tungsten carbide needle holders can be detected by the appearance of a shiny or smooth spot on the jaw insert. This method also works well for smooth-jawed needle holders such as Webster or Halsey instruments. Alternatively, a suture needle can be placed in the jaw; the needle holder is closed tightly, and the needle is twisted and pulled. If the needle can be turned or removed from the jaws, the needle holder needs repair. Ratchet and clamp tests should be performed in the same manner as for forceps. These tests do not have to be performed each time the needle holder is processed; they are mainly done when OR personnel complain that the needle holder does not feel right when handled or experience other difficulties with the instrument. Figure 9-12 Missing piece of tungsten carbide jaws 14

15 Needle holders are referred to as Mayo Hegar, Crilewood, Webster, or other names according to the size of the jaws. The larger the suture needle, the larger the needle holder jaws must be. Needle holders should never be used as pliers to pry open or twist caps; such misuse can break the jaws of the needle holder. Figure 9-13 Inspection of instrument for stiffness Forceps: There are many types of forceps. They vary in length. Some (called tissue forceps) have teeth; others (usually called dressing forceps) do not. Specialty forceps used in surgery are called atraumatic. Atraumatic forceps have specially designed gripping surfaces that will firmly grip delicate tissue without damaging it. When inspecting forceps, it is important to ensure that the tips and serrations are clean and free of debris. A lighted magnifying lamp can be used to check for missing teeth in toothed forceps; the teeth can be very small, and a missing tooth might not be readily noticeable with the naked eye. The tips of forceps should also be checked for proper alignment and to ensure that the forceps are not sprung. The handle end of the forceps (where the parts of the forceps are connected) should be checked for cracks. Serrated handles are difficult to clean and need to be inspected for residual soil. Figure 9-14 Check that forceps tips approximate (using lighted magnifying glass) 15

16 Retractors: As noted earlier, retractors are used to hold an incision open or to hold other organs or tissue out of the way so that the surgical site can be visualized. Many types and sizes of retractors are used for this purpose. Which specific retractor is used depends on the type of surgery being performed. Examples of retractors include Richardson-Eastman, Mayo, Jansen Mastoid, Weitlaner, Cerebellum, Gelpi, Volkman Rake, Green, Goiter, Army-Navy, Balfour, and Deaver retractors. There are three basic types of retractors: hand-held, self-retaining, and table retractors. The use of hand-held retractors requires the help of an assistant, whereas self-retaining retractors have a mechanism that allows them to be used by the surgeon without need for an assistant. Selfretaining retractors are held open by their own action and may be used in conjunction with hand-held retractors. Small retractors, such as skin hooks, are held by the fingers or hand and are used to retract skin and subcutaneous tissue in shallow surgical areas. Larger, heavier instruments are used to retract muscle tissue and organs in deeper surgical sites. Most small retractors are used at the beginning of surgery; the larger retractors are used later during the surgical procedure. Table retractors are large, have a variety of blades, and are used primarily in major surgical procedures. The Bookwalter retractor can be used for cholecystectomy, retroperitoneal resections, nephrectomy, abdominal aortic aneurysms, iliac femoral grafts, abdominal hysterectomy, appendectomy, hernia repair, and transplant procedures. The Thompson-Farley retractor is used primarily in anterior cervical, posterior lumbar, anterior lumbar, and other spine procedures. The Omni-Tract retractor can be used in general, gynecological, vascular, urological, and orthopedic procedures. Multi-part retractors (e.g., Balfour retractors) might have to be disassembled for cleaning and sterilization and reassembled before use; the manufacturer s IFU should always be followed. When being inspected, retractors should be checked for cleanliness, loose or missing screws, broken welds, burrs, nicks, and loss of plating. Self-retaining retractors should be checked to ensure that the mechanism that holds the retractor open is working properly. The release lever should be activated and should spring back into place without assistance. Hand-held retractors are commonly used in pairs. They can be sharp or blunt. If a pair of retractors is needed for a set, it is essential that the two retractors are identical (e.g., four-prong, sharp rakes). Figure 9-15 Matched four-prong blunt retractors All edges should be checked for sharpness. Thumb ratchets and other mechanisms should work smoothly. The ratchet teeth should engage properly, with adequate holding power. Table retractors must be inspected to ensure that all screws, bars, couplings, and other parts are present. 16

17 The metal finish of ratchets and other surgical instruments will eventually flake off. The first indication of this wear is the appearance of the metal surface. To determine if a finish is unstable, follow the steps below: 1. Put on a pair of examination gloves. 2. Hold the instrument above a white piece of paper. 3. Aggressively rub the instrument with your gloved hands. 4. Examine the piece of paper for metal flakes. 5. If there are flakes on the paper, remove the instrument immediately and discontinue use. Rongeurs: Rongeurs are manually operated instruments used for cutting or biting bone during orthopedic procedures and surgery of the skull or spinal column. The tips should be inspected to ensure that the cutting surfaces meet evenly and, in the case of ejector rongeurs, that the pin/bar is not bent. If the cutting surfaces do not meet evenly or the pin/bar is bent, the tip could be weak, which might lead to tip failure. Various models of rongeurs are available for various uses; the Kerrison rongeur, for example, has standard, detachable, ejector, and non-ejector models. The ejector permits opening of the top of the rongeur to facilitate cleaning; the top remains attached to the instrument. The ejector Kerrison also has an ejector pin that is ideal for keeping debris from backing into the jaw. The detachable model permits complete removal of the top part of the rongeur for cleaning and inspection. The ejector tip pin/bar should be examined to ensure that it smoothly retracts into the instrument shaft. Kerrison rongeurs also come in single-action and double-action models. The single-action Kerrison is used for delicate cutting in confined areas, whereas the doubleaction model is used in larger places. Figure 9-16 Various types of rongeurs 17

18 The traditional Kerrison rongeur cannot be opened for cleaning. It is critical that the SPD technician be thoroughly in-serviced in the opening, closing, and reassembly of the ejector and detachable types of Kerrison rongeurs. Some Kerrison rongeurs are indicated for cervical procedures and others for lumbar procedures. Cervical rongeurs are lighter and more delicate than spinal rongeurs. The specified type of procedure (e.g., cervical) is sometimes stamped on the instrument. For Kerrison rongeurs without ejectors, bone is prone to becoming wedged inside the tips. Several products on the market can be used to test the sharpness of rongeurs. The rongeur s jaws (cup) should be measured to ensure that the size is correct. Kerrison rongeurs should be tested for sharpness with an index card (e.g., 3 inch x 5 inch [7.6 cm x 12.7 cm]). The jaws of the rongeur should cut through the card with no tearing or snagging. The same process should be used for double-action rongeurs. In the inspection of rongeurs, it is very important to check the screws because the vibration from ultrasonic cleaners might cause the screws to loosen or fall out. Rongeurs must be free-moving and have no bone or tissue in the cup, no burrs on the cutting edges, and no gaps when closed. They should be left open for sterilization. Ultrasonic cleaning removes all lubrication; therefore, proper lubrication is required to ensure that parts move smoothly and freely. The manufacturer of the Kerrison rongeurs should be consulted about lubrication; some manufacturers recommend that the rongeur be placed in an instrument lubricant bath and operated to ensure that the lubricant reaches all moving surfaces. Figure 9-17 Kerrison rongeurs Rasps: Bone rasps are used to smooth, cut, and clean bone. Because of their design, they are prone to entrapping bone in the serrations. Rasps should be carefully inspected using lighted magnification and routinely sharpened by an instrument repair service. Figure 9-18 Bone rasp 18

19 Suction tubes: Suction tubes are used to remove blood, tissue, and fluids from the surgical site to allow the surgeon a clear view during the operative procedure. Suction tubing is connected to a suction canister marked with volume measurements to show how much fluid has been removed. Suction tubes are available in a variety of lengths and diameters; many have a stylette, which is used to clean out the suction tube during the surgical procedure. The stylettes should be included in the set but should not be inserted inside the suction tube for sterilization. Several types of suction tubes can be used, depending on the procedure. Some suction tubes have removable tips that require close attention during the cleaning process. Unless otherwise directed by the suction tube manufacturer, the tip should be separated from the suction tube for sterilization. It is important to ensure that the tip does not get misplaced inside the set (for example, it can be placed in an autoclaveable bag). It is also important to ensure that suction tubes are free of debris: a blocked suction tube is of no use in surgery. Examples of suction tubes include the Poole Abdominal, Frazier, Rhoton, and Yankauer suctions. A risk management clinical engineer at a major hospital system found that standard suction tips contain debris, even after being cleaned and disinfected according to the manufacturer s IFU. The clinical engineer claimed that a design flaw in regular Yankauer suction tips caused debris to clog out of reach of cleaning brushes. That is, the poor design of some tools makes them impossible to clean. When the clinical engineer s team cut open and viewed 350 suction tips, they found blood, bone, tissue, or rust debris still left inside the instruments. This problem is illustrated in the photo below (Figure 9-19). (SurgiMark, 2016) Figure 9-19 Inside of a sterile Yankeur suction tube Dermatomes: Dermatomes are surgical devices used in plastic surgery to obtain or create skin grafts of various sizes to be used to replace damaged skin, especially for burn patients. Dermatomes require blades for cutting, which are usually provided pre-sterilized by the manufacturer. The system should be visually inspected for damage or wear, and the action of the moving parts should be checked to ensure that they are working smoothly throughout the intended range of motion. If any damage or operating deficiencies are found that could compromise the function of the instrument, it should be sent out for repair as soon as possible. 19

20 Figure 9-20 Dermatome Skin graft meshers: Meshgraft is a tissue expansion system that is used in conjunction with a dermatome to prepare skin grafts for burn patients. The system creates perforations in the skin graft to expand donor skin when the grafting site is large and the supply of donor skin is limited. The unit consists of a ratchet handle, stable handle, continuous feed roller, cutter, and guidance plateau. The system can accommodate various skin thicknesses through the use of a skin carrier. To minimize damage to the blades, it is important not to place the cutter directly on a table. The cutters cannot be re-sharpened so they must be replaced if damaged or worn. Figure 9-21 Graft mesher with cutter in front Demagnetization: Demagnetization eliminates magnetically induced changes in the material of a surgical instrument, but does not change the material s basic properties. Most surgical instruments, including forceps, clamps, scissors, and retractors, are made from combinations of metals, such as iron, cobalt, nickel, and alloys, and can therefore become magnetized. Some common causes of magnetization of surgical instruments are the machining stresses during manufacture, as well as scrubbing, repair, polishing, and handling. Some delicate and microsurgical instruments become magnetized when they are exposed to a motorized device or are used near a magnetic pad or needle counter. Magnetization is most often a problem associated with eye, plastic surgery, and microsurgical instruments. When an instrument becomes magnetized, it causes surgical needles to cling, 20

21 wrap around, and bend away from needle holders, instruments to cling together on trays, fine tissue to stick to the instrument, and metal particles to cling to instruments. When OR personnel report that instruments have become magnetized, the instruments can be demagnetized by an outside instrument repair service or by means of a demagnetizer purchased by SPD. When using a demagnetizer, the manufacturer s IFU should be followed. To confirm that the demagnetization has worked, the demagnetized instrument should be placed next to a paper clip; the instrument should not attract the paper clip. Figure 9-22 Demagnetizer **NOTE: The Quiz for this topic is given AFTER you complete Module 23. Please click on the link below to go to Module