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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
Optical
Channel
Air/Water
Channel*Suction
Channel
*Some Flexible Scopes have
separate Air and Water Channels
Distal Tip
Flexible
Fiberoptic
Endoscope
Video Monitor
Water Bottle Light Source
Suction
Canister
Common FFE’s
Bronchoscope
Used for the direct visualization
of the tracheobronchial tree
Cystoscope
Ureteroscope
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. Preclean
2. Leak Test
3. Clean
4. High-Level Disinfect or
Sterilize
5. Dry
6. 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 Instruments
Minimally 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...

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Chapter 12 complex surgical instruments

  • 2. 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.
  • 4. What We See and Don’t See
  • 5. Powered Surgical Instruments Look Simple – Are Complex Look Durable – Are Delicate Look Plain – Are Expensive Look Easy to Clean – Are Difficult to Clean
  • 6. 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)
  • 7. 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)
  • 8. Battery Powered Instruments  Least cumbersome because there is no cord or cable  Requires batteries and a battery charger
  • 9. Example of a Battery Powered PSI and Two Styles of Batteries
  • 10. 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
  • 11. Fluid Invasion  Occurs when water or cleaning solution is allowed to enter PSIs  Fluid invasion can severely damage a PSI
  • 12. Decontamination of Batteries and Cords can protect PSIs from Fluid Invasion
  • 14. PSI Accessories  Chucks  Keys  Burr Guards  Cords  Batteries  …and much, much more!
  • 15. 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
  • 16. PSI Instrument Cleaning  PSI’s must be processed manually.  Care MUST be taken to prevent Fluid Invasion.
  • 17. 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
  • 18. Endoscopy Instruments  Endoscopes greatly reduce patient trauma when physicians perform minimally invasive surgery.
  • 19. Endoscopeman* *with permission from Lighthouse Imaging Corporation
  • 20. 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.
  • 21. Flexible Fiberoptic Endoscope  Provides optical access using a flexible, maneuverable scope most commonly inserted through a mucous membrane opening.
  • 22. 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.
  • 23. Infection Control Concerns  Flexible endoscopes pose significant infection control challenges. Their configuration makes them difficult to clean and dry and they can harbor bacteria.
  • 24. 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
  • 25. 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.
  • 26. 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
  • 28. Glutaraldehyde  High Level Disinfectant  Can be used manually or in automatic processors  Must be tested  Takes Time  Employee Safety Concerns (ventilation a must!)
  • 29. Ortho-Phthaladehyde (OPA)  High Level Disinfectant  May be used manually or in an automatic processor  Must be tested
  • 30. Automatic Endoscope Reprocessors (AERs)  Automated equipment designed to clean, disinfect, and rinse flexible endoscopes
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 39. Bronchoscope Used for the direct visualization of the tracheobronchial tree
  • 40. Cystoscope Ureteroscope Used to visualize the urethra and bladder (cystoscope) and to look for obstructions such as kidney stones (ureteroscope)
  • 41. 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)
  • 42. 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)
  • 44. Steps in Endoscope Processing 1. Preclean 2. Leak Test 3. Clean 4. High-Level Disinfect or Sterilize 5. Dry 6. Store
  • 45. Fluid Invasion  Fluid invasion can cause damage to flexible fiberoptic endoscopes
  • 46. 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
  • 47. Storage  Scopes must be dry when stored  Do not kink or bend
  • 48. Endoscope Accessories  Diagnostic Accessories  Therapeutic Accessories  Follow manufacturer’s instructions for the proper processing of each type of accessory
  • 50. An Important Note:  The term “Rigid” is misleading! Rigid Endoscopes are VERY DELICATE and can be easily damaged
  • 51. 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
  • 52. Clean carefully and check for missing parts
  • 53. 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
  • 57. Loaner Instrumentation  Owned by the vendor and brought in for a specific case  Can have a significant impact on Central Service workload
  • 58. 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.
  • 59. 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
  • 60. As technology advances, instruments (and the Central Service Technician’s job) become more complex...