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CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

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Lesson Plan CIS 200
Sterile Processing of Surgical Robotics
[Reprinted from Communiqué: March/April 2007]

Robotic surgery is not a dream of the future for today's hospitals; it is a reality. Surgical teams, including the surgeon, assistant, scrub person and circulating nurse are provided extensive specialty training before using the robotic system. Because the patient and surgical team require the support of dedicated sterile processing technicians to assure positive patient outcomes, they too must be provided specialty training. This training must take place prior to scheduling the first robotic procedure. While the sterile processing team may be the last to receive the training required to properly process robotic devices, they are vital to the overall success of the program.

Training to process robotic devices should include a brief introduction of the robotic concepts. Information outlining advantages and limitations that relate to procedures performed using this technique will be helpful. Explicit instructions are required regarding specific handling, packaging and sterilization techniques of the devices to be utilized. The manufacturer will be your resource for education materials. Insisting on written policies, procedures and competency evaluations will help to ensure the facilities 1.5 million-dollar investment is handled and processed appropriately.

Our collective imaginations have 'grown' incredibly versatile robots over the years, resulting in 'generations' of the fictitious man-made creations. Real life is following the lead. Two types of surgical robots are currently available for use in the United States. The Food and Drug Administration (FDA) must approve the robotic systems, as well as each specific type of surgical procedure to be attempted. Several additional systems are currently pending FDA approval.

Surgical robots are not designed to replace the surgeon, or any team member; they function as an extension of the team members. Advantages of utilizing surgical robots include the ability to work through even smaller port incisions. Smaller ports mean less tissue damage, and less tissue damage means less healing time is required for the patient to return to normal activities. Less physical trauma also means less pain for the patient and less potential for blood loss requiring blood replacement. Reduced hospitalization time reduces the potential for a hospital acquired infection. Using a robotic camera provides a superior view of the surgical site. Traditional laparoscopes provide the surgical team with a two dimensional picture. Robotic scopes provide the surgeon with a three dimensional view. Other team members continue to see two dimensional views on monitor screens. The robots do not get tired or hungry and have to be relieved during a procedure. Their movements are consistent in speed, force, and form. One of the more simple models consists of a single 'arm' that mounts to the operating table. It may be controlled by the surgeon utilizing a foot pedal or voice activation with the surgeon remaining in the sterile field at the patient's side. The single arm typically manipulates a traditional laparoscopic camera or holds a retracting instrument. The more complex model currently available may utilize up to five 'arms' attached to a mobile base. The surgeon scrubbed and at the sterile field, makes incisions for placement of the ports. Next, the base station that has been covered with sterile drapes is moved into very close proximity to the patient. Instrument arms are placed into the ports then 'docked' to the base station arms. As this is being completed, the surgeon drops out of the sterile field and takes his place at the control console. Both the base and control console are quite large, each being larger than a refrigerator. These components communicate by computer link-up so distance is irrelevant. They can be located across the room or across the state from each other. Microphones and speakers allow the surgeon and the surgical team members who remain in the sterile surgical field to communicate verbally. Working from the control console, the surgeon can perform a variety of procedures. Currently the FDA has approved robotics for use in open heart, urology, gynecology and neurology procedures. Voice, hand and foot controls are used simultaneously to manipulate the robotic instruments. Movements generated from the control console can mimic every movement of the human hand. Even better, the device can compensate for fine muscle motor tremors the surgeon may experience. It is truly amazing to watch just how delicate and precise the movements are to accomplish each task.

The instrument list will sound familiar to the Sterile Processing and Certified Instrument Specialist. There will be one or more flexible endoscopes, light guide cable, light guide cable adaptors, camera arm sterile adaptor, camera sterile adaptor, instrument sterile adaptor, graspers, scissors, large and small needle drivers, blades, instrument arm cannula (sheath), cannula adaptors, obturators and reducers. Education for processing these instrument components is vital. There is one critical difference from common laparoscopic instrumentation; both the instruments and scopes have electronic and microprocessors built into them. The adaptors are the computer links that connect the control console to the operating end of the instrument. Robotic instrumentation is even more fragile than general laparoscopic instruments. Currently, not all the components can be cleaned or sterilized by the same method. As with general laparoscopes, current robotic endoscopes can not be cleaned in an ultrasonic bath. The remaining components vary in the recommendation for ultrasonic cleaning. All of the current robotic endoscopes may be sterilized with gas plasma or ethylene oxide. All components (other than the actual endoscope) are to be steam sterilized, and not presently approved for processing by any other sterilization method. Flash sterilization is specifically NOT recommended for any of the components. All these variances add to the importance of thorough training and written guidelines.

Instructions for proper cleaning begin with the surgical team who should not allow debris to dry in or on the instruments. Soaking them in water or enzymatic cleanser between operative use and instrument processing is strongly recommended by the manufacturer. Flush ports and intricate movable parts require a combination of manual and ultrasonic cleaning. This process may need to be repeated until the instrument rinses clear. All instruments should be protected from mechanical shock (being dropped, striking other instruments, etc.) and stress (bending, placed under heavier instruments, etc.). As with other surgical instruments, avoid use of hydrogen peroxide, bleach, or alkaline-based cleaning agents.

Packaging and sterilization of robotic components requires a keen adherence to processing guidelines. Improper packaging or labeling of package contents will contribute to utilization of incompatible sterilization processes. Severe instrument damage can result. Labeling is also key to avoiding misplacement of individually packaged components. And as noted earlier in this lesson, the names are similar to other more common laparoscopic instruments. A great deal of stress is avoided when the proper instrumentation, in proper working order is available to the surgical team as requested. Attention to detail is crucial in selecting the appropriate packaging system and applying complete and correct labeling of the devices. Limited availability of these exquisitely expensive instruments means each piece can impact the success of every robotic surgical procedure. The Certified Instrument Specialist will play a vital role in providing sterile processing support to their facility's robotic program.

References:

Lind, Natalie; Instrumentation Resource Course: Identification, Handling and Processing of Surgical Instruments.

Intuitive Surgical, 2006; Instrument Cleaning and Sterilization Instruction Manual

Pott PP, Scharf H-P, Schwarz MLR, "Today's State of the Art of surgical Robotics", Journal of Computer Aided Surgery, 10,2 101-132, 2005

Prosurgics - Precision Robotics for Surgeons; http://www.prosurgics.com/

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