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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Surgeons perform surgical procedures on kidneys, ueters, bladder, male prostate gland and internal/external male and female genitalia. Such surgical procedures are designed to cure disease, correct defects of the urinary-genital systems or transplant organs. The doctors who specialize in the diagnosis and treatment of the urinary-genital systems are called urologists. When urologists perform surgical procedures, they frequently require specialized instruments unique to the anatomy of the urinary-genital system. The following article provides information on the specialized instrumentation necessary to perform urological procedures. This article is presented as two lessons; the first lesson will review self-retaining retractor systems, microscopic instruments and dilators. Lesson two will present information concerning hand held surgical instruments used for urological procedures. Each lesson will discuss the cleaning, care and sterilization requirements the CIS must follow.
Performance of open surgical procedures on the kidneys, bladder or prostate requires the surgeon to make an incision into the abdominal cavity or the side of the patient; the latter incision is called a flank, or retro peritoneal approach. The kidneys, bladder and prostate gland are located deep within the body and, thus, retractors with deep blades are needed to provide proper exposure to the surgical site.
Hand-held retractors such as the Richardson, Deaver, Mayo and Renal Vein are commonly used for retraction during kidney or prostate surgery. Today, many surgeons use “self-retaining” retraction systems to provide the necessary exposure; these systems provide continuous exposure without the need for a surgical assistant. Since urinary-genital procedures can last several hours, the self-retaining retractors are especially helpful. In addition, self-retaining retractors can accommodate numerous retractor blades, providing exposure of the surgical site in several directions at once.
Common retractor systems are the Bookwalter®, Wishbone® Thompson® and Omni-tract®. Each system can be attached to the surgical table using metal bars. The retractor blades are fixed to the table support bar to provide exposure to the surgical site. The types of blades will vary - some will have rigid blades in the style of a Deaver, Richards or Mayo retractors; others are malleable style blades similar to Ribbon retractors.
Once the blades are locked into place, the retractors will not move. If during the surgery, it becomes necessary to reposition the retractor blades, the surgical team can easily disengage the locking mechanisms to move the blades. The CIS is responsible for learning about the different types of retracting systems used at their healthcare facility.
The urinary system contains many passageways (lumens) to help move fluids through the body to the outside. Common passageways are the ueters, urethra, and vas deferens. Passageways can be obstructed by strictures or can be intentionally closed by surgery. Dilators are instruments used to open or stretch lumens in the body to reduce strictures or to allow other types of surgical instruments to enter the lumens. Urethral dilators are a set of long smooth metal instruments, all of similar length. Dilators are differentiated by their circumference. Manufacturers’ mark the sizes of the dilators at the distal tip of each instrument. Many manufacturers use the “French” (Fr) measurement method of marking dilators. Dilator circumferences can range from 8 Fr up to 32 Fr with many incremental sizes in between.
The most common type of dilator used by urologists are urethral dilators. Urethral dilators are most often used to gradually increase the size of the urethra to allow insertion of instruments, such as a cystoscope, which will be used to visualize the interior of the urinary bladder. The most common style of urethral dilators are called “Van Buren” of which there are two basic types: the female style is a straight dilator, and the male style is curved at the tip. The urologist must always have a complete set of urethral dilators; if one size is missing, the set cannot be used. The CIS must ensure that dilator sets are always properly assembled, wrapped, labeled and sterilized before they are delivered to surgery.
Microscopic instruments used for urological procedures are designed for the anastomosis (connecting) of vessels. The vas deferens is a common structure on which a urologist would attempt re-anastomosis. The vas deferens allows the passage of sperm from the testes to the prostate. The procedure to perform a re-anastomosis on the vas deferens is called a vasovasotomy, or vasectomy reversal. This is a microsurgical procedure requiring very fine, delicate instruments. The key is small — the instruments are small and the tips of the instruments even smaller. A set of microsurgical instruments will include fine, delicate scissors, needle holders, ring and tying forceps. The ring forceps have very small open oval tips which allow for a secure grip on tissue.
Another instrument required for procedures on the vas deferens are Bowman lacrimal duct probes. Frequently found in eye trays, Bowman probes are excellent for dilating, probing, and checking the patency of the vessel or passageways. These probes are malleable; this allows the surgeon to bend them to conform to the vessel being probed.
In order to hold the vas deferens during suturing, the urologist will frequently use approximating clamps. Approximating clamps are very small single or double clamps that hold the vas deferens close together for suturing. Either disposable or reusable approximating clamps can be purchased. These clamps come with a special forcep that opens the jaws and allows gentle application to the vas deferens. Approximating clamps come in a variety of lengths and widths. The CIS must confirm that the proper sizes are included in a micro vascular tray.
Self-retaining retractors systems: Refer to and follow the manufacturer’s recommendations for specific care, cleaning assembly and sterilization of each system. Most systems can be placed in the ultrasonic cleaner and washer-decontaminator. These systems have many parts that will require disassembly prior cleaning. Some of the retractors are malleable which are bent during the surgical procedure. If bent, the CIS must press the malleable retractors back to their original (flat) shape. Knobs and securing ratchets must be opened and retractor blades removed to allow proper cleaning. Secure small washers and other pieces to prevent them from being lost in mechanical cleaning systems or down sink drains. These systems cannot be used if parts are missing.
After cleaning, the CIS will inspect all parts to ensure that they are completely clean and in proper working order. Since retractor systems have many moveable parts, the manufacturer may recommend lubrication with an approved lubricant which allows sterilant penetration. Excess lubrication should be wiped from the surface. During the assembly process, the CIS will validate that all parts are placed correctly inside the tray.
The tray should be organized to maximize instrument exposure to the sterilant, as well as, at the conclusion of the sterilization cycle, allow sterilant removal. The tray must be organized to allow a scrub person to remove the items without causing contamination. It is recommended that retractor systems be placed in a container system for sterilization. Retracting systems are often among the heaviest trays requiring sterilization. Always use good body mechanics when moving the system, and ask for assistance if necessary. Make sure that the trays do not exceed your facility’s weight limits.
Microsurgical instruments require special care not only from the CIS, but from all members of the surgical team. During surgical procedure, the micro-instruments must be handled carefully and placed on the sterile field in a manner to prevent damage. In addition, blood and saline must be constantly wiped off the instruments during the procedure. After the surgical procedure, the delicate micro-instruments must be returned to their trays or separated to prevent heavier instruments from damaging them.
When delicate microsurgical instruments arrive in decontamination, they should be hand-washed using appropriate detergent and then rinsed with copious amounts of deionized water. An automatic washing system should only be used if it will not damage the instruments. For added protection, microsurgical instruments should have their own sterilization case. The case should contain a silicone mat or other material that cushions and protects the instruments while allowing appropriate sterilant penetration.
Dilators and Probes: Decontamination of urethral dilators can often be accomplished using automated processes. During the assembly process, the CIS will inspect the surface to ensure it is clean and smooth. Nicks or defects on the surface of the dilators can tear the mucous membranes that line passageways in the body. A torn membrane increases the chance of a patient developing scar tissue and/or an infection. Clean the Bowman probes using a soft cloth to wipe the surface, and if bent, gently reshape the probes to straighten them. The Bowman probes are often sterilized as sets; ensure that all probes and the different sizes are accounted for before sterilization.
Next month the lesson will continue with a discussion about the different types of hemostatic clamps, tissue forceps, scissors and vascular clamps required for urological procedures.