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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This is the second article of two presented to instruct the CIS about surgical instruments used for urological procedures. In the first lesson, the CIS learned about self-retaining retractor systems and their uses, instruments used to dilate and open anatomical passageways of the body and delicate instruments used for microscopic surgical procedures performed on the genital-urinary system. In this lesson, the CIS will learn about instruments used by the urologist to perform surgery on the kidney, bladder and prostate gland. The lesson will describe the need for specialized instrumentation, cleaning, care and sterilization practices to ensure that high quality care is delivered to the patient.
Urologists utilize many different types of tissue forceps and hemostatic clamps. The type of forceps and clamps used will depend on the patient’s anatomy and the planned operative approach and location of the surgical site. For example, a prostatectomy can be performed through a suprapubic incision, a retropubic incision, or by transuretheral resection. Some kidney procedures can be performed laparoscopically. Each operative approach to a procedure utilizes different instruments. The kidneys and prostate are located deep within the body; trans-abdominal surgery on these structures requires long and specialized instruments. Standard “Major” surgical trays used at many healthcare facilities frequently do not have instruments long enough to be useful for urological procedures. For this reason, many healthcare facilities will use secondary trays containing instruments that are longer and are specifically designed for such procedures. These trays are frequently identified as Major Kidney, KUB (Kidney Ureter, Bladder) or Prostate trays and will be used in conjunction with a Major tray. The CIS is responsible for learning the labeling system for their facilities surgical instrument sets and the types of procedures where each is used. Inside these specialized trays are tissue forceps, hemostatic clamps, scissors and needle holders which are eight inches or longer in length. Different types of hemostatic clamps, such as extra-long Mixter, Lahey or Tonsil clamps, can be found in these trays. The CIS should always verify that these instruments are paired and that they match in length, shape (contour) and size.
Vascular clamps that can be found in the Kidney or Prostate trays are extra-long vascular clamps. These clamps are used to manipulate and occlude vessels to prevent blood loss. Vascular clamps have very small interlocking ridges on the inside and running lengthwise of the jaws. The design provides a sure hold without causing damage to delicate tissues. Types of vascular clamps frequently placed in urology trays include the DeBakey, Renal Artery, Glover, Spoon, Wylie “J” and Santinsky. The variety of available angles, curves, overall length and tip length are necessary to accommodate the differences in anatomic structure, procedure and surgeon preference.
Tissue forceps commonly used in kidney and prostate trays are extra long Debakey, smooth ‘thumb’ forceps, Singley and Russian forceps. Like vascular clamps, the DeBakey style forceps have very small interlocking ridges inside the tips which grasp and hold tissue without causing tissue damage. The tips of the Russian forceps are cupped with ridges which allow surgeons to securely grasp and hold onto kidney stones or stones located in the bladder. Similarly, the Singley forceps tip has a loop which is open in the center that looks much like the end of a delicate sponge stick.
Randall stone forceps are another type used to grasp stones lodged inside the kidney. Randall stone forceps come as a set of five, each with a cupped tip that is designed to grasp and secure stones for removal. The forceps are about seven inches in length; one is straight while the remaining forceps have curved shanks. Each of the forceps in a set has a different degree of angulation. The downward curve of each forceps is progressively more acute. This allows the surgeon access to different areas inside the kidney. A distinguishing feature of Randall stone forceps is there is no locking ratchet mechanism.
In addition to the clamps and forceps, trays for these surgeries will contain extra-long scissors and needle holders. The most common type of needle holders used in a urology tray are: Mayo-Hegar, Ryder and Crile-Wood. Each type, as a pair, should be identical in style (design) and length.
It is the responsibility of the CIS to understand and employ the best practices when cleaning, inspecting, assembling and sterilizing instruments used in open urological procedures. The extra length, coupled with delicate design, means these instruments are even more susceptible to damage than their regular length counterparts. The weight of other instruments or retractors lying on top, over the extended shanks, can cause the instruments on bottom to bend and become misaligned. Because of their length, it is difficult to organize them on a regular instrument stringer. Damage occurs when they are ‘forced’ into and pulled out of a tray. Using a shorter stringer permits easier placement in the tray with instrument shanks parallel along the length of the tray. The variety of angles and curvature also challenges maintenance of instrument integrity. The tips can become entangled easily since the instrument does not lay flat in the tray. Placing the instruments in a single layer provides some protection. Taller rigid containers allow a combination of tray depths to permit segregation of delicate instruments. Inspection of urology instruments for cleanliness, functionality and integrity follows the same protocol as general surgical instruments. Lubrication of these instruments should be performed regularly and as recommended by the manufacturer.
Thousands of urological procedures are performed in the United States each year. Such procedures include prostatectomies, urinary bladder procedures, kidney procedures, surgeries on the ureters and kidney transplant. The CIS plays a critical role in providing quality surgical instruments to the urologist. The CIS must constantly be learning and accept new challenges. Every instrument must be free of debris. Scissors must be sharp and cut cleanly. Clamps and forceps must grasp and hold tissue without traumatizing it, and multiple part instruments must be complete. Surgical trays must contain the required items, be well organized and available when they are needed for surgery. This responsibility makes the CIS an important and vital member of every healthcare team.