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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Polar instruments are typically used for minimally invasive electrosurgical procedures, and they can be configured as cutting and/or grasping tools that produce heat by concentrating electric current to achieve desired results. Unfortunately, laparoscopic instruments, the most frequently used devices for electrosurgery, are very difficult to process. CIS technicians must know how to properly disassemble, inspect, clean, lubricate and assemble, and sterilize these delicate instruments, and these topics were discussed in Part One of this two-part series. There are also special processing concerns when cleaning electrosurgical bipolar forceps and when handling the electrical cords of these devices. These are the topics of this lesson.
Special processing attention is required for the electrodes (gold stems about one inch long through which electric current passes) that are located on the handle of the instrument to which the cord attaches. For example, enzymatic cleaners and detergents can lead to residue build-ups on the electrodes’ contacts. These, in turn, can result in intermittent activation during use
if the components are not rinsed, wiped-off, and/or cleaned properly. Methods helpful
in preventing the build-up of cleaning residues on contacts begin after cleaning but before wrapping for sterilization. One protocol involves the use of an alcohol
swab rotated around the connectors three-five times. Another recommendation is to wipe down high frequency surfaces with a gauze pad moistened with a 3% hydrogen peroxide (H2O2) solution to dissolve encrustations and then rinse with sterile water. However, it is always best
to contact the instrument manufacturer and carefully follow the specific processing
recommendations that are provided. Examples of these recommendations include:
All About Bipolar Forceps
Figure 1 shows the sections and parts of a bipolar forceps. It is a commonly used operating tip for coagulation in traditional (open) spinal, neurosurgical, and otolaryngological (ears, nose, and throat: ENT) surgeries.
Notice the following details:
Bipolar forceps may be insulated to eliminate the potential for accidental coagulation of peripheral (surrounding) tissue at the surgical site. The indication (the condition which suggests a specific treatment) and depth of the target tissue are two factors that surgeons consider to determine whether an insulated forceps should be used. A coating comprised of sequential layers of polymer plastic film with color added in the last coat is applied to all the metal surfaces where electric current should be blocked. Various colors can be added into the last coat, and they assist in the identification of the forceps by surgeon or service.
An irrigation tube can be added to many forceps for use during a surgical procedure. The tube is attached to the inside surface of the forceps blade and allows sterile irrigation fluid to be dispersed at the tips. The tube runs along the blade on the ventral (bottom) side, passes through the cup, and connects to the fluid source at the rear of the forceps.
Bipolar forceps can be made from non-stick, stainless steel, titanium, and disposable non-stick materials. They can also be over-molded: manufactured with an injection form used to mold the grip. Forceps have traditionally been stamped (rough formed) and then hand-finished so they have less mass. Over-molded forceps may be disposable or reusable (non-stick). Disposable forceps use a plastic material as a jacket for best performance and minimal cost. Reusable over-molded forceps use a thermal plastic rubber material as a jacket. The jacket provides insulation and prevents leakage of electrical current that can burn the surgeon and the patient.
Forceps can be specialized by “mixing and matching” handle styles with desired features. For example, they can be lengthened or shortened, and tip sizes can be modified to be larger or smaller, angled, gold-coated, or even made into loops. Note: the manufacturing lead time for custom-made forceps ranges from one to seven weeks.
Proper handling, cleaning, rinsing, inspection, and sterilization processes are required for reusable electrosurgical forceps. The tips should not be spread too far apart while they are being cleaned because this can break the spring and damage the forceps. The correct-sized brush should be used and, for instruments with insulation, the brush stroke must be in a one-way direction beginning at the insulation moving toward the metal tip. Brushing in the opposite (wrong) direction can cause damage to the insulation. Nicking or lifting the insulation can create a space for bacteria to become trapped and a potential site for leakage of electrical current. Using the correct detergent followed by a thorough rinse avoids residues on the tips and electrical connections that can impede the flow of electrical current.
Forceps should be inspected frequently (before and after each use) for damage including:
When an instrument is inspected and found to be defective, it must be removed from use to be repaired or replaced. However, CIS technicians should not consider their responsibility to be completed at this point. The surgery department should be informed because a defective instrument could have caused thermal injury to the patient on whom it was used, and medical follow-up may be required.
The useful life of a forceps depends upon the care used during its processing and handling, on the sterilization methods selected, and on the surgical procedures for which it is used. Manufacturers typically provide processing recommendations that can be used as guidelines for within-facility validation:
Blood, mucus, tissue, and other gross organic contaminants should not be allowed to dry on forceps. Accumulated debris should be removed immediately after the surgical procedure, and the forceps should be de-contaminated by rinsing thoroughly with sterile, purified water.
The surface of the forceps should be hand-washed with a small tipped, soft-bristle cleaning brush while taking care not to spread the tips too far apart. The forceps should be handled carefully to keep it in alignment. Enzymatic cleaners can be used to remove visible residual debris. Spotting and/or discoloration may result if there is inadequate cleaning and/or rinsing before sterilization, or if there are mineral deposits in the water used for sterilization.
After hand washing, surfaces should be thoroughly flushed with purified water until no visible detergent residue remains. Note: the process may need to be repeated to remove all residues. After debris and cleaning solutions have been removed from the forceps, the instrument should be thoroughly dried with a clean lint-free cloth before storage or sterilization.
Forceps should be completely dried before storage. To protect the instrument from damage during storage, the tips should be protected by instrument tip covers or special “cradle style” storage trays. Extreme temperature and humidity levels should be avoided.
Forceps should be properly sterilized according to the instrument manufacturer’s written instructions.
Electrosurgical cords can be disposable (single use) or reusable. The angled connector on reusable cords helps to reduce strain by supporting the cord when the instrument is unplugged. It also allows the cord to lie in the surgeon’s hand to reduce the cord’s weight and drag during use. The connector is made of brass, and it will accept most domestic-made electrosurgical forceps and pencils.
Reusable cords have a flexible wire construction that uses soft, loosely-wound copper wires jacketed (surrounded) with one of two materials: thermal plastic rubber (with a useful life of 50-100 uses) or silicone (which typically survives 100-200 uses).
CIS technicians must consistently use processing protocols that conform to the instructions issued by instrument manufacturers. As noted several times in this lesson, the slightest variation from standard processing procedures can cause patient injury and/or instrument damage or destruction.
Susan Klacik, CRCST, ACE, FCS
Department Head, Central Services
Humility of Mary Health Partners
Carla McDermott, RN, ACE
Clinical Nurse 3
South Florida Baptist Hospital t
Plant City, FL
Jack D. Ninemeier, Ph.D.
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI.
Mary Olivera, MS, CRCST, CHL, FCS