CRCST
Technical Continuing Education (TCE)
SELF-STUDY PLANS

This series of self-study lessons on Central Service topics was developed by the International Association of Healthcare Central Service Materiel Management (IAHCSMM). The lessons are administered by Purdue University’s Continuing Education Division.

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Lesson Plan CRCST 95
Care and Maintenance of Surgical Instruments
[Reprinted from Communiqué: July/August 2007]

Central Service technicians have no responsibility more important than meeting exacting standards for surgical instrument processing, to assure that the instruments are sterile and will function properly. Each surgical procedure must have the correct instruments, in complete sets that are available for use exactly when they are needed. The wide variety of basic instruments and the increasing sophistication of specialty devices make this responsibility increasingly difficult and important. This self-study lesson provides an overview of the topic that is “central” to the mission of every Central Service department.

Objective 1: Explain the importance of consistently providing safe and functional instrumentation in a timely and cost-effective manner.

The success of every surgical procedure depends on the quality of the instruments that are used. Central Service personnel have an on-going responsibility to assure that the necessary instruments are available, in the right sets at the right time, and that they are functioning correctly.¹

Central Service technicians handle thousands of instruments daily, and each has the potential to significantly influence patient outcomes:

• Instruments that are not sterile pose a serious risk of infection.

• Damaged instruments can cause cases to be delayed or canceled, and, if undetected, can cause patient injury.

• Instruments that are not cared for and handled properly have a shorter useful life, leading to higher repair and maintenance costs.

• If not processed in a timely manner, instruments will not be ready for use when they are needed for procedures.

• Delays in processing instruments can put patients in danger, disrupt operating room schedules, and create frustration for surgeons.

Decontamination, inspection, assembly, packaging, and sterilization procedures must be completed correctly for the goals of safe, functional, and timely instrumentation to be met.

A Central Service technician’s education and training in instrumentation never ends. The wide array of available instruments is continually supplemented with new, increasingly-complicated and hard-to-process devices. Technicians must learn about the function and purpose of each instrument, paying close attention to details, because instruments that look alike can be very different. They must also know details about decontamination, assembly, and sterilization protocols for each device, which cannot be done properly until each device is identified correctly.

Instrumentation management also involves knowing when instruments must be repaired or refurbished, when they must be replaced, and when individual parts must be tested, repaired, or replaced.

Another attribute effective Central Service technicians have is the ability to work with people, both coworkers who assist with processing, and customers, such as surgical staff, who use the products and services provided.

Objective 2: Review points of inspection for six common instruments: scissors, needleholders, suction devices, retractors, hemostatic forceps, and tissue and dressing forceps.

The most important factors in extending the life of instruments are proper use, cleaning, sterilization, and maintenance. Appropriate handling will, therefore, help ensure that surgical instruments perform as intended over a long life. Proper handling begins when post-operative care is provided. Never let blood dry on any device. Soak instruments in an enzymatic solution, or cover them with a towel saturated with water within 20 minutes of use.²

Scissors

Scissors are used to cut, incise, and dissect tissue, suture, and other material encountered in surgery. With the exception of those with serrated edges, all scissors are designed to be re-sharpened. They dull first at the distal tip, which is the part of the scissors where cutting occurs. Scissors can also crack in the screw hinge area.

Most surgical scissors are produced with various blade definitions, depending on the surgical specialty and material to be cut. The finger ring handles are color-coded to identify the type of blade:

• Stainless blades – Scissors made of stainless steel are the most common, and they do not have a color-coded finger ring. The ring handle is, then, the color of stainless steel.

• Tungsten carbide blades (gold ring handles) – Tungsten carbide strips are inserted along the blade’s cutting surface. These strips are much harder than stainless steel and, once sharpened, they remain sharper longer. Because the strips are attached to the scissors by welding or vacuum brazing, however, they cannot be replaced.

• Black ring handled scissors – Also known as Microgrind or Supercut scissors, their unique feature is the sharpening technique used on
  the edge of one blade, which will lance, or slice through tissue, rather than crushing or cutting, like other scissors. While these scissors are the sharpest available, they also dull the quickest. They require special sharpening techniques, and must be re-sharpened three to four times annually.

Points of inspection for scissors include:

• Blunt tips – Tips should be rounded to prevent puncturing and tearing, and they should be inspected for corrosion and burrs.

• Sharp tips – See that both tips are present, and inspect them for bending or damage.

• Blades – Inspect for chips or burrs on cutting surfaces. Remember that tungsten carbide blades cannot be replaced. Inspect tungsten carbide inserts for cracks, and check for pitting where the tungsten carbide meets the stainless steel.

• Screw hinged area – Inspect both sides for cracking, staining, and bioburden trapped in head of the screw.

• Rings – Inspect for cracks.

To inspect a scissor’s cutting action, open and close the scissors three or four times to assure a smooth glide that is not loose, tight, grinding, or jumping.

Sharpness tests for scissors depend upon their size: for scissors larger than 4.5 inches, use red test material and yellow test material for scissors smaller than 4.5 inches. Choose two or three days each week when all scissors that are processed will be tested, and conduct the tests before trays are assembled. Note: While most test material contains latex, non-latex materials are available.

Needleholders

Needleholders are used to drive suture needles closed and to rejoin wounds and surgical sites. They are made from stainless steel, and those with gold-ring handles have tungsten carbide inserts in the gripping portion of the jaws. In addition to being harder than stainless steel, these inserts offer several other advantages:

• The tungsten carbide inserts will last longer that stainless steel.

• They grip the suture needle more precisely.

• When the jaws wear out, the inserts can be replaced (unlike other needleholders).

Points of inspection for needleholders include:

• Jaws – Jaws first wear out at their tips, and may also crack in the box lock or jaw areas. If the blades are serrated, inspect the serrations for wear; look for cracked or missing inserts and worn or chipped edges. Inspect jaws for dark-colored bioburden and stains. If the needleholder has smooth jaws,
  close the rackets and hold the device up to light. If you see light between the jaw tips, the device needs repair.

• Neck – Inspect for cracks.

• Box lock – Inspect for cracks on both sides, and for blood and baked-on bioburden.

• Shanks – See that they are not bent or misshapen.

• Ratchet – Test ratchets by opening and closing. This action should be precise and smooth. When ratchets are closed completely, all edges should meet evenly.

Suction Devices

Suction devices extract (suction) blood and fluids from the surgical site. Points of inspection include:

• Tips – Inspect for sharp or abraded edges, dents, and trapped surgical debris.

• Shaft – Inspect for bending or dents.

• Suction control – See that the tubing’s union is soldered properly.

• Stylet – Confirm that it can be inserted at the proximal end. Note: the stylet should not be inserted during sterilization.

When cleaning suction devices, use a cleaning brush that enters and completely exits the suction device, and that touches all interior surfaces.

Retractors

Retractors are used primarily to move aside tissue and organs to keep them exposed during a surgical procedure.

Points of inspection for retractors include:

• Distal ends – Inspect for bent blades or prongs.

• Release lever – When the release lever is used, it should spring back into place, and open and close smoothly.

• Screw – Inspect for cracks.

• Spring area – Check for cracks.

Hemostatic Forceps

Hemostats are used primarily to control blood flow by occlusion (stopping the flow of blood in a vein or artery). They are designed to hold on all ratchet settings, and they should never be used to clamp any type of tubing or other materials.

Points of inspection include:

• Tips – Tips of serrated hemostatic forceps (such as Rochester Pean, Crile, and Kelly) should meet equally, with no overlap. The teeth of hemostatic tissue forceps (such as Allis and Kocher) should all be intact, straight, and inter-fit precisely. Inspect teeth for bioburden.

• Jaws – Inspect serrations for blood or bioburden. They should fit together and not overlap.

• Box lock – Check for cracks on both sides of the hinged area, which is the most common site for blood and baked-on bioburden.

• Ratchet – Test by opening and closing the hemostat before each tray assembly. The action should be smooth and the ratchet should hold on each engagement (click). To determine if a ratchet is sprung, set the hemostat on the first ratchet, and then tap both rings softly and evenly on a flat table.
  If the hemostat does not remain closed on the first ratchet, or springs open while tapping, it needs repair.

The rings of homeostatic forceps should always be separated completely after use by opening the ratchets. Blood and bioburden should not be allowed to dry on a hemostat.

Tissue and Dressing Forceps

The primary purpose of a tissue and dressing forceps is to manipulate, grasp, and hold tissue. Note: Tissue forceps have teeth and dressing forceps (also called thumb forceps) do not.

Points of inspection include:

• Tips – Inspect tips to assure that there is no overlap and that tips meet evenly.

• Teeth – See that teeth are not broken off and that they inter-fit smoothly.

• Distal serrations – Inspect serrations for blood or baked on-debris.

• Proximal end – Check for cracks.

• Other tests – Be sure the forceps do not click or stick.

Objective 3: Explain how to determine if an instrument is rusted or stained and how to assess the stability of an instrument’s finish.

While stains can be removed, rust causes permanent damage (pitting) to instruments. To determine if a brown-orange discoloration is a stain or rust, rub a pencil eraser over the discoloration. If the discoloration is removed, and the exposed surface metal is smooth and clean, this is a stain. If there is a pit mark, however, this is corrosion and rust will likely continue.

The metal finishes of old surgical instruments may flake off, causing metal particles to enter a surgical site when the instrument is used. The first indication of flaking is the appearance of the metal surface under the finish. To assess the stability of an instrument’s finish:

• while wearing examination gloves, hold the instrument above a piece of white paper,

• rub the instrument aggressively with your gloved hands, then

• examine the paper for metal flakes.

If there are flakes on the paper, discontinue use of the instrument immediately.
When assembling trays, use storage or sterilization racks and tip protectors to protect delicate surfaces and cutting edges.

Objective 4: Discuss basic care and maintenance procedures for laparoscopic instruments.

Laparoscopic instruments are used in minimally-invasive surgical procedures, where small incisions are necessary.

There are several common inspection points:

• Grasper – If there is space between the collar and insulation, the instrument must be re-insulated. Inspect for bioburden in the jaws and for bioburden and cracks in the working mechanism. The shaft should be inspected for
  nicks and cuts.

• Insulation testing – Visually inspect the entire shaft for nicks or cuts after each use. Lightly pull back on the insulation; if you can slide it, the insulation needs to be replaced. Note: Insulation testers are available to help with
  this inspection point.

• Scissors – Test scissors to see that they can cut through at least one thickness of facial tissue.

• Needles – Inspect for cracks and burrs.

• Hooks and spatulas – The entire insulated area should be inspected for cracks and chips. The edges should also be examined for chips.

• Linkage wear – Test to determine if the inner linkage is worn, stretched, or fatigued. Wiggle the drive ring back and forth. If the jaw does not move, the linkage has been altered. If the ring moves, the jaw should move well.

Rigid endoscopes consist of an eyepiece with glass lenses, fiber optic light bundles, and a metal shaft containing the lens train, fragile glass fibers, and objective lens. They are very fragile and must be inspected before and after every endoscopic procedure. All telescopes must be inspected for scratches, dents, protrusions, and evidence of distal tip burrs or other surface irregularities after every procedure. Avoid touching the telescope’s ocular or the objective lenses to avoid fingerprints and debris that will impair the view and possibly cause scratches.

Examine the non-video scope for optical clarity. Holding the light post up to a light source, look through the lens at a sheet of non-glare white paper, with printing. Start with the scope’s distal tip about three inches from the paper and move the tip until it is about one-quarter inch from the paper. The printing should appear crisp and clear, with minimal distortion.

If the printing is discolored or hazy, this indicates improper cleaning, disinfectant residue, a cracked or broken lens, moisture within the shaft, or external shaft damage which has broken some fibers. Clean the outside of the proximal and distal lenses with a lint-free applicator saturated with 70 percent isopropyl alcohol. Repeat the inspection process. Do not use the scope if the view through either lens remains cloudy or distorted after cleaning.

Inspect the optical fibers surrounding the lens train at the scope’s tip. Hold the light post toward a moderately bright light (such as an overhead light or x-ray light box) and look at the distal tip. The light carriers should be seen as white areas at the perimeter of the lens. Black dots and irregular or shadowed areas may indicate broken or damaged fibers. Pointing the tip of the scope toward a bright light and observing the light post provides the same information.

Check the eyepiece seal for signs of visible damage. Assemble the telescope into the desired instrument by aligning the locking pin with the notch on the instrument. Inspect for proper alignment of the telescope in the instrument by visually confirming a clear view.

Endnotes

1. This discussion is adapted from: Instrumentation Specialist Course. Natalie Lind. Identification, Handling, and Processing Surgical Instruments. Chicago, IL. International Association of Healthcare Central Service Materiel Management. 2005.
2. Information in this section is from: Rick Schultz. Inspecting Surgical Instruments: An Illustrated Guide. Available from: International Association of Healthcare Central Service Materiel Management. 2005.

Additional Resource

Basic Surgical Instrumentation. Chapter 11 in: Central Service Technical Manual. Seventh Edition. Chicago, IL., International Association of Healthcare Central Service Materiel Management. In process.