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CIS
Instrument Continuing Education (ICE)
SELF-STUDY PLANS

Instrument Continuing Education (ICE) lessons 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.

You can use these lessons as an in-service with your staff, or visit www.iahcsmm.org for online grading at a nominal fee ($5 per single lesson plan, or bundled packages are available for quantities of 6 lessons for $25 (save $5) or 12 lessons for $50 (save $10) for greater savings).

Each lesson plan graded online with a passing score of 70% or higher is worth one point (contact hour). You can use these points toward either your re-certification of CRCST (12 points) or CIS (6 points).

Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the ICE Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions of the ICE Lesson Plans).

Lesson Plan CIS 205
Surgical Instrumentation for Gynecological Procedures
[Reprinted from Communiqué: January/February 2008]

Surgical instrumentation designed for gynecological procedures cover a wide range of specialties, including laparoscopic, robotic, and microscopic. This lesson will focus on basic instruments utilized in open gynecology procedures. Unique attributes of female anatomy has given life to Plato’s expression, “Necessity is the mother of invention.” (circa 375 B.C.) Instrument designers, frequently the surgeons themselves, have worked to meet the need with an eye toward safety. Certified Instrument Specialists (CIS) continue the tradition by maintaining and processing gynecologic instrumentation to the highest standard.

Objective 1. Discuss common gynecological surgical procedures.

The CIS will utilize their knowledge of medical terminology and anatomy to assure the proper instruments are prepared for specific surgical procedures. For instance, if the surgery schedule lists the procedure as “Bilateral Tubal Ligation”, a phone call will be placed for additional information. To appropriately prepare the instrument set and/or case cart for the procedure, the CIS needs to know if the procedure is being performed in the ‘post partum’, ‘interim’ or laparoscopic mode.

If the patient has very recently delivered a baby, the procedure is ‘post partum’ and only short instruments are required since the uterus and fallopian tubes are still very high in the abdomen. An ‘interim’ tubal ligation is performed six weeks or longer past the previous pregnancy so longer Babcocks and Kellys are required in the instrument set. The fallopian tubes are very deep in the pelvic area and not accessible with shorter instruments. The laparoscopic procedure is only done in the ‘interim’ and requires a GYN laparoscopic instrument set. Preparing instrumentation for a hysterectomy also requires the CIS to exercise their knowledge.

Information must be included in the scheduling function that identifies the specific approach, abdominal versus vaginal, and open versus laparoscopic. Likewise, if the patient is scheduled for an endometrial ablation, the CIS must verify the specific surgical approach and whether a laser will be utilized. By following through to obtain adequate information, the CIS helps assure a more positive experience for the patient, surgeon and surgical team. Preparation allows smooth delivery of care for the patient and decreases frustration for the team by eliminating delays.

Objective 2. List five instruments unique to gynecology instrument sets.

Instruments specific to gynecology include retractors, vessel clamps, scissors and needle holders. Retractors unique to gynecology include the O’Connor – O’Sullivan self-retaining ring retractor, Balfour retractor with bladder blade and Heaney hand-held retractor. A crucial consideration in processing these retractors is assuring the edges are smooth. A burr on the blades can cause tissue and nerve damage. The self-retaining retractors have multiple moving parts that must be thoroughly inspected for cleanliness, burrs and all removable parts. Blades, wing-nuts or set screws assure proper function in use.

Any missing or broken part delays the procedure and causes undue stress. Should missing or broken pieces go undetected until the conclusion of the procedure, valuable time is wasted searching for an item that was not present as expected. Clamps designed to grasp and occlude large blood vessels and ligaments supporting the uterus in the pelvis include the Heaney, Ballantine and Rodgers. These large sturdy clamps can be straight or curved jaws with serrations running horizontally or longitudinally. The strength and size is critical in controlling blood loss. The CIS’s inspection of this clamp must include the ratchet strength to assure secure closing and prevent inadvertent opening of the clamp in use, cleanliness and smooth operation of the jaws. A set usually includes three of each kind in exactly matching size and shape. This helps optimize available space for the surgeon’s hand and required clamps in the surgical field.

Clamps of unequal length increase the risk of bleeding. Scissors must be of appropriate length. Routine sizes are needed for opening and closing the incision and length of 8 to 9 inches are needed to reach structures deep in the pelvis. The Jorgensen scissor is a curved right angle scissor used to seperate the cervix from the vaginal mucosa. The prudent CIS will test the cutting edge of this scissor with each use because of the dense, fibrous nature of the cervix. This scissor dulls quickly. Needle holders and forceps must be matching in length to enable the surgeon to repair the tissue severed in removal of the uterus. Heaney needle holders have curved jaws to increase visibility of needle placement. The jaws of the needle holders are critical in this function. The needles used to repair this tissue are round bodied. The jaws are flat surfaced. Undue wear of the serrated jaw surface will not hold the needle securely causing it to spin in the tissue. Bleeding results, and can be difficult to control. Inspection is key in providing quality instruments and a positive patient outcome.

Objective 3. Name three anatomic structures potentially damaged by faulty instrumentation.

Vital structures not directly involved in gynecological surgeries are at risk of damage from instrumentation. Abdominal wall tissues and nerves can be compressed by malfunctioning or poorly placed retractors, resulting in increased post-operative pain. A burr on the blade used to retract the bladder or bowel can tear the tissue requiring additional repair. Major blood vessels can be damaged by clamps that are sprung and do not hold properly. Damaged blood vessels means increased blood loss that may require blood transfusion for the patient, which significantly increases the risk of the procedure.

Objective 4. Review instrument set audit procedure for quality improvement.

Quality improvement is a vital function for the CIS. Along with the routine care and maintenance of surgical instruments, education is required to assure a strong knowledge base of the instrumentation. It is difficult to recognize when items are missing or damaged if there is no information describing complete and functional use of the instruments. Maintaining a record of preventative care provided by a reputable instrument service company helps determine budgeting for repair or replacement of instrumentation. Surgical teams appreciate knowing the instrument sets are properly cared for each time they are used. Processing and sterilization do take a toll on the instruments. Audits that reveal “use versus presence” of instruments in the set can guide set make-up. Removing instruments no longer used decreases wear and tear on the instrument and reduces unnecessary work load of inspection and handling. An added plus for the surgery team is they do not have to count instruments that will not be used. The audit can also point out instruments that need to be placed in the set. Are there instruments that are opened for a majority of cases? Placing them in the set reduces the time and expense of handling, packaging and sterilizing wrapped or peel pouched instruments. The surgery team saves time and effort in opening an additional item. Improving quality provides benefits for the patient, surgeon and the facility!

Bibliography

International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Sixth Edition. 2005.

Schultz, R. Inspecting Surgical Instruments, An Illustrated Guide. 2006.

International Association of Healthcare Central Service Materiel Management. Instrumentation Resource Course: Identification Handling and Processing of Surgical Instruments. 2006.

Chen, NC; Towler, MA; Moody, FP; McGregor, W. Mechanical Performance of Surgical Needle Holders. Journal of Emergency Medicine. 1991; 9:477