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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 210
Polar Express: Monopolar and Bipolar
Instrumentation (Part I)
[Reprinted from Communiqué: November/December 2008]

There is a children’s story about the “Polar Express” which centers on a child who receives instructions from a train conductor. Surgical polar instrumentation has some similarities with the story including an emphasis on a patient (rather than a child), a conductor (“electricity” instead of a person,) and different types of polar instruments (rather than train cars). Polar instruments can be monopolar (the topic of this lesson) or bipolar.

Monopolar instruments are used for minimally invasive procedures commonly referred to as laparoscopy. These instruments can be configured as cutting and/or grasping tools, and they are made of a tubular shaft (lumen) with two jaw parts located at the distal (furthest) end of the shaft. The jaw parts are constructed of a metallic material and are coupled by a joint. Electrical connections in the instrument generate high frequency electric current which increases the cutting effect when a cutting tool is used and the coagulation of tissue contacted when a grasping tool is used.

Monopolar instruments are used for electrosurgical purposes, and they use alternating current (AC) in which electrons alternate direction at the speed of light. The patient is included in the circuit, and the electrical current enters the patient’s body. Note: The term “electrocautery” is sometimes used incorrectly to describe electrosurgery. However, electrocautery uses direct current (DC) in which electrons flow in one direction to heat a wire. Since only the wire comes in contact with the patient, the current does not enter the patient’s body.

The purpose of electrosurgery is to produce heat by concentrating electric current in target tissues to achieve desired results. The smaller the area of tissue-instrument contact that concentrates the current, the more resistance is built, and more voltage (the force pushing electric current through the resistance) is required to move the current through the limited space.

There are two basic types of electrosurgery:

• Monopolar – The active electrode instrument is placed in the entry site and is used to cut tissue and coagulate bleeding. A return electrode pad is attached to the patient, and the high frequency electrical current then flows from the generator to the instrument through the patient to the patient return electrode pad and back to the generator. The monopolar circuit includes a generator, instrument, active electrode, patient, and patient return electrode pad. Monopolar electrosurgery is the most commonly used type of energy because of its versatility and effectiveness. Monopolar generators typically produce outputs of 1 to 300 watts of energy in the cut modes and 1 to 120 watts in the coagulation mode.
  
  
• Bipolar – Active output and patient return functions both occur at the surgery site because both the active and return electrodes are contained in the instrument because it contains two electrodes. The path of the electrical current is confined to the tissue between the two electrodes that are contained in, for example, the bipolar instrument’s forceps. Bipolar electrosurgery allows the use of lower voltages and less energy is required. However, it has limited ability to cut and coagulate large bleeding areas, and is ideally suited for coagulation (sealing) of small arterial or venous blood vessels to control blood loss. Bipolar generators produce 1 to 80 watts of energy.

Figure 1 provides a general illustration of monopolar and bipolar circuits.

Laparoscopic instruments are the most frequently used devices for monopolar electrosurgery, and Figure 2 illustrates basic components of a laparoscopic handle instrument.

Figure 2: Laparoscopic Handle Components

Laparoscopic instruments can be challenging to clean. They have evolved from a first generation device which presented an extreme cleaning challenge to a second generation model with, at least, a cleaning port, to modern versions which allow for complete disassembly for proper cleaning.

After use and prior to the next surgical procedure, laparoscopic instruments must undergo several pre-processing steps, and they must then be cleaned, lubricated, and sterilized before reuse.

Pre-Processing. The reprocessing of laparoscopic instruments begins at point of use. As with all devices, excess body fluids and tissues must be removed immediately in the surgical suite, and keeping instruments moist prevents blood and body fluids from drying on them.

Several steps are necessary before laparoscopic instruments are processed. Devices must be disassembled by carefully following the manufacturer’s written instructions because some models of laparoscopic instruments can be completely disassembled, some have flush ports, and some have neither. The required cleaning agents should be prepared according to the manufacturer’s use/dilution and temperature recommendations.

Instruments should be inspected for any obvious damage including insulation and bent or missing parts. If the CIS technician discovers any insulation damage or missing parts, this should be reported to the supervisor immediately for patient follow-up to assess whether the patient has been harmed. End-of-life indicators for instrument handles include electrical performance problems and, for lumens, insulation damage that exposes metal. End-of-life indicators for laparoscopic inserts include dulling of scissors, binding/impaired mechanical functions, bent or damaged housing, rods, or tips, and wear of external surfaces.

Cleaning. Remember these basics when cleaning laparoscopic instruments:

• Manual cleaning is required for all instruments with lumens and hollow spaces. Automated cleaning with a washer/disinfector alone may not be effective.
  
  
• Metal brushes or scratch/scouring pads should not be used on the insulation because they will damage the instrument’s surface and finish. Instead, use soft-bristle, nylon brushes and cotton-tip swabs.
  
  
• Use distilled, de-mineralized, or reverse osmosis deionization (RODI) water, especially for the final rinse. Note: Water with high mineral content (hardness) can leave residues that affect performance.
  
  
• Neutral PH enzymatic detergent cleaning agents are recommended. Alkaline detergents, if used, must be completely rinsed from the devices. Do not use corrosive fluids such as bleach-based products to avoid damaging the instrument.
  
  
• Do not exceed 284°F (140°C) during the washing and sterilization process.
  
  
• Cold soak sterilization is not typically recommended and, as is always necessary for all instrumentation, the manufacturer’s instructions for specific devices should consistently be followed.
  
  
• Totally immerse instruments during cleaning to prevent aerosolization. Do not use steel wool, wire brushes, pipe cleaners, or abrasive detergents. Anything other than high-quality brushes specifically designed for instrument cleaning may damage the device.

After disassembly, the following manual cleaning steps are important:

• All components should be immersed (soaked) in a blood-dissolving enzymatic solution prepared according to the manufacturer’s instructions for at least five minutes with gentle agitation. Note: Soak longer if protein-containing material is present. It is advisable to soak instruments vertically to reduce the possibility that air bubbles will form. Vertical soaking also enables the solution to enter, rise through, and exit the device if the solution is sufficiently deep.
  
  
• Remove the device from the enzyme solution, and rinse it thoroughly under running tap water for at least three minutes.
  
  
• Immerse all components in a detergent solution prepared according to the manufacturer’s instructions and clean all surfaces.
  
  
• Use a hand-held, soft bristled brush with a back-and-forth motion to brush all surfaces. Pay special attention to the cord connector, crevices, grooves, fittings, and joints.
  
  
• While still submerged, use a soft bristled brush with a gauge recommended by the manufacturer to clean inner lumen surfaces. If a recommendation is not made, select a brush with soft bristles that are slightly larger in diameter than the actual lumen. Use complete strokes and ensure that the bristles exit the lumen. Push and pull the brush completely through the lumen several times. If necessary, repeat the brushing process by entering the opposite end of the lumen.
  
  
• Flush irrigation channels with de-mineralized water and use a stylus, if necessary, to remove clogs. If instruments have cleaning ports, a luer lock syringe filled with enzymatic solution can be attached to the cleaning port to flush the lumen. Note: Keep the distal end of the lumen under water. If there are no cleaning ports, a three-inch piece of tubing can be inserted over the distal tip, and a syringe can be attached to the tube’s opposite end for flushing. Compressed air can also be used for flushing if a precise nozzle is available and if the pressure can be controlled. Ultrasonic irrigators are also a useful way to flush instruments with lumens to remove debris from hard-to-reach areas, and they can do so more effectively in a shorter time than a manual process. The cycle time should be five minutes or less, and water temperature should not exceed 122°F (50°C).
  
  
• Some detergent solutions may leave a residue on the gold electrical post connector surface that can cause occasional cord alarms. The residue can be removed with an alcohol-soaked swab rotated completely around the gold connector surface.
  
  
• Remove the device from the detergent solution and rinse thoroughly under running distilled or de-mineralized water for at least three minutes.
  
  
• Most instruments can be processed through a washer/disinfector after manual cleaning is complete using the instrument cycle. If this is done, assure that no residue remains.

Remove excess moisture and allow the instrument to dry before sterilizing.

Inspection. Laparoscopic instrument insulation is susceptible to pin holes, cracks, tears, and overall loosening. These defects must be discovered as the instruments are assembled so electricity cannot escape through insulation failures and cause burns not immediately detectable by the surgeon. Patient infections, extended recovery times, and the need for a possible return to surgery may result from the burns. If defects are observed, a process should be in place for patient follow-up to determine if the insulation failure occurred during the last surgical procedure and injured the patient. To inspect the insulation, locate the metal collar at the distal tip. The insulation should fit tightly against the collar with no spaces visible. Next, grip the insulation, and try to slide it back. If the insulation slides (moves), the instrument needs repair. Finally, check the instrument shaft for insulation cuts, cracks, and nicks, and inspect the handle for chips or cracks because these defects also indicate the need for repair or replacement.

Electronic testing devices can detect microscopic holes in a laparoscopic instrument’s insulation, and the testing should be done before set assembly on the clean side of sterile processing. These test devices can also be used to inspect electric cables, forceps, electrodes, and insulated bayonet forceps.

Lubrication and Assembly. After cleaning and before sterilization, laparoscopic instruments should be carefully inspected for visible contamination or damage. The lumen and all moving parts of the jaw insert should be lubricated with water-soluble medical instrument lubrication as recommended by the manufacturer.

CIS technicians must properly re-assemble instruments taken apart for cleaning. Trumpet valves which control the instrument’s suction and irrigation functions are one especially challenging component. To clean these valves, it is necessary to press down on the valve and brush it in one direction. The valve must then be disassembled and brushed in the other direction to clean out the barrels which enable the plunger to move freely. Reassembly of the trumpet valve involves lining up a groove in a pin inside the valve. Remember to place lubricant in that groove if this is recommended by the manufacturer.

Packaging. Sterilization containers and organizing sets designed for laparoscopic instruments are available to protect instruments from damage during transport, sterilization, and storage. Both the container and instrument manufacturer should be consulted for sterilization recommendations. Product testing should be conducted to assure sterilization can be achieved prior
to use.

Sterilization. Instruments must dry thoroughly before sterilization, and typical sterilization methods (assembled or disassembled) are:

• Gravity steam (wrapped) at 270°F (132°C) minimum for at least
  15 minutes.
  
  
• Pre-vacuum steam (wrapped) at 270°F (132°C) minimum for at least
  four minutes.
  
  
• Gravity steam (unwrapped/flashed) at 270°F (132°C) minimum for at least 10 minutes. Note: Do not exceed temperatures of 284°F (140°C) to avoid damage to the handle’s outer insulation.

Plasma (hydrogen peroxide) and rigid container sterilization methods should only be used if they are included in the manufacturer’s recommendations.

Storage. Sterile, packaged laparoscopic instruments should be stored in a designated, limited-access area that is well-ventilated and that will provide protection from dust, moisture, insects, and vermin and temperature/humidity extremes.

REFERENCES

International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Seventh Edition. Chicago, IL. 2007. (See Chapter 12)

Rick Schultz. Tube Scoop: Insider’s Guide to Cleaning Lap Instruments. Materiels Management. November, 1997.

Encision AEM Laparoscopic Instruments. AEM Handle Assembly and Inserts. Instructions for Use/Care. 2008. See also: Care, Maintenance and Sterilization.