Introduction

Laparoscopic instrumentation ranging from operating telescopes and fiber optic light cables to surgical instruments represents a substantial investment for the operating theater department [1, 2]. The delicate nature of these devices and the high cost involved in the acquisition and subsequently to maintain or repair them when damaged, warrants surgeons, nurses, and reprocessing personnel to handle them carefully and appropriately at all times. Proper care and handling of laparoscopic instrumentation can help to prolong their lifespan and maintain them at an optimal performance level. With the goal of delivering the finest in-patient care, all surgical team members and reprocessing personnel must be familiar with the use of and recommendations for care and handling of all laparoscopic instrumentation.

Care and Handling of Telescopes

The telescope is the most expensive and fragile component of laparoscopic instrumentation. It is also an integral part of the instrumentation, providing image and light through two distinct systems. As such, telescopes must be handled with care from the start to the end of the surgery, and also during the cleaning and sterilization process.

All surfaces of a telescope should be inspected regularly for any scratches, dents, or other flaws. The telescope should also be inspected before each use to assess functional integrity. The eyepiece should be examined to evaluate the clarity of the image from the reflected light. In addition, it is also important to check the optical fibers surrounding the lens train at the tip of the telescope by holding the light post toward a bright light. If the image is discolored or hazy or there is the presence of black dots or shadowed areas, it may be due to improper cleaning, a disinfectant residue, a cracked or broken lens, the presence of internal moisture, or external damage.

When using a metal cannula, the telescope should be inserted gently into the lumen, so as not to break or scratch the lens. At any point of time during use or cleaning and disinfection process, the telescope should not be bent during handling, and avoid placing any heavy instruments on top of the telescope. The telescope also should never be placed near the edge of a sterile trolley or surgical field to prevent it from accidental dropping onto the floor. When transferring the telescope from one point to another, it is best done by gripping the ocular lens in the palm and never by the shaft. Immediately after use, wash the surfaces of the telescope with a soft cloth or sponge using a neutral pH enzymatic solution and a thorough rinse with distilled water to remove any residual cleaning solution.

Care and Handling of Light Cables

Another important component of laparoscopic instrumentation is the use of a light source cable to transmit light through the telescope to view the operative field. Light cables are made of hundreds of glass fibers to transmit the light, and these fibers can be broken if the cable is dropped, kinked, or bent at extreme angles. Following are some general guidelines regarding the care and maintenance of light cables:

  • Avoid squeezing, stretching, or sharply bending the cable.

  • Grasp the connector piece when inserting or removing the light cord from the light source. Never pull the cable directly when disconnecting it from the light source.

  • Avoid puncturing the cable with towel clips, when securing the cables to the surgical drape.

  • Do not turn the light source on before connecting the light cable to the telescope to prevent igniting a fire on the surgical drape.

  • Inspect the cable for broken fibers before each use.

  • Inspect both ends of the cable to ensure they have a clean, reflective, and polished surface.

  • Wipe the fiber optic light cable gently to remove all blood and organic materials immediately after use using a mild detergent.

Insulation Care

The majority of laparoscopic instruments have an insulation sheath; this isolates the current flow along the hand instrument from the electrosurgical post to the tip of the instrument where the desired tissue effect is needed. Damage to the insulation results from a combination of physical insult, mechanical degradation, cleaning, temperature cycling from repeated sterilization, and high-voltage corona heating [4,5,5].

Insulation failures can result in inadvertent electrosurgical injuries by providing alternate pathways for the current; these breaks need not be large, as the current density is inversely proportional to the area size of the break which it passes. A good portion (18%) of these insulation failures have been detected in the segment described as “Zone 2” by Voyles and Tucker; proximal to the segment in view by the monitor but outside of the port cannula and is likely to cause devastating injuries.

Visual inspection of the insulation sheath is suggested before use, after use, and after the processing of the instruments [6]. Some instrument manufacturers have designed the insulation in double layers, the underlying brighter colored layer ease detection of a break in the outer layer. However, only 10% of insulation failures are detected visually.

The use of a current leak or insulation break detector improved break identification, Yaznadi and Krause [3] noted a significant decrease in the prevalence of insulation breaks after an institution established routine testing with such a device.

Cleaning, Disinfecting, and Sterilizing of Laparoscopic Instruments

Reprocessing laparoscopic instruments is one of the toughest challenges to OR personnel today. These instruments are extremely difficult to clean because of their long shaft and complex jaw assemblies, which may trap infectious bioburden and debris. The positive pressure of the CO2 in the insufflated abdomen may also cause blood and other body fluids to flow up into these channels, and making them difficult or impossible to remove. Many of these instruments cannot be disassembled to facilitate manual cleaning, an ultrasonic cleaning system may be contraindicated due to the small joints and jaws. Nevertheless, for effective sterilization to take place, surgical instruments need to be clean and free from all bioburden. And meticulous cleaning should begin at the point of use and immediately after a surgical procedure.

To assist in the subsequent cleaning process, laparoscopic instruments should be periodically wiped down with a wet sponge and flushed with solutions during surgery to prevent bioburden solidification. The instruments should also be immersed in an enzymatic solution immediately following a procedure to initiate the decontamination procedure. Items in these instruments that can be disassembled should be disassembled to its smallest parts, and those with flush ports should be flushed, before soaking and cleaning. For the cleaning process, a detergent with a neutral pH of 7.0 is recommended and avoids using abrasives, such as steel wool, that could disrupt the surface of the instruments. Instead use appropriate cleaning tools, such as soft bristle brushes, to adequately clean ports, lumens, serrations, fulcrums, box locks, and crevices. Both the external and internal surfaces of the instruments must be cleaned thoroughly if not, they cannot be sterilized. If available, automatic cleaning devices, with port and lumen flusher systems, can be used to assist in completely cleaning the instruments. Contradictory to telescopes and light cables, which should not be routinely cleaned in an ultrasonic device (as the vibration may damage the tiny fiberoptic bundles), laparoscopic instruments can be cleaned using an ultrasonic cleaner, where appropriate.

Following the cleaning process, the devices should be sterilized or high-level disinfected using chemical agents. Glutaraldehyde is one of the most appropriate chemical high-level disinfectants for soaking laparoscopes and accessories because they do not damage rubber, plastics, or lens adhesive. For sterilization, steam, liquid immersion, or plasma are some of the sterilization modalities that can be used. Nevertheless, since the manufacturers are responsible for developing instructions for a process, which will render a properly cleaned instrument sterile while preserving its function, the instruments should be sterilized according to the manufacturers’ written instructions.

Conclusion

Proper care and handling of laparoscopic instrumentation can help prevent malfunctions and rapid deterioration, which in turn eliminates costly repairs and replacements. Every member of the surgical team together with the reprocessing personnel must work collaboratively to achieve this important goal, to ensure the delivery of the safest and highest quality of patient care.