INSTRUMENTATION ASSESSMENTS

NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE USING GOLDPOLYTETRAFLUOROETHYLENE COMPOSITE FILM
Takeshi Mikami, M.D.
Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan

Yoshihiro Minamida, M.D.

Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan

Izumi Koyanagi, M.D.

Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan

Kiyohiro Houkin, M.D.

Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan Reprint requests: Takeshi Mikami, M.D., Department of Neurosurgery, Sapporo Medical University, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan. Email: tmikami@sapmed.ac.jp Received, April 26, 2006. Accepted, August 31, 2006.

OBJECTIVE: Advancement in new technology has been necessary for the development of surgical hemostasis. The purpose of this study was to assess novel bipolar forceps plated with gold-polytetrauoroethylene (PTFE) composite lm. METHODS: Novel bipolar forceps with goldPTFE composite lm were invented and compared with commercially available forceps with 50-m gold-plated tips in terms of their physical properties and coagulation performance. The contact angle was measured to determine the degree of wetting tension. Then the surface roughness, electric resistance, and changes in local temperature on the surface of the tip were recorded. Coagulation performance of the two sets of bipolar forceps was determined comparing the amount of protein in the adhered coagulum on the tips and comparing the ease with which the coagulum could be removed. RESULTS: This goldPTFE composite lm-plated metal has a signicantly higher contact angle than conventional gold-plated metal, and the plating maintains the matrix metal property. The amount of coagulum sticking was smaller than with the ordinary goldplated forceps. The ease of removal was also superior with the goldPTFE composite lm-plated forceps. CONCLUSION: The concept of promotion of protein repellence is important for achieving reduced adherence of protein to neurosurgical instruments. This protein repellent plating is indispensable to achieve safer and more accurate microneurosurgery.
KEY WORDS: Bipolar forceps, Gold polytetrauoroethylene composite lm, Neurosurgical operation
Neurosurgery 60[ONS Suppl 1]:ONS-157ONS-161, 2007
DOI: 10.1227/01.NEU.0000249252.86417.85

ipolar forceps, introduced by Greenwood (9) in 1940, are an invaluable tool for neurosurgical operation. Further improvements made possible precise control of bleeding and fine dissection (1, 46, 11, 12, 1418). Occasionally, however, problems of charring and tissue adherence occur (4, 13), and recently, the possibility of prion disease from surgical instrument contamination has arisen (3, 7, 8, 19, 20). Adherence of protein to the tip of the coagulation device is a problem that must be resolved immediately. The metal polytetrafluoroethylene (PTFE) composite lm has superior water and protein repellence (3, 10). This composite lm is electroconductive, heat resistant, extremely durable, and has antifouling properties (10). Because PTFEs protein repellence contributes to the reduction of adherence to bipolar forceps during coagulation, we applied this tech-

nology for plating the tip of bipolar forceps. In this report, we introduce the characteristics and performance of these novel bipolar forceps with goldPTFE composite film during experimental coagulation.

MATERIALS AND METHODS

Two types of bipolar forceps with 1.0-mm wide tips were assessed. These consisted of a trial tip plated with goldPTFE and a commercially available tip plated with 50-m gold (KH-2001; Codman/Johnson & Johnson, Tokyo, Japan) (Fig. 1). Before starting coagulation, the bipolar forceps were washed with deionized water and ethanol and then dried at 50 C. The coagulation was carried out with a Malis bipolar coagulator (CMC-III; Codman & Shurtleff, Inc., Raynham, MA).

NEUROSURGERY

VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-157

MIKAMI ET AL.

Physical Properties of the Material

A metal 1 cm2 sample of the material used for the tips of each product was prepared before the measurement of wetting tension. Wetting tension is the maximum liquid surface tension that will spread, rather than bead up, on the film surface. Wetting tension is specic for any given system and is determined by the interactions across the three interfaces. It is a measurable property that reects the surface energy of the lm. To determine the degree of wetting tension, the contact angle of a water drop (1.5 mm in diameter) on the surface of the goldPTFE composite lm and gold-plated lm was measured at 25 C in air saturated with moisture (CA-X; Kyouwa Kaimenkagaku, Saitama, Japan). The contact angle is the angle between the surface of a solid and the surface of a liquid droplet on that surface, and it is the primary measurement to determine wetting tension. Measurement was repeated five times with each type of material. The surface roughness of the tips was measured by a laser scanning electron photomicroscope (1LM21W; Lasertec, Yokohama, Japan). Two-dimensional z axis images and threedimensional images were obtained in addition to the usual scanning electron microscopic images. From these electron micrographs, the average roughness (Rz) was calculated at 10 points. Details of the method of calculation were reported previously (13). Measurement and calculation were repeated ve times with each type of material. Electric resistance was measured using a digital instrument (digital multimeter 753306; Yokogawa, Tokyo, Japan). We measured electric resistance between the tip of the bipolar forceps and the arm. Measurement was repeated ve times with each type of material. Changes in local temperature on the surface of the tip were measured using a thermograph (TH5100; NEC, Tokyo, Japan). One hundred microliters of human whole blood preincubated at 37 C were put on a slide glass, and the tips of the bipolar forceps then were placed in the blood with a gap of 1 mm. Measurement was started from 30 C, and increases in heat were measured. After coagulation nished, we left the bipolar forceps as they were and measured the decrease in temperature in a similar manner. Measurement was repeated ve times with each type of material.

FIGURE 1. Photographs depicting the gold-plated bipolar forceps (A) and gold PTFE composite lm plated bipolar forceps (B).

Adherence of coagulum to the tips was assessed by measuring the ultrasonic irrigation time necessary to remove the coagulum. The coagulation of the blood was carried out at 15 Malis units (1.6 W) for 20 seconds. The tip with adhered coagulum was held in 5 ml 1% Triton-X 100 at a distance of 5 mm from the ultrasonic processor, and the rinsing was performed (output, 2.0 W). The time it took for detachment of the adhered coagulum was averaged over 10 procedures and was expressed in seconds.

Statistical Analysis
Data are expressed as the mean standard deviation. Correlations were analyzed using a two-factor analysis of variance. The items measured were contact angle, roughness of the surface, and electric resistance, and the time it took to remove the stuck coagulum was analyzed using the Mann-Whitney U test. The level of statistical signicance was set at a P value of less than 0.05.

RESULTS
Physical Properties of the Material
Table 1 shows the physical properties of the gold-plated bipolar forceps and goldPTFE composite lm-plated bipolar forceps. A water drop on the surfaces of the bipolar forceps is shown in Figure 2. The average contact angle of the sample piece of each material differed: 74.9 2.1 degrees for the goldplated lm, and 142.6 3.6 degrees for the goldPTFE plated lm. There was a signicant difference (P 0.009). The surface of both materials was examined by laser microscope and the data were calculated. Mean roughness (Rz) values of the two samples were signicantly different for each

Coagulation Performance
Details of the method were previously reported (13). We used human whole blood for evaluation of adherence in this study. One hundred microliters of human whole blood preincubated at 37 C were put on a glass slide. The coagulation was performed at constant electric power (15 Malis units 1.6 W) for 8 to 20 seconds. After the coagulation, the adhered coagulum was removed by an ultrasonic processor in a solution of 5 ml 1% Triton-X 100, and the protein content of the solution was assayed by a bicinchoninic acid protein assay reagent (Pierce, Rockford, IL). The coagulation at each condition was repeated ve times and the amount of coagulum was expressed as the average milligrams of protein in these ve procedures.

TABLE 1. Physical properties of gold-polytetrafluoroethylene composite lm plated bipolar forcepsa Gold plated Contact angle (degrees) 74.9 2.1 Roughness (Rz) 0.07 0.03 Electric resistance () 0.6
a

GoldPTFE 142.6 3.6 0.97 0.10 0.6

P value
0.009 0.009 NS

PTFE, polytetrauoroethylene; NS, not signicant.

ONS-158 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007

www.neurosurgery-online.com

NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE

FIGURE 2. Photographs depicting a water drop on the surfaces of the bipolar forceps with gold plate (left) and goldPTFE composite lm plate (right). Different congurations of wetting tension were obtained.

material (P 0.009): 0.07 0.03 m in the gold-plated forceps and 0.97 0.10 m in the goldPTFE composite lm-plated forceps. Electric resistance of both types of bipolar forceps was 0.6 ; thus, there was no signicant difference. Local temperature on the surface of both tips suddenly elevated to 81.2 5.6 C until 10 seconds of electricity time, and plateaued thereafter. When the electricity power continued for 30 seconds, the temperature of both tips rose to approximately 89.3 2.9 C. After coagulation ended, the temperature of both tips gradually decreased to 35.8 1.5 C after 130 seconds. There was no signicant difference between the two forceps.

Coagulation Performance
The amount of adhered coagulum, measured by its protein content, increased as the coagulation time became longer. The adhered coagulum was signicantly less on the goldPTFEcomposite lmplated forceps (P 0.0001) (Fig. 3). The mean ultrasonic irrigation time for coagulum removal from the goldPTFE-plated forceps (7.42 0.78 s) is shown in Figure 4. It was signicantly shorter (10.84 1.79 s) than that for the gold-plated tips (P 0.002).

DISCUSSION
We previously reported that the chemical and physical properties of forceps have a significant impact on the extent of adherence during bipolar coagulation. Electric and thermal features at coagulation depend on the characteristics of tip material, which include heat and electrical conductivity, ionization tendency of metals, electrical distribution of the tip surface, and the wetting tension of the material (13). The recent invention of nonstick bipolar forceps with cooling technology (IsoCool; Codman & Shurtleff, Inc., Raynham, MA) was made from the viewpoint of heat conductivity. We focused on wetting tension in this study, and this concept guided the development of these novel bipolar forceps. Polytetrafluoroethylene (E.I. du Pont de Nemours & Company, Inc., Wilmington, DE) is a material resembling Teon, and metalPTFE composite lm plating has high wetting tension and superior water repellence (2, 10). The results of our experiment showed that when this material was used as the tip of the bipolar forceps, a more ideal coagulation could be

achieved because the material itself resists water and protein. MetalPTFE composite film is prepared by electrodeposition in a metal sulfamate plating bath in which ne PTFE particles are suspended by using a cationic surfactant. It has the same hardness as matrix metal and it achieves a high d e g re e o f a t t a c h m e n t t o underplating metal. This process is not difficult and FIGURE 3. Graph demonstrating the the resources are readily amount of protein in the coagulum available. In the manufactur- and the duration of coagulation time. ing process of the bipolar for- Values represent the average of five coagulation procedures. The amount ceps, the goldPTFE composof protein was signicantly lower on i t e f i l m w a s p l a t e d o n the gold-plated forceps tips. The stainless steel instead of gold asterisk denotes a P value of less than plating. The estimated cost 0.05. for the goldPTFE composite film plated forceps is the same as that of the goldplated forceps. The actual selling price for these two different forceps is similar. Ceviker et al. (5) reported previously that a Tefloncoated bipolar coagulator reduced adherence. However, given its low electric conductivity, Teon cannot be used FIGURE 4. Bar graph demonstrating to cover the entire surface of the time for removal of coagulum by the forceps, so Teon-coated ultrasonic rinsing. Values represent bipolar forceps have both the average of 10 procedures. There were significant differences in time nonconducting coated parts between the two materials tested. The and uncoated conducting asterisk denotes a P value of less than parts. Also, Teon comes off 0.05. easily because of its poor surface tension. Although the wetting tension of metalPTFE composite lm plating is as low as that of Teon, the plating maintains the property of a matrix metal. Moreover, metalPTFE composite lm has a high coefcient of friction because of the roughness of its surface. The coefcient of friction is a dimensionless scalar value that describes the ratio of the force of friction. Consequently, the grasping power of the material is superior to the conventional gold-plated forceps. We conrm that the PTFE composite lm-plated bipolar forceps can withstand conventional sterilization; however, particles of the PTFE may come off as a result of daily cleaning before reuse of the forceps. After more than 10 gas sterilizations, particles began to come off, and the tip showed some changes in color. Improvement in durability is feasible in the future by application of a supplementary diluted metal coating. Otherwise, there is a possibility of disposable use of this tip.

NEUROSURGERY

VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-159

MIKAMI ET AL.

CONCLUSION
Starting from the concept of protein repellence, we developed novel bipolar forceps. The PTFE composite lm used has a high wetting tension and superior water repellence. Therefore, it did not adhere easily, and coagulum that became stuck came off easily. Moreover, this composite lm has a high coefcient of friction because of its roughness, and the grasping power of the material is superior. These characteristics result in an improved performance. We think that this technology is superior and will be widely used in the future for microneurosurgery.

Acknowledgments
We thank Hajime Kiyokawa, Ph.D., Kiyokawa Plating Industry Co., Ltd., and Tomohiko Asahara, Ph.D., Codman/Johnson & Johnson, Tokyo, Japan, for their technical support in the preparation of the bipolar forceps. None of the authors has a nancial interest in the bipolar forceps used in this study.

COMMENTS

REFERENCES
1. Bergdahl B, Vallfors B: Studies on coagulation and the development of an automatic computerized bipolar coagulator. Technical note. J Neurosurg 75:148151, 1991. 2. Brenner A: Electrodeposition of Alloys: Principles and Practice. New York, Academic Press, 1963. 3. Brown P, Preece M, Brandel JP, Sato T, McShane L, Zerr I, Fletcher A, Will RG, Pocchiari M, Cashman NR, dAignaux JH, Cervenakova L, Fradkin J, Schonberger LB, Collins SJ: Iatrogenic Creutzfeldt-Jakob disease at the millennium. Neurology 55:10751081, 2000. 4. Casotto A, Piattelli M: A new device for electrocoagulation of small vessels. Acta Neurochir (Wien) 71:151160, 1984. 5. Ceviker N, Keskil S, Baykaner K: A new coated bipolar coagulator: technical note. Acta Neurochir (Wien) 140:619620, 1998. 6. Dujovny M, Vas R, Osgood CP, Maroon JC, Jannetta PJ: Automatically irrigated bipolar forceps. Technical note. J Neurosurg 43:502503, 1975. 7. Fichet G, Comoy E, Duval C, Antloga K, Dehen C, Charbonnier A, McDonnell G, Brown P, Lasmezas CI, Deslys JP: Novel methods for disinfection of prioncontaminated medical devices. Lancet 364:521526, 2004. 8. Flechsig E, Hegyi I, Enari M, Schwarz P, Collinge J, Weissmann C: Transmission of scrapie by steel-surface-bound prions. Mol Med 7:679684, 2001. 9. Greenwood J: Two-point coagulation. A new principle and instrument for applying coagulation current in surgery. Am J Surg 50:267270, 1940. 10. Ibe T, Kiyokawa H, Chong Y, Yonezawa S, Takashima M: Electrodeposition and surface properties of nickel-PTFE composite film. Materials Science Research International 4:148152, 1998. 11. Jacques S, Bullara LA, Pudenz RH: Microvascular bipolar coagulator. Technical note. J Neurosurg 44:523524, 1976. 12. Malis LI: Electrosurgery. Technical note. J Neurosurg 85:970975, 1996. 13. Mikami T, Takahashi A, Hashi K, Gasa S, Houkin K: Performance of bipolar forceps during coagulation and its dependence on the tip material: A quantitative experimental assay. Technical note. J Neurosurg 100:133138, 2004. 14. Ohta T, Funatsu N, Kuroiwa T, Matsui T: Bipolar diathermy forceps with automatic irrigation. Technical note. J Neurosurg 62:933934, 1985. 15. Sakatani K, Ohtaki M, Morimoto S, Hashi K: Isotonic mannitol and the prevention of local heat generation and tissue adherence to bipolar diathermy forceps tips during electrical coagulation. Technical note. J Neurosurg 82:669671, 1995. 16. Samii A, Dujovny M: Kirwan non-stick bipolar forceps. Surg Neurol 45:297298, 1996. 17. Sugita K, Tsugane R: Bipolar coagulator with automatic thermocontrol. Technical note. J Neurosurg 41:777779, 1974. 18. Vallfors B, Erlandson BE, Wieck BO, Hansson HA, Svensson J: Coagulation in neurosurgery. Acta Neurochir (Wien) 55:2934, 1980. 19. Yan ZX, Stitz L, Heeg P, Pfaff E, Roth K: Infectivity of prion protein bound to stainless steel wires: A model for testing decontamination procedures for transmissible spongiform encephalopathies. Infect Control Hosp Epidemiol 25:280283, 2004. 20. Zobeley E, Flechsig E, Cozzio A, Enari M, Weissmann C: Infectivity of scrapie prions bound to a stainless steel surface. Mol Med 5:240243, 1999.

ikami et al. meticulously present their objective data comparing the use of gold-polytetrauoroethylene (PTFE)-coated bipolar forceps with standard bipolar forceps. They assessed a number of variables not limited to, but including, protein adherence, electric resistance, and roughness of the surface of the bipolar tips. They also present a subjective evaluation of the clinical use of the PTFE-coated forceps. In summary, the authors found that protein adherence was signicantly decreased, which was conrmed in a clinical setting with signicantly less intraoperative charring and tissue adherence. The authors are to be commended for their concise, well-organized assessment of the PTFE-coated bipolar forceps. Certainly, any technological advancement that decreases the amount of tissue adherence to bipolar forceps would be welcomed by the neurosurgical community. We use Isocool bipolar forceps (Codman/Johnson & Johnson Professional, Raynham, MA), which have signicantly decreased the amount of tissue adherence we experience. A side-by-side comparison of PTFEcoated and Iscool bipolar forceps would be interesting. Robert F. Spetzler Jeffrey Klopfenstein Phoenix, Arizona

M M

ikami et al. have introduced two learning opportunities to the readership. First, they have educated us regarding the physiology and mechanics of surface tension and protein repellency as it pertains to coagulators. They have also provided basic science data regarding a new modication of traditional coagulators. For both of these, they are to be congratulated. Edward C. Benzel Cleveland, Ohio ikami et al. have developed a novel bipolar design incorporating a tip plated with a protein and water repellant gold-PTFE composite lm. A variety of physical parameters were examined to determine the characteristics of this new bipolar forceps when compared with conventional gold-plated tips. The authors found that the increased microscopic roughness of the gold-PTFE lm provides an increased surface area for coagulation and, perhaps, tissue grasping, while at the same time diminishing coagulum adherence. These factors improve coagulation performance and the ease of cleaning. Although this device is not yet available for purchase, the manufacturing process is not difcult and the component materials are neither rare nor expensive. The authors estimate that the eventual cost would be comparable to that of gold-plated forceps. Of some concern is an apparent vulnerability to repeated sterilization. Particles of PTFE begin to shed after only a few gas sterilizations. Perhaps disposable tips are the answer. This group should be commended for applying modern material design to improve upon a basic instrument used by neurosurgeons every day. The subtle enhancements in utility provided by these new bipolar tips may facilitate improved hemostasis and surgical efciency. These authors may have succeeded in building better microsurgical mousetraps. Joel D. Macdonald Salt Lake City, Utah

ONS-160 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007

www.neurosurgery-online.com

NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE

he authors describe a modification to bipolar forceps that may interest all neurosurgeons. Sticking of a bipolar forceps is a problem in brain tumor surgery and could be disastrous in vascular neurosurgery. Sticking can be reduced by frequent cleaning of the forceps tips (I usually have it cleaned after each coagulation); however, this can be

an inconvenience and can prolong operative time. The modication described in this report should reduce sticking and require less frequent cleaning. My only question is where do I get one? Patrick J. Kelly New York, New York

Govard Bidloo, 16491713, Ontleding des Menschelyken Lichaams. Amsterdam: By de weduwe van Joannes van Someren, de erfgenaamen van Joannes van Dyk, Hendrik en de weduwe van Dirk Boom, 1690 (courtesy, of the U.S. National Library of Medicine, National Institutes of Health, Bethesda, Maryland).

NEUROSURGERY

VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-161