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Sontec Instruments
A guide to ensure you, that every time you need an instrument to work properly, it Does.

Everything you ever wanted to


know about surgical instruments
AND A LITTLE BIT MORE...

7248 South Tucson WayEnglewood, CO 80112(303)790-9411(800)821-7496Fax(303)792-2606


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In 1937 the author first realized the importance continues to use it, the tooth on the male jaw usually
of checking surgical instruments in the operating room. In breaks off. Thus, not only is the instrument destroyed, but
those days most of the surgeons owned their own instru- pieces of the tooth may be lost in surgery.
ments. Problems were many for the Operating Room
supervisors because the number of surgical instruments How to test a forcep for jaw alignment
surgeons had was limited. Surgeons were forced to bor-
row from each other to complete their sets, especially Start with a visual test. Close the jaws of the for-
when some of their instruments were set aside for repair. cep lightly. If the jaws overlap, they are out of alignment
In an average hospital it was not uncommon to . On forceps with serrated jaws, observe to see if the teeth
have 20 to 25 surgeons each owning his personal instru- are meshing properly. Holding the shanks of the forcep in
ments. It was necessary for Operating Room supervisors each hand , with the forcep open, try to wiggle the instru-
to receive the surgeons permission prior to having his ment. If the box lock has considerable play, and if it very
instrument repaired. If a surgeon worked in several hos- loose, this will cause jaw misalignment. If this occurs, the
pitals in a city, his instruments had to be transported from instrument is faulty and should be repaired.
one hospital to another. In emergencies, the OR supervi-
sor had to improvise to make up sets, and much dissension Forceps and Hemostats which spring open
occurred among doctors as to who had borrowed their
instruments. It is extremely annoying to a surgeon, and hazardous to the
George Pencer taught many nurses the technique patient, when a forcep or hemostat springs open; especially
of checking instruments, and in hospitals of 200 beds or when clamped on a duct or a large vessel, such as a kidney
more , he would actually set up portable repair equipment pedicle. Operating room nurses have surely seen this hap-
allowing the repair and sharpening of instruments without pen.
removing them from the hospitals. The above problem is usually caused by forcep
Since 1937 many advance in the quality, repair, misalignment, worn ratchet teeth, or by lack of tension at
and ownership of surgical instruments have taken place. the shanks. As ratchet teeth are subject to constant metal
But we feel this handy check list, reviewing the care and to metal wear, they are the fastest wearing parts of a for-
maintenance of surgical instruments, should still prove cep. By constant strain of closing and opening the instru-
helpful for all members of the surgical team. ments, there is continues friction and wear; in particular
on the first ratchet tooth. Therefore, when a surgeon takes
Forceps and Hemostats a large bite with the forcep and locks it on the first ratchet
tooth, a small jar of any kind may cause it to spring open.
A surgeon faces a most irritating and frequently
frustrating problem when a forcep or hemostat does not How to check the ratchet teeth on instruments
function properly. In most cases, this can be avoided if a
surgical nurse knows how to check and test these instru- Clamp the forcep on the first tooth only. When
ments correctly before including them in the surgical sets. clamped, the instrument should produce a sounding snap.
Forceps are probably abused more than any other After the instrument is locked on the first ratchet tooth,
instrument. Experience indicates that breakdown of high take and hold the instrument at the box lock; then tap the
quality forceps is often the direct result of their misuse. ratchet teeth portions of the instrument lightly against a
They are most frequently misused in orthopedic surgery. solid object (a weighted vaginal retractor is ideal). If the
Here they are often applied to steinman pins, bone plates, instrument springs open, it is faulty and should be re-
screws, and nails-usually when pliers are not avail- paired.
able. They also are used to clamp large sponges, tubing,
needles, etc. The smaller the misused forcep, for example How to check the tension between the shanks
a Mosquito or Kelly, the greater the damage. As the jaws
of a forcep are overloaded, inevitably misalignment of the Close the forceps lightly. When the jaws touch,
jaws occurs and reduction of tension in the shanks. Thus, there should be a clearance of 1/16" or 1/8" between the
the instruments effectiveness is greatly impaired. When ratchet teeth of each shank. Such clearance provides ad-
this situation occurs in a Kelly or similar type instrument, equate tension at the jaws when closed.
the forcep will not hold tissue securely: therefore, fail- For a forcep to work effectively and efficiently,
ing to accomplish the job for which it was intended. If a the jaws must align and meet exactly; the serrations should
surgeon continues to use the instrument, further damage mesh correctly; the shanks should be flexible and resilient
at an accelerated rate will result. For example: when the to compensate for a larger bite. The ratchets must hold.
jaws of a Allis clamp do not align, the teeth will not mesh The forceps, when closed, must not spring open. The
properly, and they will break or wear very rapidly. When ratchet teeth should slide over each other smoothly when
the jaws of an Ochsner forcep do not align and a surgeon opening and closing. In short, the forceps should open and
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close easily, permitting the surgeons to work rapidly and for each adenotome.
efficiently.
Tonsiltomes
Orthopedic Instruments
If blades do not close properly, the sluder presents
Chisels, osteotomes, and gouges in constant use the same problem as ill-fitted adenotomes. In checking,
need sharpening and honing at frequent intervals. If they be sure the blade slides close, so that no light is visible be-
are accidentally misused, such as on a steinman pin, bone tween blade and tip of tonsiltome. Also, the blade should
plate, or screw, the edges become dull and nicked. In these not extend beyond the tip of the tonsiltome.
cases, the instrument should be sharpened immediately.
Your author has been told that it is difficult for a surgeon Tonsil Snares
not to occasionally encounter a pin, a bone plate, or a
screw with an osteotome; particularly when it is neces- On tonsil snares, Tydings and Eves type, one
sary to remove an old plate which has some bone growth should inspect the tip of the cannulas. Tonsil snare wires
around it. In such a situation , it is prudent to have an older have a tendency to wear grooves into the tips of the can-
or special osteotome or chisel available for the surgeon. In nulas, thus causing the wire to stick or catch and not pull
the regular course of cleaning and sterilization, care must through the cannula completely. If the wire sticks, it will
be exercised not to hit the edges of the chisels, gouges, and have a pulling and tearing effect on the tissue instead of
osteotomes against each other or other instruments. Such a clipping effect. If grooves are visible in the tips of the
jostling not only dulls the edges of the instruments, but it cannulas, the instrument should be repaired.
can also chip or dent the sharp edges.
Eye Instruments
Visual test for checking orthopedic instruments
Cataract Knives, Keratomes
Check for nicks and burrs on edges on chisels It is very important to know how to test a cataract
and osteotomes. On bone cutting forceps and double knife correctly. Once the eye surgeon penetrates the con-
action ronguers, one should again check to see whether junctiva of the eye with a cataract knife only to discover it
the jaws align. If the screws at the fulcrum are slightly will not cut, he is in trouble.
loose, the jaws inevitably become misaligned; conse- A small buckskin is the proper device for de-
quently damage occurs to the jaws when the instruments tecting a faulty knife. This item is a must for testing eye
are used. Frequently, a bone cutting forcep or ronguer is knives. To make the test, lay the handle portion of the eye
used to cut wire or a pin. To preclude this practice, it is knife across the palm of your hand. Do not touch it with
very important to have wire cutter or pin cutter available your fingers. Hold the buckskin drum in your other hand.
to the surgeon. Orthopedic instruments are very expensive; Then, push or slide the knife blade through the buckskin
therefore, they merit exceptional care. drum while it still rests in you palm. The blade should
penetrate the drum as though it were passing through
Tonsil Instruments butter. If it sticks or has a tearing effect, then the knife is
in need of repair. The same procedure is used for testing
Adenotomes Keratomes.
The proper fitting of the adenotome blades is a Extreme care should be taken in handling all eye
problem. An adenotome blade should slide smoothly in the instruments. Too much emphasis cannot be given to this
channels of an adenotome. When closed the blades should matter. During cleaning and sterilization, caution must be
not overlap the adenotome. If overlapping does occur, taken to prevent the instruments from touching each other.
the blade is too long and could be hazardous in use. If the Metal to metal contact should never be permitted. Eye
blade is to short , it will not close completely, causing tear- instruments, even at best, can stand improvement.
ing of tissue rather than a clean cut. There are a number of other fine eye cutting
Check the blades. Be sure they slide smoothly instruments which are too numerous to mention in this
and close so that no visible light can be seen between the article; however, the same procedure of care should be
tip of the blade and the adenotome. When ordering new followed on them as on the cataract knives previously
blades, send your adenotomes to your surgical instrument discussed.
repair company and have the blades fitted to each adeno-
tome. This is very important because no two adenotomes Scissors
are alike, even though they may be the same size. Also,
be sure to have each blade stamped or lettered with the Scissors, especially Mayo operating and Metzen-
same code number as the adenotome. For instance, if the baum dissecting, which do not cut on the tip of the blades
adenotome is coded 1-A, the blade should be coded 1-A. can cause surgical havoc. Not only should a dissecting,
This identification procedure insures a proper fitting blade or an operating scissor, cut tissue on the tips, but it is also
4 needle holder. It is the only instrument involving constant
important that the scissor blades glide over each other metal to metal contact. Many times when pliers are not
smoothly. Only a correctly ground scissor with properly available, especially to orthopedic surgeons, needle hold-
set blades can provide this action. The precise setting of ers are used on screws, pins, bone plates, etc.
the blades is very important. To achieve this state involves How to test a Needle Holder
a highly skilled procedure. And it takes an exceptionally The test is very simple. First, clamp the needle
skilled craftsman with years of experience to grind and set in the jaws of the needle holder. Then, lock the instrument
blades correctly. on the second ratchet tooth. If the needle can be turned
Various types of scissors are made for different easily by hand, the instrument should be set aside for re-
types of use. It is important, therefore, that the surgeon pair. When the instrument is new, it will hold securely on
has the proper scissors available to him. Light, fragile the first ratchet tooth for a considerable time.
scissors, such as eye scissors with fine blades, should be Needle Holders, such as a Crile Wood, Derf, or
meticulously guarded against misuse. For the surgeon to Halsey used in plastic surgery, should hold at least 6-0
work quickly and methodically, an eye scissor must have suture. Eye needle holders, such as a Castroviejo or Kalt,
a particularly smooth and delicate action and cut on the should hold 7-0 suture.
tips of the blades. Dissecting scissors are made for the ac-
curate cutting and dissection of tissue. The tips and edges Lubricating surgical Instruments
of the blades of these scissors should not be used for any
other purpose. If a dissecting scissor, especially a Metzen- Ordinary oil or mineral oil is not permeable by
baum, is used for cutting heavy sutures or catgut, not only steam and should never be used on surgical instruments.
will the edge be dulled, but there will be a tendency for the Neither should it be used for oiling the screw lock on scis-
blades to separate thus causing the scissors to loosen and sors or the box-lock on forceps.
lose their effectiveness. Extensive test have shown that oil will harbor
Suture scissors should be available to the surgeon bacterial spores in box-locks even though the instruments
for cutting sutures. Wire of any kind should never be cut are autoclaved. Common lubricating oil acts continuously
with scissors. A wire cutter should be available for this as a collector of dust and dirt. The problems caused by
purpose. A scissors should be used only for its intended indiscriminate oiling if instruments are matters of grave
purpose. concern.
Sharpening surgical scissors is a highly skilled The development of a lubricant called Instru-
procedure. Very often when scissors are incorrectly ment- Milk resulted in a dramatic break through in the
ground by a incompetent repairman, the blades become science of instrument maintenance. After the Instrument-
overheated. Consequently, they loose their temper, and Milk dip is applied, the instruments are autoclaved. The
the edge of the scissors is caused to soften. This situation lubricant's unique characteristics permit complete steril-
practically ruins a scissor because the blades will not hold ization of both lubricant and instrument while lubricating
their edges and must be repeatedly sharpened. Constant qualities are fully retained.
sharpening, in turn, causes the tips to eventually become A knowledge of the operating and the testing
pointed and sharp . In addition , the fact that they do not characteristics of surgical instruments can substantially
close properly makes the instrument useless for dissecting. benefit many segments of the nursing profession. In-
struments which are kept in optimum conditions by
How to test a scissor for maximum efficiency periodic testing, at least monthly, and which are repaired
as required, produce multiple profitable gains. Surgeons
All operating Mayo and Metzenbaum scissors save time and are able operate with unerring precision.
should cut four layers of gauze at the tips of the blades. Operating Room supervisors abide in an atmosphere of
Smaller scissors less than 4" in length should cut at least satisfaction which comes from doing an important as-
two layers of gauze at the tips. Additionally, eye scissors signment exceptionally well. Subsequently they develop
should have a delicate touch when cutting. The Mayo and enjoy increased rapport with surgeons and gain their
and Metzenbaum scissors should cut with a fine, smooth respect. Hospitals save money be keeping their surgical
feel and a minimum amount of pressure by the blades. instruments in optimum condition. As with the mainte-
Check the action the scissors; it should not be too tight or nance of most technical equipment, the best maintenance
too loose. Check the tips (points) of the scissors. Are is the cheapest. In consequence, the patient gains the most
they too sharp? Are there burrs on the tips of the blades, from the increased potential for a completely successful
especially on the Mayo and Metzenbaum scissors? When operation.
the scissors are closed, are the tips of the blades open? A
scissor should both cut on the tips and feel very smooth
when cutting.

Needle Holders

No instrument receives greater abuse than a


CORROSION OF STAINLESS STEEL SURGICAL 5
INSTRUMENTS face upon which a continuous layer of chromium oxide
may form. Surfaces which may not be effectively polished
Corrosion of stainless steel surgical instruments are usually the first to show corrosion. Thus, knurled
is a constantly recurring problem to both the surgeons and handles or handles with milled grooves may rust , while
the instrument maker. The surgeon is justly chagrined the remainder if the instrument is unaffected. Even the
when he finds rust on his delicate hand made instruments. satin-like, dull finish used to reduce glare is somewhat
The blame is likely to fall on the instrument maker when more prone to surface corrosion than highly polished sur-
no other cause is apparent. However, corrosion is not faces. This surface corrosion will not penetrate deeply and
uniformly observed. In some hospital corrosion of stain- usually may be removed by scrubbing with a brush and an
less steel instruments is rarely seen, while in others, each abrasive soap. Instruments with surface corrosion can be
sterilization produces a coating of corrosion. The purpose repolished and passivated by the manufacturer to new con-
of this paper is to explore some of the causes of corrosion dition. Usually, the surface corrosion does not reappear
and to indicate what is being done by the user to minimize under proper maintenance thereafter.
corrosion. A more distressing type of corrosion is that which
There is a need for some explanation as to the takes place on blades of knives, in box-locks or between
choice of stainless steels used for fabricating surgical the blades of scissors. In these cases the function of the
instruments. Also a question may arise as to why stainless instrument may be impaired. The most common causes of
steel should rust under any circumstances. In the usual in- this type of corrosion are as follows:
dustrial situation a manufacturer's choice of raw materials
is guided by economics. He must balance desired physi- •Inadequate cleaning and drying immediately
cal properties against costs. This is not the case in the after use.
manufacture of hand made surgical instruments. Here, raw •The use of corrosive sterilizing solution or too
material costs are insignificant compared to labor costs so long exposure to sterilizing solution.
that only metallurgical properties are considered.
A wide range of metallurgical properties are of-
•The use of faulty autoclave.
fered by the class of metals called stainless steel. These
Probably the single most important consideration
metals have iron and chromium in common, but contain
in the care of surgical instruments is cleanliness. Any
carbon, nickel, sulfur, tungsten, manganese, molybdenum
foreign material either organic or inorganic on the surface
and many other elements. It is chromium which imparts
of hardenable stainless steel is likely to promote corrosion.
the stainless quality; and in general, the more chromium
Thorough cleaning is more difficult than is realized by
present in the alloy, the more resistant it is to the cor-
some surgical nurses. This was shown by investigation
rosion. Carbon reduces the corrosion resistant effect of
of Allegheny Ludlum Steel Corporation to determine the
chromium, but it is necessary to produce hardness. Hard-
specific cause of corrosion on certain surgical instruments.
ness is a prime consideration in instruments that require
A microscopic examination revealed foreign material scat-
extremely sharp edges or accurate jaw approximation. It is
tered over the surface of these instruments. Also chlorides
a unhappy circumstance that there are only a few stainless
were found in the corrosion products. These findings
steel alloys which may be hardened sufficiently to be used
indicate that the instruments had not been thoroughly
in the manufacturer of delicate surgical instruments. These
cleaned or rinsed. A good soap and rubbing is required.
alloys are low in chromium content and high in carbon
Often a soft brush is needed. Such as the Whisk'R Brush
content. They belong to the broad class known as stainless
available from Sontec Instruments. Finally the instrument
steel, but are the least corrosion resistant of the group.
should be disassembled after use, thoroughly cleaned, and
In order to minimize corrosion of these harden-
thoroughly dried before they are reassembled. Instruments
able stainless steel alloys, special handling is required
of this type will corrode if they are stored with trapped
by the processor. A properly made instrument will have
moisture.
passed through two processing steps which increase its re-
A convenient method of removing corrosion
sistance to corrosion. In one of these steps, called passiv-
products from inaccessible places is to soak the instrument
ation, the instrument is treated with nitric acid. This dis-
in a mixture of equal parts ethyl alcohol and aqueous am-
solves away any particles of carbon steel which may have
monia. After contact with this solution for about twelve
been ground in during processing. All tools necessary for
hours, the corrosion products may be rinsed or lightly
fabricating are of necessity made of carbon steel (regular
brushed away. This procedure is particularly useful in
steel). The nitric acid bath also promotes the formation
freeing box-locks which have frozen because of corro-
of a surface coating of chromium oxide. The formation
sion. Box-locks present a problem due to a tendency to
of the chromium oxide coating is usually considered the
retain sterilizing solutions and moisture; furthermore, the
mechanism by which chromium produces resistance to
intersurfaces are not polished.
corrosion in stainless steel.
Sterilizing solutions are a likely source of the
Polishing is the second processing step which
chloride found in the corrosion products. Certain qua-
reduces corrosion. Polishing removes sites of possible
corrosion attack by producing an extremely smooth sur-
6 utilizes proper technique during the use, care, and handling
ternary ammonium chlorides make good cold sterilizing of its surgical instruments.
agents as they have very strong germicidal properties as
well as being detergents. Manufacture
The detergent property results from the molecular
structure which contains a large organic group and an ionic Metallurgical research has enabled instrument
portion. Such compounds are inherently corrosive due makers to produce accurate, long lasting surgical instru-
to the presence of the chloride ion. These materials are ments. The steel used in most O.R. instruments is a 400
usually compounded with rust inhibitor which is effective series alloy which has several useful properties. It can
for only a limited time. When cold sterilizing solutions be brought to very sharp cutting edge and will hold this
are used, they must be replaced frequently. If corrosion edge through continuous use. In addition, it has a high
still persists, the solutions should be prepared with distilled tensile strength enabling it to maintain precisely set jaw
water. approximations. The metal is often referred to as stainless
Corrosion during autoclaving will take place because of its corrosion resistant qualities. A chromium
if (1) the autoclave is not operating properly, (2) cor- content of 11.5-18% gives the steel some of its stainless
rosive materials are in contact with instruments or (3) characteristics. However, a manufacturing step known as
tap water instead of distilled water is used to generate passivation actually provides the instrument with its corro-
steam. Autoclaves in which a large amount of corrosion sion resistance properties. Passivation, which follows the
takes place should be inspected for leaking valves. Such final polishing steps, is a chemical bath which creates an
autoclaves may not be drying the instruments adequately oxidized layer on the surface on the instrument. Through
or may even be drawing corrosive matter back from the routine hospital use and exposure to the air this oxidation
drain. The source of the trouble may be as remote as the process continues, effectively maintaining and even build-
laundry. Cloth used to wrap instruments to be autoclaved ing up a barrier to most stains and corrosive elements.
may contain residual detergents, bleaches or starch. These
compounds can promote corrosion at the operating tem- Maintenance Procedures
peratures of the autoclave.
The best material now available for the manu- Designed and crafted to exacting specifications,
facturer of surgical instruments is a hardenable stainless instruments will perform for a reasonable number of years
steel. With this material, extremely fine points, sharp when the following steps are observed:
edges and durable sets may be fashioned into instruments. Instruments should be used during surgery for
However, in obtaining hardness, some resistance to corro- their intended purpose exclusively. Misusing instruments
sion is sacrificed. Special handling by the manufacturer will lead to damage that is usually not repairable. A he-
as well as the user indicated. In order to reduce corrosion mostat, for example, that is used to clamp tubing can come
, instruments must be thoroughly cleaned and dried, and out of alignment and quickly break.
they must not be given prolonged exposure to sterilizing Certain compounds are highly corrosive to
solutions. Care should be taken that no corrosive materials stainless steel and will cause serious damage despite the
are introduced into the autoclave and that the autoclave in passivated protective surface. Instruments should never be
functioning properly. Whenever the autoclave is suspect, exposed to Hydrochloric acid, Aqua regia, dilute Sulfuric
distilled water should be used. When corrosion does occur acid, Iodine, or Ferric chloride. In addition the following
in stainless steel instruments, it is usually of superficial substances should be kept away from instruments when-
nature. This surface corrosion may be removed by soaking ever possible:
in a solution of alcohol and ammonia or by repolishing by •Aluminum chloride
the manufacturer. •Ferrous chloride
Instruments used in speciality surgery are the
products of a few highly skilled craftsmen. At their finest, •Barium chloride
these instruments reflect not only craftsmanship but a high •Mercury chloride
degree of artistic ability in design and styling. When such •Bichloride of Mercury
instruments are give the very special care which they de- •Potassium Thiocyanate
serve, they will retain their beauty and function for many •Carbolic acid
years.
•Potassium permanganate
•Calcium chloride
•Sodium Hypochlorites
Every hospital owns many thousands of dollars •Dakin's solution
worth of surgical instruments. The care and maintenance •Stannous chloride
these instruments receive is critical to their performance
during surgery and to the cost containment effort of each
•Chlorinated lime
Instruments should be rinsed immediately follow-
hospital. Having made the investment in a quality product,
the hospital can expect several years of use if the staff
7
ing contact with any of these substances. cedures. Such as tip covers by Medi Spec. Avoid loading
It is important to rinse instruments that have retractors and other heavy items on top of delicate and
been exposed to blood and saline solutions before these hollow instruments.
substances dry. Blood will cause a stain that is difficult to Inspection is a vital part of proper care and main-
remove, and saline solutions are highly corrosive. Instru- tenance. Instruments in need of repair will not perform
ments should be placed in a basin of sterile distilled water accurately in surgery and breakage is likely to occur.
immediately following use. Worn ratchets, loose box locks and misaligned tips can
The box-lock portion of instruments must be kept be repaired at a fraction of the cost of new instruments.
clean and free of debris. A buildup of substance in this Contact Sontec Instruments for information regarding a
area will cause instruments to become stiff and eventually cost effective instrument repair program.
break. Manual cleaning should remove all visible residue,
and it is essential to keep the box-locks open during any Spots and Stains
automated cleaning procedure.
When cleaning, sterilizing and rinsing instru- It is common for instruments to become stained
ments, it is important to use solutions with a pH as near or spotted despite the best effort of the manufacturers and
7.0 (neutral) as possible. Distilled water is recommended the hospital staff. In nearly all cases these problems are the
rather than tap water because it is free of many compounds result of minerals being deposited upon the surface of the
which exist in ordinary water. These substances alone instruments. Adhering to proper technique during cleaning
cause stains and when tap water is combined with some and sterilizing procedures will prevent most staining oc-
detergents it will form insoluble deposits on the instru- currences. However, they will not disappear on their own.
ments. The following section identifies the various instrument
During Manual cleaning, avoid the use of steel related problems hospitals may encounter.
wool, wire brushes and highly abrasive detergent cleaners.
These will damage the instrument's protective surface and Brown Stains
lead to corrosion. Manual cleaning will be most effective
with a solution of distilled lukewarm water and a neutral Detergents containing polyphosphates may dis-
pH detergent. This should be followed by a two stage solve copper elements in the sterilizer. This results in
rinse of distilled water, first warm then cool. copper being deposited on the instruments by an electro-
The use of an ultrasonic cleaner is highly rec- lytic reaction. The hospital may try a different detergent
ommended. Avoid overloading the tank and always use or check the quantities used. Usually a dull blue or brown
a detergent created for the use with these machines in the stain is simply a buildup of oxidation on the surface. This
suggested proportions. Thorough rinsing must follow film is harmless and will actually protect the instrument
ultrasonic cleaning in order to remove suspended particles. from serious corrosion.
Never autoclave dissimilar metals together, i.e.., titanium,
silver etc. Blue Stains
Follow manufacturers specifications when using
automatic washer-sterilizers. Use a freerinsing , low- Are usually the result of cold sterilization tech-
sudsing detergent with a neutral pH (7.0), and do not alter niques. It is important to prepare the solution according
prescribed cycle times. A high-sudsing detergent may to exact proportions and to change the solution when
clean effectively but often leave residual deposits on the recommended. Serious corrosion may occur if the solu-
instruments. Again, do not autoclave dissimilar metals tion is used past the manufacturer's time limit. The use of
together. distilled water and rust inhibitor in the solution will help
Before instruments are wrapped for storage they retard discoloration.
must be thoroughly dry. Remaining moisture, particularly
in box-locks may result in corrosion that will weaken the Black Stains
instrument and lead to breakage during use. The most
effective method of drying instruments are in a dry heat May be the result of contact with ammonia.
oven, a sonic energy oven, or a hot plate. Many cleaning compounds contain ammonia and it will
The use of water-soluble instrument lubricant is remain on the instruments unless they are well rinsed.
recommended. This will help keep a clean box lock mov- A black stain may also be the result of amine deposits
ing freely and will aid in protecting the entire surface from traced to the steam in the autoclaves. Solutions contain-
mineral deposits. Note that ultrasonic cleaners remove ing amines are often used to clean the steam lines. It is
all lubricants which will result in stiff box locks; hence necessary to follow steam line cleaning procedures with a
this maintenance procedure should routinely be done after cycle of distilled water to remove all traces of amines from
ultrasonic cleaning and before autoclaving. the autoclave system.
An effort should be made to protect sharp cutting
edges and fine working tips during all maintenance pro- Light or Dark Spots
8 Are the results of slow evaporation of water PREPARATION FOR DISINFECTION
condensed on the instruments. What often remains is a AND CLEANING
mineral deposit which is related to the mineral content of
the water. Using distilled water for sterilizing procedures Disinfection of soiled instruments not only helps
will help to eliminate the formation of these residual to preserve the instruments themselves, but also serves
spots. It is also important to follow manufacturer's specific to protect those persons responsible for their transporta-
autoclave operating instructions. Spots may result, for ex- tion and cleaning. Wherever possible, instruments should
ample if the autoclave doors are opened before the steam be disinfected and cleaned immediately after use. Any
is completely vented. An additional cause of spotting can soiling left to dry will make eventual cleaning much more
be traced to the instrument wraps. During laundering pro- difficult and could result in damage to the instruments. If
cedures it is vital that detergents are thoroughly rinsed out necessary, instruments should be taken apart, allowing the
and that the final rinse is prepared so that the wraps are left disinfectant to cover all surfaces.
with a pH between 6.8 and 7.0 This will inhibit spotting For disinfection of the instruments either humid
during steam sterilization. heat or chemical disinfection can be used. Humid heat is
preferable providing the instruments are suitable for treat-
Rust Deposits ment in this manner.
Occasionally, corrosive caustic agents and
It is very unlikely for surgical grade steel to rust. medicines (e.g. silver nitrate, iodine preparations, albotyl
What appears to be rust is usually residual organic matter and mercury components) are used in operations and for
in box locks or mineral deposits which have been baked medical treatment. Remnants of these substances have to
onto the surface of the instrument. Localities where the be removed immediately.
water has a high iron content, for example, an iron deposit Under no circumstances must instruments be
will result in a metallic film on the instrument. This is not stored in physiological saline solutions as prolonged con-
the fault of the instrument and can be prevented with the tact causes pitting and rust.
use of distilled or demineralized water during cleaning Undue "dropping" can cause damage to the
procedures. instrument, hard metal tips on scissors may be chipped or
small, delicate clamps can be deformed. In order to avoid
Important Information this, carefully handle and deposit instruments after use.
To avoid encrustation and corrosion, in case of
The use of neutral pH detergents is vital to the removal in dry conditions and return to CSSD, the instru-
maintenance of surgical instruments. Contact with acidic ments must immediately be subject to machine treatment.
or alkaline solutions will remove the instruments protec- For this treatment, deposit the instruments on suitable
tive barrier of chromium oxide, often leading to corrosion, trays, e.g. perforated sterilizing trays. For effective clean-
pitting or breakage. There is no guarantee if the instru- ing, hinged instruments have to be opened (such as scis-
ments are continually exposed to acidic solutions pH4 and sors, clamps, gouge forceps).
lower or alkaline solutions pH10 and higher. Instruments which are subject to machine treat-
ment have to be immersed into a combined disaffecting
Conclusion and cleaning agent.
For removal in wet conditions and return to
The most effective method of dealing with CSSD use only noncorrosive agents in prescribed concen-
instrument problems is to prevent them from occurring. trations. Water alone is not sufficient. The instruments
The use of distilled water, careful preliminary cleaning, have to be fully covered by the solutions.
using neutralized pH solutions, following manufactur- Instruments should never be left overnight
ers instructions, visual inspection, will all help to keep before cleaning as the risk of causing permanent damage
instruments performing accurately and cosmetically free increases with the length of time between use and prepa-
of troublesome stains. It is important to act quickly should ration.
a problem arise. Delay will compound the problem and Handles and cables for HF-surgery have to be
irreparable harm may result. prepared like surgical instruments.
Microsurgical instruments require special prepa-
ration and for this reason have to be deposited on racks
or suitable holding devises. Dental materials, such as
filling materials, adhering to dental instrument have to be
removed directly after use. Otherwise there is the risk of
hardening and/or corrosion.
Rotating dental instruments such as burrs, drills,
and grinding tools, have to be separated and stored in spe-
9
cial containers or holding devices; such instruments have ery day. The following problems may occur due to using
to be prepared separately. the same solutions for too long:
If possible, surgical motors have to be dismantled
in to their components immediately after use; follow the
instructions of the manufacturer. Surfaces of the various •Risk of corrosion due to soiling
parts have to be wiped with a lint free cloth, impregnated •Risk of corrosion due to increasing
with a disinfecting and cleaning agent, or sprayed with a concentration caused by evaporation.
disinfection spray in order to avoid blockage and encrus- •Decrease if disinfecting effect due to
tation. excessive dirt concentration.
Simple tools can be prepared like surgical instru-
ments. Instruments with a narrow lumen (tubings, cannu-
Tubing sets for cooling liquid and spray nozzles lae) or with cavities are generally difficult to prepare. One
have to be rinsed immediately with water from the rinsing must, therefore, take care that the passages are free and
bottle and checked for leakage (visual control, see chapter that the inside is completely in contact with the solutions.
"inspection"). If powdered products are used, completely dis-
Prior to preparation, rigid endoscopes have to be solve the powder first. Only then should one immerse the
dismantled according to the manufacturer's instructions. instruments since undissolved particles may lead to clog-
Optical equipment has to be placed in special containers. ging of the narrow lumen and discoloration of the instru-
In case of flexible endoscopes , the insertion part ments.
has to be wiped with a lint free cloth immediately after After chemical disinfection and cleaning, the
use. The cloth should be soaked in instrument disinfectant instruments must always be rinsed well under running
which should contain either a suitable detergent compo- water. Any residue has to be removed manually (no metal
nent or a cleaning intensifier suitable for disinfectants. brushes, no scouring agents). In order to avoid water
In order to avoid encrustations and blockage, the spots, a final rinsing with demineralized water is recom-
extraction channel and any other additional channels have mended. Finally, the instruments have to be dried immedi-
to be rinsed with the same solution, The air/water channel ately.
has to be rinsed with water from the rinsing bottle. Water on the surfaces of elastic instruments made
Prior to further processing, the leak test has to of rubber or plastic may cause white spots to appear which
be carried out according to the instructions of the man- can only be removed by drying.
ufacturer. This allows for the detection of leaks and If after manual cleaning , instruments are chemi-
perforations in good time and avoids expensive subsequent cally disinfected instead of being sterilized, a separate
damage caused by the penetration of fluids. disinfectant has to be used.
A damaged endoscope together with a fault The instruments then must be rinsed thoroughly
description has to be returned immediately to the manu- with sterile demineralized water.
facturer. If pneumatic air used for drying, make sure that
Cleaning and disinfecting of endoscopes should the air flows through a sterile filter.
preferably be done in automatic machines. Preference should be given to manual preparation
Dismantle elastic instruments and breathing sys- of microsurgical instruments as they are very sensitive to
tems according to the manufacturers instructions. Cones, mechanical damage. Even then, damage is possible, e.g.
sealing surfaces, thread connections and valve plates have when removing blood encrustations, the main causes for
to be carefully handled and protected against mechanical damage are:
damage.
Prior to preparations, completely remove breath- •Metal brushes
ing line from the absorbers. Data readers have to be •Scouring agents
prepared only according to the manufacturer's instructions.
•Too much exertion
Manual disinfecting and cleaning •Dropping or knocking

For manual preparations, instruments have to be For cleaning, it is recommended to use either
immersed into a combined disinfecting and cleaning solu- lintfree soft cloths, plastic brushes or cleaning pistols.
tion with proven disinfecting effect. Drying with a pneumatic-air pistol is particularly safe and
The instructions of the manufacturer have to be effective and should therefore be given preference over
strictly followed regarding concentration, temperature any other drying method.
and induction time. Special attention has to be paid to the In general, dental instruments can be prepared
manufacturer's instructions with regard to material com- like surgical instruments. Instructions for preparation of
patibility of instruments not made of high-grade steel.
Use fresh disinfecting and cleaning solutions ev-
10
endoscope in the container filled with instrument disin-
dental instruments, recommended for separate treatment,
fecting and cleaning agent and make sure that the surface
are given as follows.
is thoroughly wet.
Hand pieces and angled hand pieces as well as
Clean the channels with the brush belonging to
turbines must not be immersed. The outside is either
the system followed by flushing with the cleaning solution.
cleaned with a cloth or sprayed with disinfectant. Only the
For this purpose some manufacturers offer a hand pump.
methods specified by the manufacturers have to be applied
Take particular care when cleaning the distal end (optical
for internal cleaning and care.
system, Albarran lever etc.).
As a result of the material used, rotating dental
Immediately after this pretreatment abundantly
instruments have to be placed in special disinfecting and
rinse the instrument inside and outside with water. Then
cleaning solutions. In order to avoid corrosion, the instru-
place the flexible endoscope into the container with
ments, after quick rinsing, have to be dried at once and
instrument disinfecting solution so that all channels are
treated with corrosion protecting agent suitable for steril-
filled. The hand, 1.c. pump can now be used. Take care to
ization. In the case of ceramic-bonded or plastic-bonded
disinfect the extraction nozzle. Soaking time and solution
grinding tools, one must first check whether the disin-
concentration have to be strictly observed according to the
fecting and cleaning agents are suitable agents for these
instructions of the manufacturer.
instruments. Unsuitable agents may destroy the bonding
After chemical disinfection, thoroughly rinse all
materials.
surfaces and channels leaving no residues. To avoid water
Root canal instruments are sensitive to me-
spots use demineralized water. Additional sterile filtration
chanical damage and, therefore , have to be prepared
of the water prevents undesired recontamination.
separately. Root canal instruments with color-anodized
Dry the outside of the flexible endoscope with
handles will loose their color codes when attacked by
a lint-free cloth. Drying the channels should be done ac-
alkaline solutions.
cording to the manufacturer's instructions by using a hand
The various components of the surgical mo-
pump, light source and suction pump or by means of com-
tor line have to be externally cleaned with lint-free cloth
pressed-air of max. 0.5 bar. Undesired recontamination is
impregnated with disinfecting and cleaning agents. Soft
prevented when sterile and filtrated compressed-air is used.
brushes can also be used. When spraying the surfaces with
Elastic instruments with lockable cavities, such as
disinfection spray, wipe the parts afterward with a cloth.
bellows and breathing masks, have to be cleaned and dis-
Under no circumstances should these components be im-
infected in closed conditions thus avoiding the penetration
mersed. Any penetrated liquid has to be removed immedi-
of liquid into the cavities.
ately by turning the aperture upside down.
To avoid damage on diaphragms and functional
Simple tools can be prepared like surgical instru-
parts of the breathing system, no compressed air should be
ments. Rigid endoscopes have cavities and channels which
used for cleaning. Machine preparation allows disinfec-
are difficult to clean. Careful preparation of these instru-
tion, cleaning, after rinsing and drying without having the
ments requires:
instrument handled.

•Removing the seals/washers Machine disinfection and cleaning


•Opening the stop cocks
•Dismantling according to the manufacturer's Machine preparation is usually done in the case of
instructions. a dry return to CSSD. When wet removal to CSSD is the
case, then either a low-foam producing disinfectant has to
When immersing the endoscope into the cleaning be used or else the instruments have to be thoroughly pre-
and disinfection solutions, make sure that all air bubbles washed as foam development in the machine can consid-
escape from the cavities by moving the instrument to and erably influence the cleaning results. This also applies for
fro or by holding it in a sloped position thus guaranteeing instruments having to be pretreated either in a splashing
complete wetting of the surface. or by ultrasonic treatment because they are soiled. (e.g.
Do not use metal brushes or scouring agents, but owing to dried-on blood and secreta or remnants of filling
only swabs, cleaning guns and brushes with natural or material).
plastic bristles. The temperature of the inflowing water should
o
Use a wooden applicator with cotton wool soaked not exceed 45 C as higher temperatures lead to protein
in alcohol to gently rub off any dirt on windows or glass coagulation and cause cleaning problems.
surfaces, otherwise use a neutral detergent (hand washing Disinfection can either be performed chemother-
liquid). mally or thermally.
Prior to preparation take off valve and caps from When using cleaning agents combined disin-
flexible endoscopes, thus guaranteeing thorough clean- fecting and cleaning agents on it is recommended to
ing and flushing of the channels. For cleaning, put the strictly follow the instructions of the manufacturer regard-
11
ing induction time, concentration and temperature. cutters and grinding tools are suitable for
Using the correct dosage rate does not only machine preparation only to a limited extent.
guarantee a perfect disinfection and cleaning result but Preference should be given to an ultrasonic bath.
also the most careful treatment of the material. If alkaline •Root canal instruments should also be cleaned
detergents are underdosed (false economy) there is a risk in an ultrasonic bath.
of pitting, which can be avoided at pH-values over 10.5.
When acid detergents are used, corrosion may occur due to •Hand pieces can be prepared in a machine only
the chlorides in the water. This can be prevented by using if recommended by the manufacturer; special
demineralized water. With machine cleaning, special at- holding devices are, however, necessary.
tention has to be paid to the following: Immediately after the end of the machine
program remove any moisture using a mainte-
nance spray recommended by the manufacturer.
•Hinged instruments have to be opened, thus
guaranteeing thorough cleaning in the joint. •Mouth mirrors may be dull due to machine
treatment which will shorten their life
•Do not overload the perforated trays so that all span.
instruments can be well rinsed.
•A thorough internal flow has to be guaranteed With the exception of simple tools and acces-
with instruments having long, narrow cavities sories, machine preparation for disinfecting and cleaning
(tubing, cannula, breathing systems). Use is not possible for the components of the surgical motor
special inserts. line.
•Place instruments in such a way that they Rigid endoscopes have to be dismantled for ma-
cannot damage each other. chine preparation according to the manufacturer's instruc-
•Place large and bulky instruments properly on tions. Seals/washers have to be removed and stop cocks
the ray thus avoiding "shadows" on other opened.
instruments Machine preparation should only be done if
•Color-anodized aluminium instruments may recommended by the manufacturer for this procedure (e.g.
lose their color and thus their coding function if optical equipment). In order to avoid damage, secure the
normal machine preparation methods are used. parts safely and make sure that the insides of all cavities
are thoroughly flushed.
Remnants from the cleaning phase have to be Flexible endoscopes can only be processed in
totally removed in the subsequent rinsing procedures as special automatic machines. Standard disinfecting and
otherwise spotting and/or discoloration may occur. Ad- cleaning machines are not suitable. If endoscopes are
ditional use of suitable neutralizing agent improves the disinfected prior to machine preparation, only use a low-
rinsing results. foam product as foam which develops in the machine will
o
For final rinsing a temperature of 70-90 C has deteriorate the cleaning and disinfecting results.
proved to be best. Prior to further processing, the leak test has to be
Should corrosion occur on surgical instruments carried out according to the manufacturer's instructions.
due to bad water quality, then the rinsing temperature This allows for the detection of leaks and perforations in
o
should be limited to 70-75 C. Corrosion, water spots and good time and avoids expensive damage caused by the
discoloration will be avoided when using demineralized penetration of fluids.
water for final rinsing . No temperature limit must then be There are machines in which a leak test is incor-
observed. porated either before or while the program is activated. A
When the machine operation is done without dry- leaking endoscope has to be returned to the manufacturer
ing, then the goods have to be removed from the machine together with a fault description.
immediately after the program has finished. If drying is Standard alkaline cleaning agents may cause
not sufficient, repeat it. damage to the endoscopes, therefore, use only those
Machine preparation for microsurgical instru- products recommended as suitable by the manufacturer.
ments is possible if the instruments are held in place in Chemo-thermical processing should not exceed a tempera-
o
reliable and safe manner, e.g. racks. ture of 60 C.
Dental instruments can be treated like surgical During machine preparation, make sure the
instruments for machine preparation. Pay special attention endoscope is secured and that all external surfaces and the
to the following: inside of all channels are thoroughly and reliably flushed.
Final rinsing should be performed with sterile
•Probes and other delicate instruments have to demineralized water. If, for technical reasons, this is not
placed in racks or holding devices to be pro- possible, at least water of drinking quality must be used.
tected against damage. Subsequent to final rinsing, machine drying should be pos-
•Rotating instruments like burrs, drills, milling sible. Prior to storage, thoroughly dry the endoscopes.
12
Elastic instruments with lockable cavities, such as opened
bellows, breathing masks etc. have to be cleaned and dis- •Only trays which do not affect the ultrasonic
infected in closed conditions thus avoiding the penetration treatments should be used.
of liquid into the cavities. To avoid overstretching of the •Large and bulky instruments such as lead hands
edge of the mask, remove the nipple prior to preparation, or kidney trays must be placed in such a way
press out some air and replace the nipple. that there are no wave shadows or inactive
Elastic instruments, made of PVC for example, zones. Place such items either vertically or put
with low temperature resistance have to be disinfected, them on top of the other instruments.
o
cleaned and dried at max. 65 C.
Care has to be taken with rubber instruments
•An excessively dirty solution in the ultrasonic
bath decreases the cleaning effect and increases
because imperfectly removed residues of cleaning agents
the risk of corrosion. Depending on the frequent
lead to irreversible damage by subsequent drying and ster-
cies of use, the solution has to be renewed at
ilization. The surface of the material depolymerizes and
regular intervals.
gets sticky. Latex-coating dissolves under blistering.
Especially serious are residue not completely •Ultrasonic treatment times of approx. 3 minutes
flushed out of functional parts of the breathing system. have proved to be efficient for cleaning at
Furthermore, all parts have to be completely dry as rem- frequencies of at least 35 KHz.
nants of moisture may lead to functional troubles.
Elastic instruments may not be dried above 95 C;
o After ultrasonic treatment, the instruments have
higher temperatures considerably shorten their life span. to be thoroughly rinsed either manually or by machine.
Functional parts of breathing systems are Rinsing has to be performed with clear water of at least
specially designed by the manufacturers of either units. drinking quality or, better still, with demineralized water in
Preparation can, therefore, only be performed according to order to avoid water spots.
the manufacturer's instructions. The instruments should then be thoroughly dried.
To avoid damage, microsurgical instruments have
Ultrasonic treatment to be deposited on special racks.
In order to avoid destruction of surfaces and
Ultrasonic treatment is particularly suitable for soldering seams on dental instruments, no acid cement
cleaning instruments of high-grade steel. Delicate instru- remover should be added to the ultrasonic bath.
ments (microsurgical instruments, dental instruments) can Hand pieces and turbines are not suitable for
be carefully and thoroughly cleaned by ultrasonic treat- ultrasonic cleaning.
ment. As a result of the material used, rotating dental
Furthermore, ultrasonic treatment is a suitable instruments have to be treated with special disinfecting
method to effectively remove encrustations. and cleaning agents. Prior to ultrasonic treatments place
In order to achieve optimum efficiency of the them on special holding devices to avoid contact damage
ultrasonic treatment, please observe the following when between the instruments (e.g. by sharp cutting edges, dia-
preparing a bath: mond grain). After a quick rinsing under running water
followed by immediate drying, rotating dental instruments
•Fill the bath to the markings.
have to be treated with a corrosion protecting agent suit-
•Add a suitable cleaning and/or disinfecting able for sterilization.
agent to the water Mouth mirrors can be damaged by ultrasonic
•Temperature above 40oC promotes degassing treatment.
and cleaning. Under no circumstances use ultrasonic treatments
•No protein coagulation occurs at higher for components of the surgical motor line, with the excep-
temperatures if suitable cleaning agent is used. tion of simple tools and accessories.
•When using disinfecting and cleaning agents Ultrasonic treatment is only allowed for those
make sure that the concentration and tempera- parts of rigid endoscopes which are suitable for this proce-
tures are correctly maintained. dure according to the manufacturers's instructions (e.g. no
optical systems).
Even with a properly prepared bath, faults can Flexible endoscopes are not to be treated in an ul-
arise. These can be avoided by observing some principle trasonic bath. Accessories, such as valves, caps, bite rings,
rules: and forceps are suitable for ultrasonic treatment.
Elastic instruments are not suitable for ultrasonic
•Instruments have to be completely covered by
treatment as ultrasonic waves have no effect on elastic
the cleaning solution. Non-immersed instru-
surfaces.
ments will not be cleaned.
Functional parts of the breathing system can also
•Hinged instruments, e.g. scissors, have to be not be prepared in an ultrasonic bath.
13
treated with silicon because of swelling which makes them
Care and maintenance inoperable. Under no circumstances use paraffin agents
for rubber and latex instruments; this prevents them from
Instruments with joints or ratchets have to be swelling up.
treated with suitable lubricating agents during the clean-
ing process. Inspection
These lubricating agents prevent the friction of
metal on metal and preserve smooth function of the instru- After each cleaning, the instruments have to be
ments, thus avoiding corrosion by friction. Furthermore, macroscopically clean, ie. free of visible protein remnants
constant use of such agents prevents "sticking" of the and other contamination.
hinged parts. Prior to functional inspection, surgical instru-
The care agents can either be applied manually or ments with movable parts should be cooled down, thus
during the final rinsing in the machine. avoiding metal friction leading to corrosion. Before car-
In any case it is indispensable that threads, joints rying out functional inspection, oil any instrument with
etc. difficult to access are directly treated with each prepa- joints, ratchets or threads.
ration. Instruments with non-traumatic toothing have to
Dental instruments have to be cared for like be specially inspected, and, if necessary, manually reclean
surgical instruments with the exception of the following: the non-traumatic toothing.
Worn out or damaged instruments should be
•Hand pieces, angular hand pieces as well as removed for repair or replacement. Corroded instruments
turbines have a very complex internal design. should be discarded immediately as these can cause con-
Therefore, they have to be treated with special tact corrosion even on a perfect surgical instrument.
agents in accordance with the instructions of the Stains on surgical instruments are due to improper
manufacturer. preparations. Cause of such stains or spots can be:

•Immediately after drying, treat all rotating •Insufficient mechanical or manual cleaning.
dental instruments (drills, burrs) with a •Unsuitable cleaning, disinfecting and care
corrosion protection agent, suitable for steriliza- agents.
tion in hot air or steam. •Failure to observe the dosage instructions for
cleaning, disinfecting or care agents.
Motor lines have to be lubricated and maintained
•Remnants of cleaning and disinfecting agents-
with agents recommended by the manufacturer. Hand
insufficient rinsing.
pieces which are not watertight have to be sprayed with
special care agents for inside cleaning and lubrication. •Poor water quality.
Apply a few drops of special oil into the supply •Residue in the sterilizing steam, when steam
channel of pneumatic surgical motor. To distribute the oil quality is not accordance with recommenda-
inside , run the motor for a few seconds with compressed- tions.
air. Proper lubrication and maintenance of the motor •Remnants of medications, marking pens or
line is of great importance, therefore, the manufacturers chemo-indicators.
instructions must be followed. •Procedural faults e.g. not cleaning brand-new
Rigid endoscopes must be lubricated. surgical instruments prior to sterilization.
However, joints and non maintenance-free stop-
cocks may have to be treated with special oil or special These and other causes for spots on surgical
grease according to the manufacturer's instructions. instruments show the complexity and difficulty of the
The only necessary maintenance on flexible endo- problems dealt with here. To facilitate tracing and finding
scopes is to treat the valves with silicon oil before inserting the cause for such stains, it is recommended to cooper-
them into the valve housing. Do not spray them with car ate with competent manufacturers. By making use of the
agents as the propellent gases will damage the instruments. company's service, you will not only take advantage of
Only silicon oils and grease-free gels should be their practical experience but their well-equipped laborato-
used as lubricants. Agents containing vaseline or paraffin ries as well.
cause swelling or softening of rubber parts. To avoid permanent damage, instruments with
Refrain from treating elastic instruments and remnants on the surface have to undergo a special treat-
breathing systems with lubricants prior to sterilization. ment. The method of treatment is adapted to the cause of
Special care and maintenance measures are prescribed by the stain. In order to avoid damage and subsequent corro-
the manufacturer, should the need arise. sion due to metal friction, under no circumstance use metal
Elastic instruments of silicon rubber may not be brushes or metal sponges to remove stains. More details
about causes of stains and corrosion are given in chapter
14
12. end of the fibre optic cable, hold it against the light and
Each surgical instrument is designed for a specific then look into the other end. Little black spots indicate
purpose. Inspection has to be carried out to ensure that breaks in the fibres. A large number of breaks reduces the
they function as they should. If any doubt, a reliable man- light output. Such fibre optics as well as endoscopes with
ufacturer can advise you on suitable inspection methods. surface damage and surface deformation should be sent for
Especially fine and delicate instruments are repair.
inspected under the magnifying glass. In order to avoid Normally, clouding of the optical system on flex-
damage during transportation, place the instruments in ible endoscopes can be removed by using a wooden appli-
specially designed racks or use special holding devices to cator (not metal) soaked in alcohol. If this does not help,
prevent them from slipping. return this instrument to the manufacturer for inspection.
Faultless surgical instruments should not be Optical fibre breaks in the optical wave guide can
packed together with instruments having damaged sur- be seen by holding the proximal end against the light and
faces. Older instruments with chipped chromium and/or looking into the distal end. Quite a number of breaks con-
nickel coating may cause discoloration or corrosion on siderably reduce the light output. Such damaged instru-
high-grade surgical instruments. It is, therefore, recom- ments have to be returned to the manufacturer.
mended to discard such instruments or pack them sepa- Endoscopes with visible external damage (e.g.
rately. deformation in the insertion part or on the supply tube,
Handles, cables and cables for neutral electrodes overstretched angled rubber) have to be returned to the
for HF-surgery have to be checked for faultless function. manufacturer.
(Caution: defective contact). It is compulsory to Flexible endoscopes are best dried while sus-
sort out defective parts. pended and should be stored unfolded. Locks and feed-
Prior to sterilization the surgical motor line with reels should be loosened. The transportation case should
accessories should undergo a functional inspection accord- be used for storage.
ing to the manufacturer's instructions. Prior to every use, check all functions of the
Units operating with compressed air should be endoscope. Use only silicon oils or greaseless gels as
checked for leaks and be given a functional inspection. lubricants. Under no circumstances should vaseline or
Any leakage will be audible or can be found by immersing lubricants containing paraffin be used as these cause soft-
the hose into water. ening or swelling.
For checking the exhaust channel additionally Breathing systems have to be inspected according
connect the pneumatic surgical motor to the compressed- to the manufacturer's instructions.
air hose. With the motor running, leaks can be best Elastic instruments have to be inspected ac-
detected in the water. cording to their function and range of use. The most
Simple tools are inspected as general surgical in- important inspections are:
struments. In order to avoid damage during transportation,
store the tools in special racks or place them in suitable •Bellows have to be undamaged and airtight
holding devices to prevent them from slipping.
The leak test for tubing sets for cooling liquid •Filling system of the bellows must not show any
can be carried out by means of a clamp and a large syringe leakage.
filled with water. Fill the tubing with water; close one end
with the clamp, and insert and empty the filled syringe in
to the other end. •Lumina of catheters and probes have to be free.
In case rigid endoscopes are used, check the ad-
ditional instruments for HF-surgery for absolutely perfect •Connections have to meet functional safety.
installation. Exchange damaged parts.
Surfaces of electrodes/loops must be free from •There should be no changes of design, e.g.
encrustations which can be removed with fine abrasive radius of curvature of tracheal tubes.
powder. Take care that neither insulation nor clips get
damaged or deformed. Elastic instruments with faults or damage have to
To avoid damage to optical systems, clean them be replaced. Frequent problems are
carefully with a swab, moistened with alcohol. If this does
not remove the clouding return the part to the manu- •Dissolvation (blister forming)
facturer for inspection. Damage can be avoided by using •Cracked surface
wooden or plastic applicators, metal is not suitable.
Optical wave guides and fibre-optic cables have to be •Sticky surface
checked for optical fibre breaks. To find this out, take one •Hardenings
•Porous surface
•Discoloration
15
•Rotating dental instruments (e.g. burrs or
To prevent premature failure, take care that elastic milling cutters) can be autoclaved.
instruments are stored in a dry place without being kinked
or overstretched. •Hand pieces should, wherever possible, be
o
autoclaved at 134 C, due to the shorter
Sterilization induction time.

General
Sterilization conditions as well as units have to be
•Check whether turbines are suitable for auto
claving with the manufacturer.
in conformity with valid quality standards.
Follow the sterilization instructions of the
manufacturer. Sterilizing accessories as well as sterilizing •For mouth mirrors, refer to manufacturer's
packings have to meet the requirements of the both the instructions.
instruments as well as the sterilizing method used.
Autoclaving All components of the surgical motor line, meant
o
Normally, autoclaving is performed with satu- for sterile application, can be autoclaved at 134 C. Refer
o
rated water steam at 134 C. In special cases a temperature to the manufacturer's instructions. Special instructions of
o
of 121 C can be used for a longer time. the manufacturer have to be observed for storage during
Sterilization procedure has to be standard suitably sterilization.
for the goods to be sterilized. Sterilizing packings have Hoses for compressed-air have to be protected
to meet the valid standards with regard to quality and ap- against pressing during sterilization.
plicable to the procedures selected. Apart from the optical system with rigid endo-
Steam used for sterilization has to be free from scopes, all endoscope parts (insert, trocar, trocar sheath,
any contamination and should neither impede the process shaft, mandrel) have to be separated from each other and
nor do damage to the sterilizer of the goods to be ster- can then be sterilized like other surgical instruments.
ilized. In order to guarantee this, meet the recommend- Sterilizing instructions from the manufacturer have to be
ations of pr EN 285 regarding the quality of the water in observed for optical systems. Optical systems suitable
o
the tanks as well as the condensate, otherwise rust particles for autoclaving should be processed at 134 C instead of at
o
from the conducting system may cause corrosion or a 121 C due to the shorter thermal stressing.
high content of silicic acid may lead to discoloration of the Flexible endoscopes are not autoclavable due
instruments. to restricted temperature compatibility. If necessary, use
Due to heating and cooling down during the gas sterilization. Instruments used for endoscopy, such as
sterilization process, a surgical instrument with a closed clamps, catheters etc. may be autoclaved.
ratchet may suffer from tension stress which causes stress Elastic instruments with and without bellows
cracking in joints or deterioration of the clamping force. made of silicon and natural latex are suitable for auto-
Therefore, such instruments have to be sterilized either in claving. Due to the shorter thermal stress, preference is
o
open condition or closed on the first ratchet only. given to a processing at 134 C. Items of thermo-materials
The loading weight of perforated trays filled with (plastic) may only be autoclaved if recommended by the
instruments should not exceed 10kg. manufacturer.
After sterilization, instruments have to be stored When elastic instruments are autoclaved, take
dry until used again. Instruments as well as the inner care that the cavities, e.g. edge of mask, bellows are open
covering of sterilized goods have to be absolutely dry after in order to avoid damage due to changes in pressure.
having cooled down to room temperature. Prior to sterilization, cavities closed with valve
Excessive condensate production during ster- (e.g. bellow catheters) have to be sucked free of air and
ilization is avoided by observation of the recommended water by means of a syringe.
maximum weight for loaded perforated trays. Drying is Functional parts of breathing systems can be
o
facilitated by wrapping the perforated trays into a cloth autoclaved at max. 134 C. Cavities must not be closed in
within the container or external paper packing. order to avoid damage to the valves.
If heavy sets are unavoidable, the instruments Hot-Air Sterilization
should be distributed among several perforated trays. In When surgical instruments are hot-air steril-
addition, special measures may be necessary for drying. ized, please take care to load and operate the sterilizers
In general, dental instruments can be autoclaved properly. To ensure safe sterilization, the temperature
o o
like surgical instruments. When separate treatment for should not be below 180 C but should not exceed 200 C as
dental instruments is necessary, obey to the following this may cause structural changes leading to irreversable
instructions. damage, especially as far as microsurgical instrument are
concerned. Instruments with parts of rubber, plastic, or
textile as well as plastic-coated instruments and handles
16
for electrodes are not suitable for hot-air sterilization. can be given only by the manufacturer of endoscopes.
The general use of lubricating agents should be After airing, flexible endoscopes should be stored in an
omitted prior to hot air sterilization. Only oil the joints and extended position.
ratchets of surgical instruments. Elastic instruments of thermolabile plastic are not
Dental instruments can generally be sterilized like autoclavable but can be gas sterilized if the manufacturer
surgical instruments. When separate treatments for dental gives instructions about a suitable procedure.
instruments is necessary, obey to the following instructions: Elastic instruments of rubber and functional parts
of breathing systems do not have to be gas sterilized; use
•Temperature should not exceed 180oC when autoclaving.
sterilizing hand pieces.
Treatment of brand new instruments
•Turbines are not suitable for hot-air sterilization.
Packings of brand-new instruments have to be
removed and instruments have to be stored in dry rooms,
•Burrs and milling cutters must not be sterilized
o open to air. Temperature fluctuations may otherwise lead
at a temperature exceeding 180 C in order to
to condensation within the plastic packing and thus cor-
avoid softening.
rosion.
Under no circumstances store instruments in
•The sterilizing of mouth mirrors has to be cupboards or rooms where chemicals are kept which can
carried out in accordance with the manufacturers produce corrosion vapors.
instructions. Prior to first use, brand-new instruments have to
be prepared. First remove any protective caps or foils.
Components of the motor line are only partly suit- Cleaning, rinsing, lubrication, inspection and sterilization
able for hot-air sterilization, due to the various materials have to be carried out according to the procedures previ-
used. ously described.
Rigid endoscopes are not suitable for hot-air ster- Prior to the first preparation, microsurgical instru-
ilization. ments have to be placed in racks or holding devices to
Flexible endoscopes are not suitable for hot-air avoid damage.
sterilization. Elastic instruments have to be kept in their
Elastic instruments are not suitable for hot-air original packing and stored in a dry, cool and dark place.
sterilization. Breathing systems are not suitable for hot-air When ordering supply, please keep in mind that in addition
sterilization. to wear through use, elastic instruments are prone to aging
Gas Sterilization even when in storage.
Gas sterilization should only be used when no Functional parts of the breathing system fre-
other method is suitable. quently contains valves or membranes which can get
Components of motor line should only be gas ster- sticky when stored for a longer period. Such valves or
ilized when explicitly recommended by the manufacturer. membranes have to be tested and operated before being
Optical systems of rigid endoscopes may be gas put to use.
sterilized, however, follow the instructions of the manu-
facturer. Special information
Flexible endoscopes can be gas sterilized at a tem-
o
perature limit of 60 C. Use higher temperatures only when
indicated by the manufacturer. •By following these instructions properly, there
For gas sterilization, the flexible endoscope is is no difference in the preparation of instru-
packed in a transparent sterilizing hose allowing a curva- ments with a mirror finish or matte surface.
ture diameter of at least 30cm. It is very important to make •These instructions do not refer to disposable
sure that the venting cap is adapted to the supply connector items
as otherwise irreversible damage will occur. •Instruments and cables with optical waveguides
To ensure protection against mechanical dam- can generally be prepared like surgical
age, the sealed flexible endoscope is put into a wire basket instruments, if the manufacturers have not given
belonging to the gas sterilizer. Again, pay attention that the other instructions. Only hot-air sterilization and
curvature diameter is not less than 30cm. ultrasonic baths cannot be used.
Goods sterilized with ethylene oxide require suf- •Fibre-optic cables should not be bent, nor coiled
ficient airing times before being used again. Depending on too tightly.
the goods sterilized and on available airing conditions, such
airing times can differ considerably. Reliable airing times
•Cables and handles for HF-surgery can be
17
machine prepared and are autoclavable. silicic acid. The remedy is in-time regeneration of the
exchanger-consult an expert.
For all other preparation processes, refer to the
instructions of the manufacturer. Materials

Water for preparation When producing surgical, microsurgical, and


dental instruments, the manufacturer will use the materials
Instruments must have certain characteristics most suitable for the purpose for which the instrument is
in order to fulfill their function (e.g. cutting ability of intended.
scissors, clamping force of clamps and forceps). Only a In most cases, the demands for high elastic and
very limited number of steels meet these requirements. toughness, good cutting ability and high wear resistance,
Unfavorable water composition can, therefore, have a together with best possible corrosion resistance can only
detrimental effect on such steels. Consequently, the qual- be answered by using metal materials for surgical instru-
ity of water must be taken into account when planning the ments. Therefore, stainless and hardenable chromium
sanitary installations. steels with a chromium content of approx. 13% are used.
Ordinary water contains dissolved salts. The Instrument characteristics, such as smooth and homo-
amount of salts contained varies depending on the water geneous surface, a matte or mirror finish, and a hardened
purification process. Evaporation of water leaves remnants condition can be achieved with steels. The user has to
of salty encrustations (lime). Of all water components, observe, however, that these instrument steels, listed in na-
chlorides have to be regarded as the most potentially dam- tional (DIN) and international (ISO) standards, are gener-
aging because in higher concentrations they cause pitting ally resistant to chemical and thermal stress as occurring in
on instruments. doctor's practices and hospitals, but are, on the other hand,
The relationship between chloride content in the very sensitive to stress corrosion and chloride induced pit-
water and pitting are not predictable in some cases. ting.
In general, the danger of chloride induced pitting Apart from the hardenable stainless chromium
rises with: steels, non-hardenable chromium steels with modified
chromium content and rust and acid resistant chromium-
•Increasing chloride content nickel steels are used. The use of the latter steels is limited
•Increasing temperature to certain instrument types due to restricted mechanical
properties.
•Decreasing pH-value For the manufacturer of rigid and flexible endo-
•Longer induction time scopes of all kinds, chromium steels are hardly taken into
•Rougher instrument surface consideration. Due to the application technique and design
•Insufficient drying of the endoscopes, the greatest variety of materials is used.
Here are some of the most important ones:
Experience shows that with a chloride content up
to approx. 129mg/1 (corresponding to 200mg/1 NaC1= •Rust and acid resistant chromium-nickel steels.
sodium chloride) the possibility of pitting is low but rises •Surface treated non-ferrous heavy metal alloy
rapidly with increasing chloride content. e.g. brass, chromium-nickel plated.
Low concentration of other components can cause
•Light metals (e,g, anodized aluminium).
brown, blue, grey-black, or rainbow colored discoloration.
Such discoloration can be caused by contact with the ele- •Non-corrosion resistant steels, e.g. for lac-
ments iron, copper, manganese, magnesium and silicon in quered modules and single parts.
the water. Generally, there is no corrosion. By immersing •Glass for optical systems.
or rubbing the instruments with suitable products contain- •Ceramic
ing acid (follow the instructions of the manufacturer) such •Cement and adhesives.
decolorization can be removed to a great extent. In addi-
•Plastic and rubber.
tion to the natural water components, sometimes there are
rust particles in the water. Almost always, such rust comes
The combination of these heterogenous materials
from corroded piping systems. When preparing the instru-
is, with regard to the preparation of the units, a weakness
ments, such rust particles deposit on the goods and cause
in the chain of materials. It may, therefore, be possible
rust spots (extraneous rust) followed by corrosion.
that the special processing, deviating from the ordinary
Make it a basic rule to use demineralized water
preparation processes, may become necessary. When in
for final rinsing.
doubt, ask the manufacturer should he not have given
Even when using an ion exchange for demin-
already recommendations for use.
eralization, tarnishing can occur due to penetration of
Elastic instruments and breathing systems also
18
demand a wide variety of materials, similar to those used normally they show sharply defined edges and are caused
for endoscope, i.e. rubber, latex, and silicon. by too high a concentration of minerals e.g. lime or or-
The full scale of materiels dealt with in this bro- ganic substance in rinsing water or sterilization steam.
chure is used for the motor line as far as design, structure The remedy is to use demineralized water for
and manufacturing is concerned. Stainless, hardenable final rinsing and pure steam.
chromium steels are used for burrs, drills, milling cutters, Overloaded sterilizing plants may cause increased
saw blades and gearing parts as well as sterilizable plastic condensation and consequently increase stains during
materials for handles, switches, gearing parts or cable and sterilization, therefore, avoid overloading.
hoses. The term corrosion refers to metallic material
Special preparation methods may be necessary for only. Corrosion is specific to materials and occurs on vari-
enamelled housing of the unalloyed steel sheet, lacquered ous metals in different appearances. Almost always the
color codes for identification of the gearing on hand pieces corrosion leads to permanent damage or even destruction
or anodized housing of aluminium for hand pieces and an- of instruments and units.
gular hand pieces. Heavily used flexible cables, bearings Any kind of corrosion on surgical instruments
and gearing parts of stainless, but also of non-stainless and units can only occur due to inductions of water, aque-
heat-treatable steels as well as bronze materials require ous solutions or steam. Following is a description of the
special preparation and lubrication methods. most important kinds of corrosion and their effects, in the
Should any questions or doubt arise, it is strongly sequence of their frequency of appearance.
recommended to ask the advise of the manufacturers. Pitting corrosion refers only to metallic materials.
Due to chemical or thermical influences dur- Unfortunately, pitting can also appear on stainless steels
ing use, preparation or sterilization, all instruments and of which not only most surgical instruments are made, but
units, dealt with in this brochure, can experience surface also endoscopes, (although fewer in number), surgical mo-
changes, corrosion or aging. tor line and parts of breathing systems. With all types of
steel, pitting is mainly caused by active chlorides (chloride
Surface changes, corrosion and aging induced pitting). Other halide ions (iodides, bromides)
have the same effect. Nonferrous metals such as copper
Surface changes are visible appearances. Nor- and aluminium alloys can also be damaged by pitting,
mally, this refers to all kinds of instruments and units, however, other electrochemical causes may also be the rea-
independent of the material. In particular this refers to son.
removable residues such as adhering or already encrusted Pitting means that holes developed on the surface
remnants from operations or other soilings. Through of the instruments. These holes indicate rust and, with
cleaning using special basic cleaning agents, such as sur- continuous corrosion, get rapidly bigger and destroy the
face changes, can be completely removed without doing instruments within a short time.
any harm to the instruments. Pitting can only be avoided in instruments hav-
Quite often, yellow-brown, to dark-brown blister- ing been in contact with chlorides or other halide ions are
like spots show on sterilized instruments and units made of cleaned immediately after use. Please note that operation
metal and are mistaken as rust. In most cases, such residue debris also contains chlorides which leads to pitting should
can contain high degrees on chlorides which then lead to these remnants stay long enough on the instruments.
chloride induced pitting on parts made of stainless steel Attention also has to be paid to the quality of
if the spots are not removed immediately. Such residues water used for cleaning and disinfection, especially with
are usually found on those places with difficult access for regard to its chloride content.
cleaning. Stress Corrosion cracking normally occurs only
Annealing colors, black tints or water spots ap- in steels used for surgical instruments; it can have consid-
pear mostly on metallic instruments and units and hardly erable effects on the life span of the instruments.
ever on rubber or plastic products. The cause of this type of corrosion can lie either
In general, discolorations do not show clearly de- in the manufacturing process or in incorrect handling.
fined edges. Flowing color shadings or deep and uniform In order to avoid damage, it is absolutely neces-
staining (black colorings) can appear. Discoloration does sary that during the complete cleaning phase, all instru-
not permanently damage or destroy the instrument or units. ments are kept in open condition.
Causes can either be the be the bad quality of water used In order to avoid damage in such as stress cracks
for cleaning or autoclaving as well as inadequate machine in the joints and a reduction of clamping force, when ster-
cleaning and installations for steam supply. The only ilizing such instruments, only close the first ratchet. This
remedy is to check the technical equipment in the house prevents stress forces from occurring while heating and
installation, in cooperation with the manufacturer of clean- cooling during the sterilizing process.
ing, sterilization and steam supply plants and also together Even tiny quantities of chloride in the water may
with the manufacturer disinfectants or cleaning agents. favor the forming of stress corrosion cracking.
Water Spots are similar in appearance. However Fretting and crevice corrosion have almost simi-
19
lar causes. Both types of corrosion occur in narrow joints also called silicon elastomer, does not age.
due to chemical or mechanical destruction of the natural Another result of aging on rubber, latex and
passive coating of the high quality steel. In addition, plastic is the so-called swelling which is caused by the
due to the lack of sufficient lubrication, metallic abrasion penetration of liquid or gases to the surfaces.
occurs in joint crevices and hinders smooth action of the Swelling can be reversible and occurs only tem-
instrument. In both cases, and together with humidity, rust porarily by the induction of volatile solutions or propellent
blisters occur in the crevices. gases of sprays. This also applies if rubber and certain
Contact corrosion can occasionally be observed plastic get into contact with either gases such as halothane.
when surgical instruments are machine cleaned. Metal- Irreversible swelling, however, occurs by contact with
lic contact of instruments and unfavorable cleaning and nonvolatile oils (paraffin), vaseline and unsuitable disin-
rinsing conditions, e.g. tap water containing chlorides, can fectants (e.g. phenol derivates). Silicon cautchouc reacts
cause rust. reversibly on propellent gases of sprays and either gases;
Particularly severe contact corrosion occurs if irreversibly on silicon oils and solvents.
stainless steel instruments get in contact with non-stain- Typical signs of swelling are soft sticky surfaces
less goods, such as needles, cutters, etc. Chromium-plated as well as damage to thin-walled instrument parts.
instruments with chipped surfaces also cause contact cor-
rosion. Brief Information
With Surface corrosion the total surface of a •Brand-new instruments have to be cleaned prior
metal part is relatively uniformly attacked by chemical or to the first sterilization
other electrochemical influences. The surface can show •Instructions for use have to be strictly observed.
parts which differ in color to undamaged surfaces. This
corrosion takes the form of rust where steels are con-
•Strictly adhere to dosage, induction, time and
temperature for disinfecting and cleaning.
cerned.
Surface corrosion hardly ever occurs with instru- •Used instruments have to be treated as soon as
ment made of stainless steel. possible.
Instruments, trays and containers of anodized •Use proper accessories for cleaning
aluminium ask for a preparation method suitable for the •Do not overload washing machines and ultra
material. Acid or alkaline solutions may cause laminar sound devises. Avoid rinsing shadows as well as
corrosion which, especially on colored parts, causes, wave shadows.
"bleaching" •Never use metal brushes or metal sponges for
Instruments and units of stainless steel or non- manual cleaning.
ferrous metal, protected by galvanically applied coatings,
show surface corrosion only with damaged protective coat-
•Rinse thoroughly and carefully after cleaning.
If possible, use demineralized water.
ings.
Any kind of corrosion leads to rust on steels. •Dry sufficiently after rinsing.
Rust particles are transferred from one instrument to •Worn corroded, deformed, porous or otherwise
another during disinfection, cleaning or sterilizing, so this damaged instruments have to be sorted out.
transferred rust causes resultant corrosion on the second •Each preparation of instruments with joints
instrument. If corroding instruments are not separated, needs a treatment with a care agent based on
further preparation processes promote rust formation on paraffin oil (this does not apply to flexible
other instruments. endoscopes and accessories).
Sterilizing steam from rusty steam supply pipes •Prior to sterilization, only close the first ratchet
may transport rust particles into the sterilizer. This extra- on the instruments.
neous rust deposits itself on the inside of the sterilizing
chamber, on the packings, on instrument surfaces. This
•Sterilization is no substitute for cleanliness.
extraneous rust also leads to resultant corrosion on instru-
ments.
Aging mainly refers to rubber and latex materials
used for flexible instruments, such as parts of endoscopes
and breathing systems. Aging is a slow going antral pro-
cess occurring also during storing. The aging process is
accelerated by the induction of dry heat with temperatures
above 80oC, by stretching and overstretching when storing
as well as by the action of light (e.g. sunlight, UV beams).
Aging is visible on rubber by decolorization (brownish) or
brittleness (cracks on the surface). Plastic also ages: it gets
hard and becomes yellow. However, silicon cautchouc,
20
I. Use stiff plastic brushes (nylon, etc.).
Do not use steel wool or wire brushes except
specially recommended stainless steel wire brushes for in-
struments such as bone files, or on stained areas in knurled
handles.
II. Use only neutral PH (7) detergents because, if not
rinsed off properly , low PH detergents will cause break-
down of stainless protective surface and black staining.
High PH detergents will cause surface deposit
of brown stain, which will also interfere with smooth op-
CLEANING, STERILIZATION & MAINTENANCE eration of the instrument.
III. Brush delicate instruments carefully and, if pos-
Rinsing sible, handle them totally separate from general instru-
ments.
Immediately after surgery, rinse instruments un- IV. Make sure all instrument surfaces are visibly
der warm (hot water. Rinse should remove all blood, body clean and free from stains and tissue.
fluids and tissue. This is a good time to inspect each instrument for
proper function and condition.
Cleaning Check and make sure that:
Scissors blades glide smoothly all the way
If not done immediately after rinsing, instruments (they must not be loose in the closed position). Test scis-
should be submerged in a solution of water and neutral PH sors by cutting into thin gauze. Three quarter of length of
(7) detergent. blade should cut all the way to the scissors tip, and not
hang up.
Ultrasonic cleaning Forceps (pickups) have properly aligned tips.
Hemostats and Needleholders do not show light
For micro and eye instruments, use manual clean- between the jaws, lock and unlock easily, joints are not to
ing (step C). loose. Check Needleholders for wear on jaw surfaces.
Suction tubes are cleaned inside.
Instruments should be processed in the cleaner for the full Retractors function properly.
recommended cycle time (usually 5 to 10 min.). Osteotomes and knives have sharp undamaged
Place instruments in a open position into the ul- blades.
trasonic cleaner. Make sure that "sharps" (scissors, knives, Test Biopsy Punches by cutting tissue paper.
osteotomes, etc.) blades do not touch other instruments. Punches should produce a clean cutout, without hanging or
All instruments have to be fully submerged. tearing.
Do not place dissimilar metals (stainless, copper, V. After scrubbing, rinse instrument thoroughly un-
chrome plated, etc.) in the same cleaning cycle. der running water. While rinsing open and close scissors,
Change solutions frequently at least as often as hemostats, needleholders and other hinged instruments to
manufactures recommends. make sure that the hinge areas are rinsed out, as well as the
Rinse instrument after ultrasonic cleaning with outside of the instruments.
water to remove ultrasonic cleaning solution.
After Cleaning
Automatic Washer Sterilizers
If instruments are to be stored, let them air dry
Follow manufactures recommendations but make and store in a clean and dry environment.
sure instruments are lubricated after last rinse cycle and
before sterilization cycle. Autoclaving

Manual Cleaning If instruments are to be reused or autoclaved:


A. Lubricate all instruments which have any "metal to
Most instrument manufacturers recommend metal" action such as scissors, hemostats, needleholders,
ultrasonic cleaning as the best and most effective way to self retaining retractors, etc.
clean surgical instruments, particulary those with hinges, Recommended surgical lubricants such as
locks and other moving parts. If ultrasonic cleaning is not instrument milk are best. Do not use WD-40 oil or other
available, observe the following steps: industrial lubricants.
B. Put instruments up for autoclaving either individually 21
or in sets.

Individual instruments

Disposable paper or plastic pouches are ideal.


Make sure you use a wide enough pouch (4" or wider) for
instruments with ratchet lock such as needleholders and
hemostats so the instrument can be sterilized in an open
(unlocked) position.
Instrument Sets

Unlock all instruments and sterilize them, in an


open position. Place heavy instruments on bottom of set
(when two layers are required).
Never lock an instrument during autoclaving. It
will not be sterile as steam cannot reach the metal to metal
surfaces. The Instrument will develop cracks in hinge
areas because of heat expansion during autoclave cycle.

Do not overload autoclave chamber, as pockets


may form that do not permit steam penetration. Place
towel on bottom of pan to absorb excess moisture during
autoclaving. This will reduce the chances of getting "Wet
Paks". Make sure the towels used in sterilization of instru-
ments have no detergent residue and are neutral PH (7) if
immersed in water. This can be real problem as laundries
frequently use inexpensive but high PH (9-13) detergents
and do not properly rinse out or neutralize those detergents
in the final wash/rinse cycle. Also, sometimes bleaches
such as Clorox are added and are not neutralized.
CAUTION-At the end of the autoclave cycle-
before the drying cycle-unlock autoclave door and open it
3
no more than a crack (about /4"). Then run dry cycle for
the period recommended by the autoclave manufacturer.
If the autoclave door is open fully before the drying cycle,
cold room air will rush into the chamber, causing conden-
sation on the instruments. This will result in water stains
on instruments and also cause wet packs.
If you have any unusual staining on your instru-
ments during sterilization, contact your local instrument
representative.

Cold Sterilization

Most cold sterilization solutions render in-


struments sterile only after a 10 hour immersion. This
prolonged chemical action can be more detrimental to
surgical instruments then the usual 20 minute autoclave
cycle. if the instruments need to be "disinfected" only,
cold sterilization is okay as disinfection will take place in
only 10 minutes. But keep in mind the difference between:
STERILE -an absolute term (no living organism survives).
And DISINFECTED- basically clean.
Always use the proper sterilization/cleaning tech-
nique to render the instruments in the required condition
for use.
22
COMPREHENSIVE SURGICAL ditionally, such compounds should be measured accurately
INSTRUMENT CARE and sterilizers filled with cold water. Purplish-black stains
indicate exposure to ammonia; thorough rinsing after use
Cleanliness, lubrication, correct handling and storage and cleaning in the usual manner should eliminate this
procedures will insure an instrument's proper perfor- stain.
mance. Additionally, inspection, troubleshooting, and a Rust deposits present a unique problem that they
professional instrument maintenance program can actually can not be rinsed off. Once an instrument surface has been
lengthen the serviceable life of your surgical instrument. rusted or pitted, it is far more susceptible to further corro-
To that end, the following instrument care habits are rec- sion. Fortunately, passivation and repolishing can return
ommended. the instrument to a like-new condition. Prevention of such
rust deposits and pitting can be aided by not sterilizing
Use of short cuts in instrument care can lead to together metals of dissimilar composition. For example,
rust, corrosion, stains and spotting. Corrosion, the gradual the sterilizer's electrolytic action can carry carbon particles
wearing away of material, will eventually impair the func- from imperfectly chrome-plated instruments and deposit
tion of an instrument. The most common causes are linked them on a stainless steel instruments causing a rusty ap-
to: pearance. Sterilize different metals separately, replace
chrome-plated instruments with stainless steel counter-
•Inadequate cleaning and drying after use parts.
•Corrosive chemicals or sterilizing solutions
•Use of ordinary tap water rather than distilled
or softened water in cleaning process •Cleanliness:
•Laundry detergent residue remaining in
operating room linens All instruments should be thoroughly cleaned
•Harsh detergents immediately after use. Never allow blood in a box-lock
•Malfunctioning autoclave or debris to dry on the instruments. Baked on blood in
a box lock or crevice can result in corrosion and subse-
Corrosion also will appear on knurled or grooved quent cracking under stress. Therefore, box locks should
surfaces. Glare-reducing satin finishes are more prone be opened and instruments with removable parts should be
to corrosion than mirror finishes. This type of corrosion disassembled.
does not penetrate deeply and can easily be removed with Cleaning solutions with a natural pH level (7.0
simple brush and detergent scrub. Should this procedure to 8.5) are recommended. An extremely alkaline detergent
fail, an instrument can be repolished. (higher than 9.0) may stain and might cause breaks; an
extremely acid detergent (lower than 6.0) may cause an
Autoclaving causes oxidation of surgical instru- instrument to pit.
ments while they are exposed to air, moisture and heat. Washing-sterilizer's are ideally suited for washing
Water left in the box locks is another offender. Never auto- and terminally sterilizing soiled instruments. However, it is
clave dissimilar metals together, i.e., titanium, silver etc. imperative that the sterilizer itself be cleaned and func-
Light and dark-colored spots are caused by the tioning properly. Hospitals in the hardwater areas should
slow evaporation of condensation on instruments. Traced implement a water softening or demineralizing system.
to mineral Surgical wrappings must be free of any laundry detergent
residue, such spots can be prevented by fol- residue.
lowing the autoclave manufacturer's directions carefully Ultrasound provides a speedy and complete meth-
and using distilled or demineralized water for all cleaning od for instrument cleaning. Although an ultrasonic cleaner
procedures and solution preparation. removes up to 90% of the soil, it does not preempt the
need for sterilization. Caution: Microsurgical instruments
Rust-colored film is particularly prevalent in new must not come in contact with one another during ultra-
hospitals due to foreign matter inside steam pipes during sonic cleaning. The units vibration may cause premature
installation. Unfortunately, nothing can be done, but the wear of their precision tips. Never clean dissimilar metals
situation is temporary. together i.e., titanium, silver etc.

Bluish-grey stains are indicative of cold steril- •Lubrication:


izing solutions. Following manufacturer's directions
explicitly will remedy the situation. A brownish stain is a It is recommended that instruments are lubricated
chromic oxide film which forms on stainless steel when after every cleaning process to guard against mineral
dishwashing compounds are used by hospitals. Frequently deposits and other water system impurities which may lead
experimentation with another compound used successfully to stains, rust and corrosion. Also prior vigorous cleaning
within the community will minimize discoloration, Ad- removes all lubrication which may result in "frozen" box
23
locks. To impede the growth of bacteria in the lubricant
wash, only antimicrobial, water-soluble lubricants •Chlorinated lime
recommended. Instrument milk baths produce
•Dakin's solution
excellent results.
•Sodium hypochlorite
•Correct Handling:
•Ferrous chloride
•Stannus chloride
Proper usage helps insure instruments will func-
•LYSOL
tion well when they are needed. To avoid unnecessary
•Tartaric acid
instrument abuse, we strongly urge that instruments be
•Mercury bichloride
used only for specifically designed purpose.
Exposure to the following solutions is extremely detri-
Needle Holders
mental:
Should never be used as pliers. This will lead to
•Aqua regia (a mix of nitric and
improper alignment of the jaws. Always match the needle
hydrochloric acids)
holder to the size needle being used.
•Ferric chloride
•Diluted sulfuric acid
•Hydrochloric acid
•Iodine (not to exceed 1 hour)

Instrument counts guard both patients and instru-


Scissors ments and reduce the instruments` chance of an unneces-
sary trip to the laundry.
Are particularly subject to abuse. Misuse can eas-
ily dull or chip the cutting edge and misalign the blades. •Storage:
Eye scissors are extremely delicate and must be treated
accordingly. Well defined storage procedures reduce the
chance of bent, broken and dulled instruments.
Do not bounce, drop or weigh down instruments.
Treat them gently; handle them individually or in small
quantities. Masses of entangled instruments cause damage.
Do not force a large instrument into a small tray.
Place heavier instruments in the tray bottom with the
lighter instruments on the top.
Instruments should be arranged accordingly:
Rinse & Sterilization
A. Place ring-handled instruments on a holder
During rinse and sterilization, never allow delicate to keep them in an open position.
instruments to be laid in a steel pan or on a tray or to be B. Instruments with curved jaws should all point
bumped against one another. Always lay instruments on a in the same direction.
towel or specially designed rubber or foam tray. C. In order that the edges do not come in contact
with another instrument, scissors should be
After Use kept separate on the rack.
D. Cupped instruments should be arranged so
Put protective tips over the ends of delicate instru- that water does not collect in them.
ments. Available from Sontec.
Meticulous care during surgery will also prolong E. Use specially designed racks for microsurgical
the life of the surgical instruments. Although blood and instruments.
saline are the most common causes of corrosion and pitting,
instrument contact with the following solutions should be •Inspection:
avoided if possible:
In addition to being completely clean and free-
•Aluminum chloride moving to insure proper function and sterilization, instru-
•Mercury salts ments must be inspected prior to packaging for reuse.
•Barium chloride Hinged instruments should be inspected for align-
•Phenol ment of jaws, meshing of teeth and stiff or cracked joints.
•Carbolic acid Rachets should close easily and firmly. To test rachets
•Potassium Permanganate clamp the instrument on the first tooth. Holding the instru-
24
ment at the box, tap the rachet end against a solid object. ments but also precludes unnecessary repairs and unwar-
Repair is required if the instrument springs open. Close ranted replacements.
instrument to test its tension, when jaws touch, a space of
1 1
/16" to /8" should exist between rachet teeth of each shank.

Ring-handled instruments can be tested by hold-


ing one handle in each hand. Open instrument and try to MICRO-INSTRUMENT CLEANING
wiggle it. If the box lock is very loose, jaw misalignment AND CARE GUIDE
will occur.
Scissor blades should be inspected for burrs. Protect your investment. Microsurgical instru-
If a needle which is clamped in the jaws of a ments are fine, delicate and precise. They require correct
needle holder locked on the second ratchet tooth can eas- care in cleaning, drying, lubrication and storage. Even the
ily be turned by hand, the jaws need replacement and/or finest stainless steel really is highly corrosion-resistant,
aligning and should be sent for repair. and is still subject to water spotting, staining and eventual
Elevated heat temperatures weaken stress points rust. Take care of your micro and regular instruments and
and can actually change molecular structures of the metal. devices with these facts in mind.
This change weakens and dulls instruments resulting in
their continual diminished performance. Be on the lookout During and after Surgery
for weakened stress points.
Deposit used instruments only on a cloth or, bet-
•Maintenance Program ter yet on a surface covered with gauze or disposable wrap
free of soap, detergent and hard mineral deposits. Do not
After repeated use and sterilization, instruments put "micros" together with heavier instruments.
will show signs of wear. They will become misaligned, •Neutral Disinfecting Solution Immersion: Such
stiff from metal fatigue, dulled and chipped. When they temporary immersion should be done after use only if im-
will no longer function properly, they will either need mediate cleaning is not possible. Do not soak instruments
professional repair or replacement. overnight, that is the worst thing you can do especially
with microsurgical instruments. Do not mix "micros" and
bigger instruments. When preparing cleaning or disinfect-
ing solutions strictly observe the manufacturer's instruc-
tions.

Cleaning

Micro-instruments should be cleaned gently and


absolutely thoroughly one at a time immediately after use,
preferably by hand with a soft cloth or a very soft brush, to
Because repairs can be costly, a specifically remove all blood, debris and most especially saline
scheduled preventive maintenance program based on usage solution. Do not use metal brushes or steel wool. Avoid
turn is the best alternative. Particular steps include: excessive pressure and instrument-to-instrument contact.
•Inspection and evaluation Never allow blood or debris to dry on instruments. Caked-
•Re-passivation on or baked-on blood in a box lock or crevice can result
•Clean and lubricate in corrosion and subsequent cracking under stress. When
•Replacement of worn and cleaning, box locks, joints and catches should be opened
missing parts ( tungsten carbide inserts, and removable parts disassembled.
lost screws, cracked springs.) Cleaning solutions with neutral pH level (7.0 to
•Restoration of finish ( grind out scratches and 8.5) are recommended. An extremely alkaline detergent
gouges and repolish.) (9.0 or more) may cause staining. A very acid solution
•Sharpening (6.0 or lower) may result in pitting and stress corrosion.
•Final adjustment to insure an instrument works Do not use scouring agents or abrasives. Calgon has two
easily and is properly aligned. popular products: "Manu-Klenz" for washing by hand and
Implementing the above program restores your instru- "Instru-Klenz" for machines, as ultrasonic cleaners. There
ments to surgical grade quality before major repairs and/or are other good cleaners. Change cleaning solutions often to
possible replacement becomes necessary. Although your keep suspended soil at a minimum.
instrument repair cost may rise, your new instrument cost Ultra sonic cleaners provide a speedy yet gentle
will decline over the long run, an important factor to con- almost complete system for cleaning micro-instruments. A
sider in the present economy. small office unit may be appropriate for your needs. The
A preventive maintenance program not only is an ultrasonic cleaner must be clean and functioning properly.
investment in lengthening the life of your surgical instru-
25
Hard water should be avoided by prior softening or demin- entangled instruments cause damage. Do not cram them
eralizing. Side by side placement of the instrument is best, in to undersized tray compartments. Place heavier instru-
not on top of one another. Treatment with ultrasonic waves ments in the tray bottom with lighter ones on top. Ring-
must be as short as possible. An ultrasonic cleaner removes handled instruments should be placed on a holder to keep
up to 90% of the soil, but further washing and sterilizing them in a open position. Curved jaws should all point in
is still required. Follow manufacturer's instructions as to the same direction, so they do not touch. Especially avoid
cleaning solution and procedure. that scissor tips and edges come in contact with anything.
Washer-Sterilizers are not recommended for Keep scissors in a separate rack. Water should not be al-
micro-instruments. The agitation may damage delicate lowed to collect in cupped instruments.
instruments. Standard instruments can survive the turbu-
lence. Non-micro instruments can be cleaned well and be Sterilization
semi or terminally sterilized in these units. The units must
be clean and functioning properly. Make sure the ejector is You can either sterilize terminally or semi-terminally,
not fouled, which may lead to the formation of detergent sterilizing again just prior to the next surgical use of the
scale. Hard water should be avoided by prior softening or instrument and devices. Autoclaves, steam or gas, are used
demineralizing. Autoclaves are better for terminal steril- for terminal
ization. sterilization. Before placing your instru-
Rinsing ment in the autoclave make absolutely certain that they are
clean of soil, blood, debris, soap, detergent, bleach, starch,
After cleaning of type, rinse the instruments thor- all of which can leave harmful deposits. It is most impor-
oughly in distilled water to remove any residue. If distilled tant to follow the manufacturer's instructions for cleaning,
water is not available, then rinse in cold or warm running care and maintenance of all equipment. A dirty malfunc-
water. tioning autoclave can be the source of many problems. Do
Drying not exceed recommended temperature, as this may cause
rapid deterioration of the instrument. Never autoclave dis-
Use a soft, absorbent non-fibrous cloth. Hot air is similar metals together, i.e., titanium, silver etc.
acceptable. Many doctors use hair dryers in their offices. Preheat instrument in the sterilizer chamber
Knurled or grooved surfaces and glare-reducing satin fin- before sterilization to avoid the problem of residue-laden
ishes (which are intentionally micro-pitted) are more prone condensation forming on the cold instruments, which can
to corrosion then mirror finishes. However, lead to subsequent staining. Also after sterilization, do not
satin open the autoclave too quickly so a blast of cold air causes
finishes are a virtual necessity when operating in a highly- steam condensation and residue deposit on the instruments.
lighted field under a microscope. Exercise especial care Wrapping can be done with either cloth or
that box locks, crevices, blades and knurled, grooved and disposal wraps. Cloth wraps must be free of any laundry
satin-finished instruments are dried thoroughly. detergents, soap or hard water residue. Disposable wraps
are free of contaminants, and therefore may be preferable.
Lubrication Unless thoroughly vacuum dried, wraps could retain mois-
ture which leads to stainless and rust. Therefore, it may be
This step is most important after cleaning, rinsing best not use wraps.
and thorough drying to avoid "frozen" box locks, stain-
ing and corrosion caused by mineral deposits and other Sealing
water system impurities. Remember that vigorous cleaning
removes prior lubrication, so it must be replaced. Only an- This can be done with either cloth or paper dust
timicrobial, water-soluble lubricants should be used. "In- covers. Cloth covers may provide protection up to 30 days.
strument Milk" is widely used. Follow the manufacturer's Paper dust covers may protect up to six months. Rester-
instructions carefully. Machine and mineral oils as well as ilization before surgical use is indicated for respective
silicones become gum-like with age and therefore are to longer storage.
be avoided. The gum formation may trap germ spores and
inhibit complete sterilization. Clogged Cannula

Assembly Use Enzyme tablets of the type used for contact


lenses to unclog deposit proteins and other impurities.
After lubrication the instruments should be reas-
sembled and placed in their respective storage trays. Use Cold Sterilization Solutions
specially-designed microsurgical racks for you micro-in-
struments. Treat your instruments sensibly and with gentle
tender loving care. Handle them individually. Masses of
26 Such as "Cydex" and "Zephrine" when fresh are
slightly corrosive. These solutions are not recommended
mainly because most professional offices do not use them
properly: First, instruments are left immersed far longer
than recommended by manufacturers, excessive hours
and even days, resulting in corrosion and dulling of sharp
edges on knives, scissors, hooks, etc. (a 20 to 30 min-
ute steam sterilization is much less corrosive.) Second,
the solutions are not changed as recommended, causing
undesirable suspensions, as blood, saline, proteins, medi-
cations, detergents, soap, debris, to circulate forward to
new instruments. Third, the instruments generally are not
rinsed with deionized (softened) distilled water after being
removed from these somewhat corrosive solutions. With
time and use these solutions become ever more corrosive.

Sontec Instruments
7248 South Tucson WayEnglewood, CO 80112
(303)790-9411(800)821-7496Fax(303)792-2606
A TRADITION OF FINE SURGICAL INSTRUMENTS