CIS SElf-Study lESSon Plan

Polar Express: Monopolar and Bipolar
Instrumentation (Part I)
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LEARNING OBJECTIVES:
CIS
1. Explain the difference between electrosurgery and electrocautery.
2. Review basic information about electrosurgery.
3. Present an overview of laparoscopic electrosurgical instruments.
4. Detail procedures for pre-reprocessing, cleaning, inspecting, lubricating, sterilizing, and storing
laparoscopic instruments.
CIS Self-Study
Lesson Plan
LESSON NO. CIS 210
CRCSTEducation-ICE)
(Instrument Continuing
Lesson Author
Susan Klacik, ACE, CHL, CRCST, FCS
CSS Manager
St. Elizabeth Health Center
Youngstown, Ohio
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in the
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technician who works with surgical instrumentation.
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There is a children’s story about the “Polar Express” which centers on a child who receives
instructions from a train conductor. Surgical polar instrumentation has some similarities
with the story including an emphasis on a patient (rather than a child), a conductor
(“electricity” instead of a person,) and different types of polar instruments (rather than
train cars). Polar instruments can be monopolar (the topic of this lesson) or bipolar.
Monopolar instruments are used for minimally
invasive procedures commonly referred to as
laparoscopy. These instruments can be configured
as cutting and/or grasping tools, and they are
made of a tubular shaft (lumen) with two jaw
parts located at the distal (furthest) end of the
shaft. The jaw parts are constructed of a metallic
material and are coupled by a joint. Electrical
connections in the instrument generate high
frequency electric current which increases the
cutting effect when a cutting tool is used and the
coagulation of tissue contacted when a grasping
tool is used.
Monopolar instruments are used for
electrosurgical purposes, and they use alternating
current (AC) in which electrons alternate direction
at the speed of light. The patient is included in
the circuit, and the electrical current enters the
patient’s body. Note: The term “electrocautery”
is sometimes used incorrectly to describe
electrosurgery. However, electrocautery uses
direct current (DC) in which electrons flow in
one direction to heat a wire. Since only the wire
comes in contact with the patient, the current
does not enter the patient’s body.
The purpose of electrosurgery is to produce heat
by concentrating electric current in target tissues
to achieve desired results. The smaller the area
of tissue-instrument contact that concentrates
the current, the more resistance is built, and
more voltage (the force pushing electric current
through the resistance) is required to move the
current through the limited space.
There are two basic types of electrosurgery:
• Monopolar – The active electrode instrument
is placed in the entry site and is used to cut
tissue and coagulate bleeding. A return
electrode pad is attached to the patient, and
the high frequency electrical current then
flows from the generator to the instrument
through the patient to the patient return
electrode pad and back to the generator.
The monopolar circuit includes a generator,
instrument, active electrode, patient, and
patient return electrode pad. Monopolar
electrosurgery is the most commonly used
type of energy because of its versatility and
effectiveness. Monopolar generators typically
produce outputs of 1 to 300 watts of energy
in the cut modes and 1 to 120 watts in the
coagulation mode.
• Bipolar – Active output and patient return
functions both occur at the surgery
site because both the active and return
electrodes are contained in the instrument
because it contains two electrodes. The
path of the electrical current is confined to
the tissue between the two electrodes that
are contained in, for example, the bipolar
instrument’s forceps. Bipolar electrosurgery
allows the use of lower voltages and less
energy is required. However, it has limited
ability to cut and coagulate large bleeding
areas, and is ideally suited for coagulation
(sealing) of small arterial or venous blood
vessels to control blood loss. Bipolar
generators produce 1 to 80 watts of energy.
IAHCSMM
CIS Self-Study Lesson Plan
Figure 1:
a) Flow of electricity: monopolar circuit.
Electrosurgical
Generator
Active Electrode
(at Surgical Site)
Through
Patient
Patient Return
Electrode Pad
(Another Site on
Patient Body)
Electrosurgical
Generator
b) Flow of electricity : bipolar circuit.
Electrosurgical
Generator
Bipolar Instrument at
Surgical Site
Figure 1 provides a general illustration of
monopolar and bipolar circuits.
Laparoscopic instruments are the most frequently
used devices for monopolar electrosurgery, and
Figure 2 illustrates basic components of a
laparoscopic handle instrument.
Scissor Insert
Rotation Knob
Cord Connection
Shield Barrel Assembly
(Insert Inside)
Handle
Trigger
Figure 2: Laparoscopic Handle Components
Laparoscopic instruments can be challenging to
clean. They have evolved from a first generation
device which presented an extreme cleaning
challenge to a second generation model with,
at least, a cleaning port, to modern versions
which allow for complete disassembly for
proper cleaning.
After use and prior to the next surgical procedure,
laparoscopic instruments must undergo several
pre-processing steps, and they must then be
cleaned, lubricated, and sterilized before reuse.
Pre-Processing. The reprocessing of laparoscopic
instruments begins at point of use. As with all
devices, excess body fluids and tissues must be
removed immediately in the surgical suite, and
keeping instruments moist prevents blood and
body fluids from drying on them.
Several steps are necessary before laparoscopic
instruments are processed. Devices must
be disassembled by carefully following the
manufacturer’s written instructions because
some models of laparoscopic instruments can be
completely disassembled, some have flush ports,
Electrosurgical
Generator
and some have neither. The required cleaning
agents should be prepared according to the
manufacturer’s use/dilution and temperature
recommendations.
Instruments should be inspected for any obvious
damage including insulation and bent or missing
parts. If the CIS technician discovers any insulation
damage or missing parts, this should be reported
to the supervisor immediately for patient followup to assess whether the patient has been
harmed. End-of-life indicators for instrument
handles include electrical performance problems
and, for lumens, insulation damage that exposes
metal. End-of-life indicators for laparoscopic
inserts include dulling of scissors, binding/
impaired mechanical functions, bent or damaged
housing, rods, or tips, and wear of external
surfaces.
Cleaning. Remember these basics when
cleaning laparoscopic instruments:
• Manual cleaning is required for all instruments
with lumens and hollow spaces. Automated
cleaning with a washer/disinfector alone may
not be effective.
• Metal brushes or scratch/scouring pads
should not be used on the insulation because
they will damage the instrument’s surface
and finish. Instead, use soft-bristle, nylon
brushes and cotton-tip swabs.
• Use distilled, de-mineralized, or reverse
osmosis deionization (RODI) water, especially
for the final rinse. Note: Water with high
mineral content (hardness) can leave residues
that affect performance.
• Neutral PH enzymatic detergent cleaning
agents are recommended. Alkaline
detergents, if used, must be completely
rinsed from the devices. Do not use corrosive
fluids such as bleach-based products to avoid
damaging the instrument.
• Do not exceed 284°F (140°C) during the
washing and sterilization process.
• Cold soak sterilization is not typically
recommended and, as is always necessary
for all instrumentation, the manufacturer’s
instructions for specific devices should
consistently be followed.
• Totally immerse instruments during cleaning
to prevent aerosolization. Do not use steel
wool, wire brushes, pipe cleaners, or abrasive
detergents. Anything other than high-quality
brushes specifically designed for instrument
cleaning may damage the device.
After disassembly, the following manual cleaning
steps are important:
• All components should be immersed (soaked)
in a blood-dissolving enzymatic solution
prepared according to the manufacturer’s
instructions for at least five minutes with
gentle agitation. Note: Soak longer if proteincontaining material is present. It is advisable
to soak instruments vertically to reduce the
possibility that air bubbles will form. Vertical
soaking also enables the solution to enter, rise
through, and exit the device if the solution is
sufficiently deep.
• Remove the device from the enzyme solution,
and rinse it thoroughly under running tap
water for at least three minutes.
• Immerse all components in a detergent solution
prepared according to the manufacturer’s
instructions and clean all surfaces.
• Use a hand-held, soft bristled brush with a
back-and-forth motion to brush all surfaces.
Pay special attention to the cord connector,
crevices, grooves, fittings, and joints.
• While still submerged, use a soft bristled
brush with a gauge recommended by the
manufacturer to clean inner lumen surfaces.
If a recommendation is not made, select a
brush with soft bristles that are slightly larger
in diameter than the actual lumen. Use
complete strokes and ensure that the bristles
exit the lumen. Push and pull the brush
completely through the lumen several times.
IAHCSMM
CIS Self-Study Lesson Plan
component. To clean these valves, it is necessary
to press down on the valve and brush it in one
direction. The valve must then be disassembled
If necessary, repeat the brushing process by
entering the opposite end of the lumen.
• Flush irrigation channels with de-mineralized
water and use a stylus, if necessary, to remove
clogs. If instruments have cleaning ports, a luer
lock syringe filled with enzymatic solution can
be attached to the cleaning port to flush the
lumen. Note: Keep the distal end of the lumen
under water. If there are no cleaning ports, a
three-inch piece of tubing can be inserted over
the distal tip, and a syringe can be attached
to the tube’s opposite end for flushing.
Compressed air can also be used for flushing if
a precise nozzle is available and if the pressure
can be controlled. Ultrasonic irrigators are
also a useful way to flush instruments with
lumens to remove debris from hard-to-reach
areas, and they can do so more effectively in a
shorter time than a manual process. The cycle
time should be five minutes or less, and water
temperature should not exceed 122°F (50°C).
• Some detergent solutions may leave a residue
on the gold electrical post connector surface
that can cause occasional cord alarms. The
residue can be removed with an alcoholsoaked swab rotated completely around the
gold connector surface.
against the collar with no spaces visible. Next,
grip the insulation, and try to slide it back. If the
insulation slides (moves), the instrument needs
repair. Finally, check the instrument shaft for
insulation cuts, cracks, and nicks, and inspect the
handle for chips or cracks because these defects
also indicate the need for repair or replacement.
Electronic testing devices can detect microscopic
holes in a laparoscopic instrument’s insulation,
and the testing should be done before set assembly
on the clean side of sterile processing. These test
devices can also be used to inspect electric cables,
• Remove the device from the detergent
solution and rinse thoroughly under running
distilled or de-mineralized water for at least
three minutes.
and brushed in the other direction to clean out
the barrels which enable the plunger to move
freely. Reassembly of the trumpet valve involves
lining up a groove in a pin inside the valve.
Remember to place lubricant in that groove if this
is recommended by the manufacturer.
Packaging. Sterilization containers and organizing
sets designed for laparoscopic instruments are
available to protect instruments from damage
during transport, sterilization, and storage. Both
the container and instrument manufacturer should
be consulted for sterilization recommendations.
Product testing should be conducted to assure
sterilization can be achieved prior to use.
Sterilization. Instruments must dry thoroughly
before sterilization, and typical sterilization
methods (assembled or disassembled) are:
• Most instruments can be processed through
a washer/disinfector after manual cleaning is
complete using the instrument cycle. If this is
done, assure that no residue remains.
• Gravity steam (wrapped) at 270°F (132°C)
minimum for at least 15 minutes.
Remove excess moisture and allow the instrument
to dry before sterilizing.
• Pre-vacuum steam (wrapped) at 270°F (132°C)
minimum for at least four minutes.
Inspection. Laparoscopic instrument insulation is
susceptible to pin holes, cracks, tears, and overall
loosening. These defects must be discovered as the
instruments are assembled so electricity cannot
escape through insulation failures and cause
burns not immediately detectable by the surgeon.
Patient infections, extended recovery times, and
the need for a possible return to surgery may
result from the burns. If defects are observed, a
process should be in place for patient follow-up to
determine if the insulation failure occurred during
the last surgical procedure and injured the patient.
To inspect the insulation, locate the metal collar
at the distal tip. The insulation should fit tightly
• Gravity steam (unwrapped/flashed) at 270°F
(132°C) minimum for at least 10 minutes.
Note: Do not exceed temperatures of 284°F
(140°C) to avoid damage to the handle’s
outer insulation.
forceps, electrodes, and insulated bayonet forceps.
Lubrication and Assembly. After cleaning and
before sterilization, laparoscopic instruments
should be carefully inspected for visible
contamination or damage. The lumen and
all moving parts of the jaw insert should be
lubricated with water-soluble medical instrument
lubrication as recommended by the manufacturer.
CIS technicians must properly re-assemble
instruments taken apart for cleaning. Trumpet
valves which control the instrument’s suction and
irrigation functions are one especially challenging
Plasma (hydrogen peroxide) and rigid container
sterilization methods should only be used if they are
included in the manufacturer’s recommendations.
Storage. Sterile, packaged laparoscopic
instruments should be stored in a designated,
limited-access area that is well-ventilated and
that will provide protection from dust, moisture,
insects, and vermin and temperature/humidity
extremes.
CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
International Association of Healthcare Central
Service Materiel Management. Central Service
Technical Manual. Seventh Edition. Chicago, IL.
2007. (See Chapter 12)
Rick Schultz. Tube Scoop: Insider’s Guide to
Cleaning Lap Instruments. Materiels Management.
November, 1997.
Encision AEM Laparoscopic Instruments. AEM
Handle Assembly and Inserts. Instructions for
Use/Care. 2008. See also: Care, Maintenance
and Sterilization.
The author wishes to acknowledge
and sincerely thank Mr. Jack Serino,
President and CEO, Encision Inc., Boulder,
Colorado, for his assistance with the
development of this lesson.
CIS Self-Study Lesson Plans
Lesson Author
Susan Klacik, ACE, CHL, CRCST, FCS
CSS Manager
St. Elizabeth Health Center
Youngstown, Ohio
Technical Editor
Carla McDermott, RN, ACE
Education Specialist
Morton Plant Mease Healthcare
Dunedin, FL.
Series Writer/Editor
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI.
Polar Express: Monopolar and
Bipolar Instrumentation (Part I)
CIS
REFERENCES
Questions (circle correct answer):
1. Electrosurgery uses direct current (DC)
and, therefore, the electrical current
does CRCST
not enter the patient’s body.
True
False
9. Laparoscopic instruments must be
totally immersed during cleaning to
prevent aerosolization.
True
False
2. Bipolar electrosurgery is the most
commonly-used type of electrosurgery
because of its versatility and effectiveness.
True
False
10. Laparoscopic instruments should, when
possible, be soaked horizontally to
reduce the formation of air bubbles.
True
False
3. Electricity from monopolar surgical
instruments flows through the
patient’s body.
True
False
11. Irrigation channels of a laparoscopic
instrument should be flushed with
de-mineralized water.
True
False
4. There are two basic types of
electrosurgery: monopolar and bipolar.
True
False
12. The cycle time for ultrasonic irrigators
used to flush instruments with lumens
should be five minutes or less.
True
False
5. Reprocessing of laparoscopic
instruments begins in the Central
Service decontamination area.
True
False
6. Damage which exposes metal is an
end-of-life indicator for laparoscopic
instrument lumens.
True
False
7. Modern laparoscopic instruments can
typically be cleaned with a washer/
disinfector and, therefore, manual
cleaning processes are not required.
True
False
8. Alkaline detergents are the preferred
cleaning agents for laparoscopic instruments.
True
False
13. Electronic testing devices currently
available are useful only for detecting
microscopic holes in the insulation of
laparoscopic instruments.
True
False
14. To clean trumpet valves, the CIS
technician should press down on the
valve and brush it in only one direction.
True
False
15. Pre-vacuum steam sterilization of
wrapped laparoscopic instruments
should be done at 270°F (132°C)
minimum for at least four minutes.
True
False
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