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Tonsillectomy & Adenoidectomy Instrumentation

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Tonsillectomy & Adenoidectomy Instrumentation CIS SELF-STUDY LESSON PLAN Lesson No. CIS 271 (Instrument Continuing Education - ICE) Sponsored by: Tonsillectomy & Adenoidectomy Instrumentation JON WOOD, BAAS, CST, CRCST – CLINICAL EDUCATOR, IAHCSMM Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical LEARNING OBJECTIVES instrument care and handling. These lessons are 1. Identify common instruments found in a tonsillectomy and adenoidectomy tray designed for CIS technicians, but can be of value 2. Review the key inspection areas for instruments in a tonsillectomy and to any CRCST technician who works with surgical instrumentation. adenoidectomy tray 3. Discuss the function of tonsillectomy and adenoidectomy instrumentation during a Earn Continuing Education Credits: procedure Online: Visit www.iahcsmm.org for online grading at a nominal fee. By mail: For written grading of individual lessons, nstrument inspection and testing needs and preferences. The following is a send completed quiz and $15 to: is one of the core responsibilities list of common T&A instrumentation: Purdue University - Online Learning of the Central Service/Sterile Ernest C. Young Hall, Room 526 155 S. Grant Street Processing (CS/SP) technician. • Backhaus towel clamp West Lafayette, IN 47907 IProducing patient-ready instrumentation • Allis clamp is significant to any successful • White tonsil clamp (similar to a curved Scoring: Each quiz graded online at www.iahcsmm.org or through Purdue University, surgical procedure. It is essential Allis clamp) with a passing score is worth two points (2 contact for an instrument specialist to have • Schnidt tonsil forceps hours) toward your CIS re-certification (6 points) or the knowledge and skills to identify • St. Clair-Thompson adenoid forceps CRCST re-certification (12 points). commonly-used instrumentation, • Foerster-Ballenger sponge holding More information: IAHCSMM provides online recognize important inspection areas forceps grading service for any of the Lesson Plan and understand the functionality of each • Baum tonsil needle holder varieties. Purdue University provides grading services solely for CRCST and CIS lessons. Direct instrument. This lesson will describe • Metzenbaum scissors any questions about online grading to IAHCSMM commonly-used instrumentation found • DeBakey forceps at 312.440.0078. Questions about written in a tonsillectomy and adenoidectomy • #7 knife handle grading are answered by Purdue University at 800.830.0269. (T&A) tray, review vital inspection areas • Fisher tonsil knife and dissector on T&A instruments and explain how • Hurd dissector and Pillar retractor instruments are used during a T&A • Wieder tongue depressor/retractor procedure. • Meltzer triangular punch (straight or curved) OBJECTIVE 1: Identify common • Yankauer suction instruments found in a tonsillectomy and • Andrews-Pynchon suction adenoidectomy tray • Laryngeal mirrors (multiple sizes) Several variations of instrumentation • Tonsil snare can be found within the T&A tray. The • Adenoid curettes (multiple sizes) variation of instrumentation can differ • Mouth gag with blades (Dingman, from healthcare facility to healthcare Jennings, Davis or McIvor with facility and is generally selected based multiple size blades) upon the surgeon’s specific procedure • Medicine cup CIS SELF-STUDY LESSON PLAN Figure 1: A. McIvor Mouth Gag B. St. Clair-Thompson adenoid forceps C. Fisher tonsil knife and dissector OBJECTIVE 2: Review the key inspection ensure instrumentation is cleaned areas for instruments in a tonsillectomy properly. and adenoidectomy tray Testing instrument functionality is Instrument inspection and testing is also an important step in the assembly an important step in the instrument process. Before testing functionality, assembly process. In the assembly phase, it is important to always review the instruments should be inspected for manufacturer’s instructions for use (IFU). cleanliness and tested for functionality. The T&A tray contains several types of Figure 2: Key inspection points for forceps Inspection is important because after instrumentation with different inspection the assembly phase the instrumentation areas, including ringed forceps, forceps, • Ratchet – The part of a surgical will not be checked again until after scissors, suction and more. When testing instrument that locks the handles in sterilization, which will be at the point ringed forceps, it is important to inspect place of use. Discovering dirty, damaged or and test the following areas: missing instrumentation at the point • Jaws – Two or more opposable parts The jaws of the ringed instruments of use can cause delays or other serious that open and close; used for holding should align and approximate when problems that may result in adverse or crushing something between them closed. The serrations in the jaws patient outcomes. • Serrations – Parallel grooves in the should be inspected for cleanliness and At first glance, instrumentation may jaws of surgical instruments damage. The box lock can be one of the appear to be clean, but closer inspection • Box lock – Point where the two jaws most challenging areas to clean on the of the entire instrument may reveal or blades of an instrument connect instrument. Residual bioburden in the areas that were not cleaned properly. and pivot box lock can damage the instrument Tools such as lighted magnifiers, digital • Shanks – The straight, narrow part of a and make it difficult to open and close. cameras, microscopes and borescopes tool that connects the working part Stress fractures are commonly found in can improve visualization and help with the handle. the box lock area, which can be caused CIS SELF-STUDY LESSON PLAN It is essential to test the sharpness of scissors. Red testing material should be used for scissors 4.5” and larger, and yellow testing material should be used for scissors 4” or smaller. Before being considered functional/acceptable, scissors must demonstrate the ability to cut through the testing material cleanly several times. The suction device is an important instrument used in a T&A procedure. The primary function of the suction is to remove blood, body fluids and irrigation solution from the operative site. Visual Figure 3 inspection of the inside of the device is just as important as inspecting the outside of the device. Tools, such as the borescope, can be used to visually inspect the innerworkings of the device. Other important instrumentation on a T&A tray includes curettes and mouth gags. Curettes should be inspected for nicks and burrs in the blade area and tested for sharpness using a plastic dowel rod. See Figure 3. The mouth gag has two main areas of interest for inspection. First, when inspecting the spring-action locking mechanism that secures the blade while in use, the spring should move freely without hesitation. Second, the silicone guard should be intact without tears or gouges, and the screws should be secure and not loose. See Figure 4. OBJECTIVE 3: Discuss the function of tonsillectomy and adenoidectomy instrumentation during a procedure After the patient is anesthetized, the Figure 4 patient is draped for the procedure. A head drape is used and secured with by over use or improper sterilization in needle holding forceps have tungsten a towel clamp. After the patient is the closed position. The shanks should carbide jaw inserts (indicated by gold fully draped, a mouth gag retractor is be symmetrical and undamaged. The ring handles) that can be removed when used to open the mouth, which is the ratchet area should be tested to ensure they become worn from use or damaged. operative site, and to secure the tongue. the instrument stays closed after being Scissors should be inspected in the It is important that the mouth gag stay ratcheted. If the ratchet springs opens same manner as ringed instruments (this in place throughout the procedure; while testing, the instrument is damaged is done by visually inspecting the key therefore, checking the spring function and should be sent for repair. Some areas previously outlined in this lesson). and lock mechanism is critical. The CIS SELF-STUDY LESSON PLAN silicone inserts or tubing help protect bleeding. The ratchet area of the sponge blood, body fluid and smoke from the the patient’s teeth, gums and lips from holding forceps should be tested to surgical site. After the tonsil areas have injury. Loose screws on the mouth gag ensure it stays in place while holding the stopped bleeding and the tonsillar spaces retractor have the potential of dislodging sponge. appear dry, the adenoid sponges are and falling into the patient’s esophagus or Next, the tonsillectomy procedure removed, and a suction electrocoagulator trachea. is performed. The tonsillectomy can and mirror are used to complete the Once the mouth gag is in place, a red be performed using several different procedure. rubber catheter is placed in the nose and techniques, such as “hot knife” which passed through the nasopharynx into uses electrocautery, coblation or “cold Note: There are several variations in the the back of the mouth. The red rubber knife,” which uses a #12 blade and the T&A procedure. Objective 3 covers some catheter is retrieved and both ends are #7 knife handle. During the “cold knife” but not all surgeon-specific instrument clamped with a tonsil forceps. This technique, an Allis clamp or White preferences or procedure styles. maneuver retracts the soft pallet and tonsil clamp, which is similar to a curved allows for access and better visualization Allis clamp, grasps the tonsil tissue. Conclusion of the adenoids. The forceps holding It is important to inspect the jaws of Procedures such as the T&A could not be the red rubber catheter must stay in the the clamp to confirm it can hold tonsil successful without the knowledge of the locked position to keep the soft pallet tissue and withstand the back-and-forth CS/SP technician. CS/SP technicians who retracted. Testing the ratchet of the tonsil twisting movement that is required understand the importance of instrument forceps will help ensure the instrument during the tonsil dissection.
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