CIS SELF-STUDY LESSON PLAN Lesson No. CIS 275 (Instrument Continuing Education - ICE) Sponsored by: Laparoscopic Appendectomy Instrumentation JON WOOD, BAAS, CIS, CRCST – IAHCSMM CLINICAL EDUCATOR 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. Describe the different instrumentation needed to perform a laparoscopic designed for CIS technicians, but can be of value appendectomy to any CRCST technician who works with surgical 2. Identify key cleaning and inspection points for laparoscopic appendectomy instrumentation. instrumentation 3. Review medical terminology associated with appendectomy procedures Earn Continuing Education Credits: 4. Discuss the function of laparoscopic instruments during a laparoscopic Online: Visit www.iahcsmm.org for online appendectomy grading at a nominal fee. By mail: For written grading of individual lessons, send completed quiz and $15 to: Purdue University - Online Learning patient walks into the facility-specific needs, and surgeon Ernest C. Young Hall, Room 526 Emergency Department with preference. The appendectomy procedure 155 S. Grant Street dull pain around the belly requires a mixture of both general West Lafayette, IN 47907 button that radiates and instrumentation and laparoscopic Scoring: Each quiz graded online at Abecomes sharper as it moves to the lower instrumentation, which can be arranged www.iahcsmm.org or through Purdue University, right abdomen. The patient reports a in a single instrument tray format or be with a passing score is worth two points (2 contact hours) toward your CIS re-certification (6 points) loss of appetite and is experiencing some a combination of several trays, including or CRCST re-certification (12 points). nausea and vomiting. The vital signs a minor or basic general instrument show a low-grade fever and the physical tray, laparoscopic instrumentation and More information: IAHCSMM provides online grading service for any of the Lesson Plan exam reveals abdominal swelling and telescope tray. The following is a list of varieties. Purdue University provides grading pain upon touching the right lower common instruments used during a services solely for CRCST and CIS lessons. Direct abdomen. After several tests, the patient laparoscopic appendectomy: any questions about online grading to IAHCSMM at 312.440.0078. Questions about written is diagnosed with appendicitis. grading are answered by Purdue University at This lesson will examine General instrumentation 800.830.0269. instrumentation needed to perform a • Knife handle laparoscopic appendectomy, identify • Crile or Kelly clamps key inspection points, review medical • Allis clamp terminology related to the appendectomy • Kocher clamp procedure and discuss the function • Needle driver of laparoscopic instruments during a • Metzenbaum scissor laparoscopic appendectomy. • Mayo scissor • Forceps with teeth Objective 1: Describe the different • Forceps without teeth instrumentation needed to perform a • Retractors laparoscopic appendectomy Laparoscopic instrument configurations Laparoscopic instrumentation can vary by design, manufacturer, • Maryland dissector CIS SELF-STUDY LESSON PLAN Figure 2: A third-generation “take-apart” laparoscopic instrument instrument has a handle, shaft, distal working end and, possibly, an electrocautery port for tissue cauterization. The second-generation instrument is similar in many ways to the first-generation instrument, except for the presence of a flushing port. The flushing port begins proximal to the handle and runs through the inner shaft of the instrument to the distal working end. The flushing port is an added Figure 1: Dissected flushing port shows the intersection with the instrument shaft feature designed to aid in the cleaning of the instrument. If the instrument • Atraumatic “crocodile” grasper available instrumentation to perform an is not treated at the point of use, the • Metzenbaum scissor open procedure. shaft can fill with dried bioburden • Right angle/Mixter dissector and become difficult to flush, thereby • Babcock clamp Objective 2: Identify key cleaning and requiring extended soaking times • Suction/Irrigator inspection points for laparoscopic to loosen debris. Figure 1 shows the • Electrosurgical tips or hooks appendectomy instrumentation flushing port dissected to visualize the • Veress needle As with all instrumentation, Central intersection with the instrument shaft. • Trocars (various sizes with reducers) Service/Sterile Processing (CS/ The third-generation instrument is a • Monopolar cable SP) professionals should review the take-apart instrument, meaning it can instructions for use (IFU) before the be disassembled into several parts (see Telescope set instrument is purchased and placed into Figure 2). It is important to disassemble • 5mm telescope 0 degree and 30 degree service. Because there are several different these instruments when cleaning to • 10mm telescope 0 degree and 30 degree manufacturers and types of laparoscopic ensure all bioburden is removed from the instruments, it is important to review the instrument. Keeping the instrument parts Camera set IFU for point-of-use treatment, cleaning together during the cleaning process • Laparoscopic camera procedures, packaging, inspection allows for a smoother assembly process. • Light cord and sterilization instructions for each Before sterilization, it is important to instrument, and then periodically review read the IFU to determine whether the *Available instrumentation the IFU for changes and updates. instrument can be sterilized assembled or • Major general instrument set There are three distinct generations disassembled. • Abdominal retractor set (Bookwalter of laparoscopic instruments. The first- After the cleaning process, every or Omni Tract) generation laparoscopic instrument is laparoscopic instrument should be *Note: When performing any laparoscopic designed as a single-piece instrument visually inspected for damage and tested procedure, it is advisable to always have that cannot be disassembled. The for current leaks, which indicate a breach CIS SELF-STUDY LESSON PLAN Figure 3: Current leak testers help identify insulation breaches that can jeopardize patient safety. in the insulation. The manufacturer’s the devices, the devices will not be surgeon. Buttons should be checked for IFU for insulation testing should be seen again until they are opened in functionality, including the white balance followed. Figure 3 shows a current leak the Operating Room (OR). The best button. The white balance button gives tester in use. method for inspecting these devices for the camera a reference to true white. A Most cameras, light cords and functionality is to insert the devices into malfunctioning button can turn video telescopes must be hand washed and a laparoscopic tower, like the towers used images blue or yellow, making it difficult should not be cleaned using an ultrasonic in the OR. Using a laparoscopic tower for the surgeon to visualize different or automated washer disinfector. It is allows the CS/SP technician to simulate structures within the abdomen. essential to rinse the devices with critical the conditions in the OR when checking Some facilities may not have access to water to remove any excess mineral the devices to ensure they are working a laparoscopic tower and the ability to deposits, which can potentially interfere properly. When checking the camera, it plug in and check devices. In this case, with the different sterilization modalities. is important to ensure the camera can a manual check of the devices should After cleaning, the camera, light focus when zooming in and out, and be performed. For example, when cord and telescope should be carefully that it produces a clear image. Spots on checking the light cord, the technician inspected. This step is critical because the lens must be removed because their can raise one end of the light cord in the once the CS/SP technician has inspected present can blur the image viewed by the air toward a light source, while visually CIS SELF-STUDY LESSON PLAN Figure 5: The four quadrants of the abdomen • Mesentery – The membranous peritoneal ligament that attaches the small intestine to the dorsal abdominal wall • Mesoappendix – The short mesentery of the appendix (behind the terminal Figure 4: A light cable with broken fibers ileum in which the appendicular artery lies) • Pneumoperitoneum – The presence inspecting the other end and looking for glass rod. of air or gas produced artificially in broken fiber optics. Broken fibers will the abdomen to achieve exposure appear as black dot or specks and will Objective 3: Review medical terminology during laparoscopic surgery not be illuminated. Because the fibers associated with appendectomy procedures • Right lower quadrant (RLQ) – The are made of glass, they are very fragile • Appendectomy – Removal of the portion of the abdomen that contains and should be handled with care. Most appendix the caecum, appendix, right ovary and light cords that have been used for any • Eschar – A thick, coagulated crust that tube, and right ureter (see Figure 5). amount of time will have several broken develops following physical • Right upper quadrant (RUQ) – The fibers. A small amount of broken fibers cauterization of tissue portion of the abdomen that contains may not affect the light output from the • Laparoscopy – A minimally-invasive the liver,