8.2 Surgical Instrumentation and Equipment Care

The longevity, functionality, and safety of surgical instruments rely on a strict cycle of care. A CSFA must know how to properly handle instruments during and immediately after a procedure to prevent damage, corrosion, and the spread of infection.

Point-of-Use Preparation

The care of instruments begins at the sterile field, during the procedure. This initial step is critical for preventing the drying of blood, tissue, and bone debris (bioburden), which makes subsequent cleaning extremely difficult.

• Wiping and Flushing: The scrub person or CSFA should routinely wipe instruments with a sponge moistened with sterile water. Lumens (e.g., suction tips, endoscopic cannulas) should be flushed periodically with sterile water to prevent clogging.
• Never use Saline: Saline contains sodium chloride, which is highly corrosive to stainless steel. Prolonged exposure causes pitting, rusting, and degradation of the instrument's protective chromium oxide layer (passivation layer).
• Post-Procedure Transport: Once the case is finished, instruments must be kept moist during transport to the Sterile Processing Department (SPD). This is achieved by covering them with a towel dampened with sterile water or spraying them with a specially formulated enzymatic pre-soak foam or gel.

The Decontamination Process

In the SPD decontamination area, personnel wear heavy-duty personal protective equipment (PPE). The goal here is to render items safe to handle without PPE.

1. Manual Cleaning

All instruments undergo an initial manual cleaning to remove gross soil.

• Instruments are submerged in a sink of warm water and enzymatic detergent.
• Brushing is performed under the surface of the water to prevent the aerosolization of contaminated droplets.
• Any instrument with multiple parts must be completely disassembled.
• Hinged instruments (scissors, hemostats, needle holders) must be opened fully so the box locks and ratchets are exposed.

2. Ultrasonic Cleaning

The ultrasonic cleaner is used to remove microscopic debris from the small crevices, serrations, and box locks of instruments that manual brushing cannot reach.

• Mechanism of Action: It uses high-frequency sound waves to create microscopic bubbles in the solution. These bubbles expand and violently collapse—a process called cavitation—creating a vacuum effect that pulls debris away from the instrument surfaces.
• Note: The ultrasonic cleaner is a cleaning device, not a sterilizer or disinfector. Dissimilar metals (e.g., copper and stainless steel) should not be mixed in the ultrasonic cleaner to prevent electrolytic damage.

3. Washer-Decontaminator / Washer-Sterilizer

After ultrasonic cleaning, instruments are loaded into an automated mechanical washer.

• Mechanism of Action: These machines use a spray-force action called impingement alongside specific detergents and hot water to clean the instruments.
• Following the cycle, the instruments are safe for personnel to handle with bare hands on the assembly/prep side of SPD, though they are not ready for surgical use until functionally checked, wrapped, and sterilized.

Instrument Inspection and Assembly

Before instruments are reassembled into sets and wrapped for sterilization, each individual piece must be meticulously inspected under bright light or magnification.

Key Inspection Points

• Cleanliness: No visible soil, blood, or rust should remain. If bioburden is found, the item must be returned to decontamination.
• Box Locks and Hinges: Must move smoothly without stiffness. Look for hairline cracks in the box lock, a common point of failure.
• Ratchets: Close the hemostat or clamp to the first ratchet. Tap the ring handles lightly against a solid surface; if the instrument springs open, the ratchet is worn and the instrument must be repaired.
• Jaws and Teeth: Teeth (e.g., on Kocher or Allis clamps) must align perfectly. The jaws of a needle holder should not allow a needle to twist or slip.
• Scissors: Must be tested for sharpness. Tissue scissors should smoothly cut through testing material (often a specialized latex or silicone band) all the way to the very tips without snagging.

Insulation Testing

Laparoscopic and electrosurgical instruments have a plastic insulating coating over their metal shafts to prevent electricity from arcing into non-target tissues. Any micro-tear or pinhole in this insulation can cause severe, unseen internal burns to the patient. These instruments should be periodically tested with a commercial insulation tester (a wand that detects electrical leaks).

Lubrication

Stiff instruments with box locks should be lubricated with a water-soluble, antimicrobial lubricant commonly referred to as "instrument milk."

• Oils, grease, or WD-40 must never be used, as they are not water-soluble, will interfere with steam sterilization, and can harbor bacteria.

Care of Power Tools and Specialty Equipment

Surgical power tools (drills, saws, reamers) and delicate items like camera heads and fiber-optic light cables require exceptional care.

• Do Not Immerse: Unless specifically labeled as submersible by the manufacturer, power tools and cameras must never be fully immersed in water or placed in an ultrasonic cleaner. Water intrusion will destroy the internal motors and electrical components.
• Cleaning: Wipe down the exterior with a mild detergent and a soft cloth. Use a brush to clean the chucks and crevices.
• Hoses and Cords: Inspect air hoses for cracks, leaks, or bubbling. Fiber-optic light cables should be held up to a light source; if numerous black dots are seen at the end, it indicates broken glass fibers inside, which will result in poor illumination.
• Lubrication and Testing: Power tools must be lubricated according to manufacturer instructions and briefly connected to a power source (air, battery, or electric) to verify they are functioning correctly before being packaged for sterilization.