Laparoscopic instruments are a major investment for many surgical centers. One procedure's equipment can cost many tens of thousands of dollars when you consider the price of a scope, scope holders, irrigation probes, suturing devices and drainage systems. Here's advice for handling, cleaning and sterilizing, starting with laparoscopic instruments and moving on to endoscopes.

Indecent exposure
If it's properly cared for, an instrument should last about 20 years. That's if. There are many opportunities for and causes of damage. The top three:

• misuse (the instrument isn't used as intended by its design),
• abuse (dumping, stacking, and improperly cleaning and sterilizing instruments) and
• exposure (to chemicals and detergents, including saline, chlorine bleach, blood and even water).

Of these, exposure is the most insidious, creeping up on you, even when you believe you're using the right cleaning agents. This is where knowing the manufacturers' instructions inside-out is especially important, as exposure of metals to incompatible solutions can cause a chemical and electrochemical attack called corrosion, which may be irreversible.

Liquids, especially chlorides (such as bleach) are of concern for stainless steel; you should never expose surgical instruments to bleach. You shouldn't expose some instruments to saline; if you can't avoid exposure to saline, then immediately rinse the instrument off with sterile water.

The quality of water can have a great impact on instrument life. Ask your detergent manufacturer to analyze your water (it should do so at no charge). Most water supplies contain minerals such as sodium, magnesium and iron. All of these can adversely affect cleaning and detergent efficacy, thus influencing the lifespan of the instrument.

Feeling rusty
Stainless steel will corrode and when it does, the corrosion usually appears as surface blemishes such as roughness and rust. This creates difficulties for cleaning, disinfection and sterilization. Corrosion can also indicate locations where future device failure can occur. Be sure to carefully inspect instruments for corrosion.

Corrosion is often found in box locks and other joints of instruments, sometimes appearing as red rust. A major factor in corrosion is improper cleaning: Blood or other soils left in the joint and box lock will precipitate corrosion. Further, any type of corrosion interferes with proper cleaning and can inhibit the disinfection and sterilization processes.

Stainless steel can corrode by pitting, crevice corrosion and stress corrosion cracking (also known as hydrogen cracking). This is usually caused by exposure to blood, or chloride- or bromide-containing solutions. The effect is deep pockets or pits that look like black holes on the surface. You can't repair pitting - rather, you have to replace instruments when pitting occurs.

Steps for protection
Use all instruments only as intended. Handle them carefully and individually - never dump them from a tray - and keep them as clean as possible while they're in use. Here are four ways to keep your laparoscopic instruments safe as they go through reprocessing.

• A strong case. At the end of the procedure, put instruments in their containers. Don't stack instruments (unless they're in a rigid container), place heavier items on the bottom of the set and lighter items on top, and separate scopes from instruments to avoid damaging scopes. In the case of protective containers, place the items in the designated location to protect instruments from damage in transport. Specialty containers help keep delicate items secure before and after use. When you buy delicate instruments, they should come with a specialty container to help avoid unnecessary damage. Protect delicate items and those with fine or sharp tips by using tip protectors.
• Competency testing. All individuals handling surgical instruments and devices must know how to care for, handle and process them. Surgical instruments are the extension of the surgeon's hands and they therefore must be functional when used in the OR. Offer regular in-services and continuing education opportunities to reprocessing staff, and encourage them to become certified in their trade.
• Quality control. Using a lighted magnifying lamp, inspect all instruments for cleanliness, to make sure all components are present, that the instrument works as intended, that there is no damage to the instrument and that the instrument is the one identified for the set. Further, test scissors for sharpness each time you process them, check ratchets for tension and finger forceps to make sure the tips meet and that teeth are present if indicated. If you're using reusable trocars, test them for sharpness each time. Identify the maximum number of uses that would indicate re-sharpening. Look for nicks and defects that would interfere with passage of the scope.
• Special care. Insulated instruments require special inspection. Damage to the insulation can occur due to normal wear and tear, high voltages, the cleaning and sterilization process and contact with sharp instruments. Minute tears may go unnoticed during cleaning and inspection. During surgery, the defective insulation could allow 100 percent of the electrical current (700?F) to flow from the defect to the patient's organs and tissue. What's even more important to note is that the smaller the crack, the more dangerous to the patient: More concentrated current can escape from a small hole. Keep in mind that most of the instrument is outside the surgeon's visual field, so the defect could go unnoticed. Inspect insulation each time you process the instrument. This is imperative. You can use a reusable insulation tester in the processing area or a sterile single-use tester, usually used in the sterile field before surgery. (See 'Toward Safer Laparoscopic Electrosugery' on p. 38).

Protect your investment from abuse and damage
Surgical instruments represent a small fortune. Two take-home points to leave you with:

• You should always obtain and follow the manufacturer's written instructions for cleaning, packaging and sterilization, and you should verify this information each time you receive a new device.
• Outside your facility, you need to identify qualified repair services for all scopes and instruments to maintain your investment.

References:
1. Chobin, N. 'The Ten Commandments for Surgical Instrument Processing.' Managing Infection Control. June, 2001.
2. Envision Laparoscopic Instrument Web site.
3. JARIT Surgical and Endoscopic Instruments catalog.
4. McGan Insulation Tester user manual.
5. Spectrum Surgical Instruments, 'Care and Handling of Instruments.'