BEST OF BOTH WORLDS Reposable instruments can be sturdy enough to handle delicate tissue, but light enough to easily manage.

It's been about 10 years since I converted to reposables, and now virtually every laparoscopic tool I use — scissors, bowel clamps, specialty graspers — has a reusable handpiece and a disposable tip. While you may like the economics of reposables, take it from me that your surgeons will like the efficiency and ergonomic benefits of these take-apart instruments even more.

My introduction to reposable instruments was a eureka moment. As a colorectal surgeon, I'd found that manipulating the plastic handles on disposable devices was uncomfortable to the point that it was causing pain and numbness in my hands, especially during long and complicated cases. It was getting so bad, I began to wonder whether I'd be able to keep doing those procedures.

I was also concerned that the disposable grasper I'd been using wasn't suitable for delicate bowel tissue. A grasper tip that's too small or too sharp can tear tissue and cause serious complications, including putting a patient at risk for sepsis. I had to be able to manipulate and move various organs during procedures, so I had to have instrumentation that could safely handle tissue.

At the same time, reusable instruments came with a different set of challenges. For example, we can use reusable trocars for laparoscopy — they function well and they last forever — but they're much heavier. Along with being clunky, you can't see through them and there's no balloon on the end. Additionally, I find that the factory tips on reusable instruments are very coarse. That's understandable, because they have to be made in such a way that they don't break for a long time. But over time, they can get a little bit off-kilter and stop working as well. What do you do then? Just get rid of the whole instrument? It's a potentially expensive quandary.

CUTTING COSTS It makes sense to use a fresh scissor tip and insulated shaft every time you operate, but you don't need to replace the handpiece for each patient.

Game changer
Along came reposables. The shaft of my laparoscopic scissors is very sturdy and handles tissue well. And the reusable handpiece comes with gel foam pad rings that go inside the finger holders, instead of consisting solely of hard plastic. That makes it much more comfortable — like the difference between sitting on a cushion and sitting on a hard wooden bench. When I made the switch, the numbness in my fingers went away immediately, which was a huge factor and a huge relief for me.

But there's also an intrinsic logic to reposables. If you tried to give me reusable surgical scissors to use laparoscopically, I'd throw them out after each use. Things that are used to dissect, like scissors, need to be very sharp. So it makes infinite sense to get a fresh scissor tip and a new insulated shaft for every patient. But using disposable graspers every time you do a case seems a little silly to me. It requires spending a lot of money, and I'm not sure what you're really getting for that money.

How many uses will you get out of a reposable instrument? That depends on the instrument and how you use it. Generally, manufacturers will give you a number, but I think that's done more to protect them. Often it comes down to how you're using the device. With lower-fidelity instruments, you don't necessarily have to keep track. You'll know when the tip doesn't work right and you need to get rid of it and get a new one. Higher-fidelity instruments often have mechanized lockouts that kick in after a certain number of uses. Robotic instruments, for example, may have a 25-use limit, and they'll give you a countdown as you go. In general, you'd use new scissor tips after every case, but you'd be able to reuse graspers and dissector tips numerous times.

Might there come a time when you're using a reposable instrument and you find that it's not functioning the way want it to? Of course. But that happens with disposable instruments, and it happens with reusable instruments, too. Anyone who hasn't had that experience probably hasn't been doing it long enough.

The sweet spot
So how much can you expect to save by switching to reposables? That's tough to say. In general, you can say that disposables are more expensive than reposables, which are more expensive than reusables. But you have to think about other factors, too, like prolonged time in the operating room and morbidity. What I like about reposables is that they give you a high-quality, well-functioning piece of equipment at a reasonable price. There's also a green factor, in that they produce less waste than disposables, and therefore may also save money on disposal costs, but to me, that's less important. The key is to do what's best for the patient. Reposables are indicative of a trend I think we'll see more and more of as scrutiny increases and reimbursements shrink. OSM