Quality Matters in Microsurgical Instruments

Endoscopic sinus surgery requires surgeons to maneuver mere millimeters from critical structures. They operate near the orbital lamina papyracea, and sometimes inside the orbit itself, and often use image guidance to help them move microsurgical instrumentation with pinpoint accuracy. To say they need to have supreme confidence in the condition and performance of their tools is a gross understatement.

“Working with a finely crafted instrument that’s comfortable to use and consistent in action is absolutely critical,” says Andrew N. Goldberg, MD, director of the division of rhinology and sinus surgery at University of California, San Francisco (UCSF). “There’s nothing more frustrating than working at the skull base or in the ceiling sinus next to the orbital nerve and carotid artery during a critical stage of surgery and having the instrument you’re using fail.”

Dr. Goldberg says surgeons must also have confidence that microsurgery instruments function smoothly. “The jaws of graspers need to align, they have to grab properly, and they must be strong and sharp enough to cut through bone,” he says. “The instruments must work as intended, and they have to be thoroughly cleaned and well maintained.“

A tool as seemingly straightforward as a nasal speculum must be in prime working condition, according to Dr. Goldberg. “These devices come in specific designs and, to be honest, I’m a stickler for how they function,” he says. 

It’s not that he’s overly picky; the way the instrument works and feels in his hand can impact how well he’s able to operate. During surgery, for example, he often holds a speculum for 20 minutes at a time. If the instrument is too stiff, muscle fatigue becomes a real concern.

Dr. Goldberg also says speculums with jaws that aren’t configured properly — in shape or angle — can impede his view of critical anatomy. He works with a specific type of speculum because he knows its jaws are slim, angled correctly and curved appropriately. The device’s spring-action is gentle but firm, and it’s durable. “I’m confident that the instrument will remain in good working order and in my ability to perform surgery smoothly and effectively with it,” he says.

Listening to and acting on feedback received from members of the sterile processing department about instruments in rotation or new tools surgeons are considering is important, says Dr. Goldberg. “If instruments are too delicate or too difficult to clean, we’ll move away from using them and look for alternatives,” he explains. “Working with preferred instruments is not worth it if they’re not available when they’re needed.”

Josh Seaman, CHL, CIS, CRCST, head of performance improvement of perioperative services at UCSF Medical Center, is one of the instrument care experts who partners with Dr. Goldberg to ensure he has the instrumentation he needs. Mr. Seaman understands the importance of having the surgical team involved in the decision-making process when it comes to adding new instruments and properly caring for the tools surgeons use regularly. “It’s important for ORs and sterile processing departments to share knowledge, to understand the key role each group plays in maintaining instruments in good working order,” he says.

Mr. Seaman implemented a sharpening schedule for microsurgery instruments, so each tool remains in peak working order. “Over-sharpening a microscopic needle driver or micro scissor forceps impacts their performance,” says Mr. Seaman.

His team also designed trays specifically for microsurgery instruments that contain individual slots where the delicate instruments are housed before and after use. Sterile processing techs assemble the trays in a specific way and members of the surgical team are instructed to return the tools to the slot from which they retrieved them. It took some work and plenty of reminders, but the team caught on to the new directives. In addition, the workstations in UCSF Medical Center’s sterile processing department are equipped with large, lighted magnifying glasses that reprocessing techs use to inspect the instruments before sending them back to the OR. The techs also test the grasping and cutting performance of each tool during the reprocessing cycle.

Mr. Seaman suggests assigning specific reprocessing techs to the task of cleaning and inspecting microsurgery instrumentation because it requires a certain amount of experience to know how a tool should feel and operate before it’s returned to a surgeon. “Reprocessing techs who handle microsurgery instruments develop an innate sense for when tips are over-sharpened or aren’t bent to the correct degree,” he says. 

Most surgeons prefer to work with instrumentation they used during residency, primarily because the tools had been vetted for peak performance and many surgeons have used them successfully, according to Dr. Goldberg. That doesn’t mean they’re opposed to trialing new options. “Surgeons assessing current instrumentation based on clinical need is an important part of the selection process,” he says. “While we often use tools we’ve trained with, we also have to evolve over time.”

While at annual otolaryngology conferences, Dr. Goldberg makes it a point to walk through the exhibit hall and stop by the booths of instrument makers — from major manufacturers to smaller, independent firms — to shop the latest options and see how they feel in his hands. He often finds finely designed instruments that are well engineered, durable and have good action. He’s even designed his own instruments to meet specific clinical needs that other surgeons have adopted into their practices.

It’s also common for reps from instrument manufacturers to watch him perform surgery with a new instrument to gauge how it feels in his hand and see how it’s used in practice to help them develop better products. “Patients are ultimately the ones who benefit,” says Dr. Goldberg. “That’s at the center of microsurgery instrument care.” OSM

Note: This three-part article series is supported by Synovis.