05- Cleaning, Maintenance & Steralization in Laparoscopic Surger

7/30/2019 05- Cleaning, Maintenance & Steralization in Laparoscopic Surger

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Cleaning, Maintenance & Sterilizationin Laparoscopic Surgery

Training In Basic Laparoscopic Techniques

R.G. Kar Medical College & Hospital

Kolkata


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Decontamination

Its a combination of procedures used to make a reusable

item safe for further use on patients and staff by reducing bioburden.

Use

Inspect

Transport

Disinfect

Clean

Storage

Transport

Sterilization

Pack


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Cleaning pathOn table wipe / keep in water bowls

Running water decrease the organic load

Dismantle & clean the channelsDip in detergent & enzymes solution

Clean the channel, joints & serrations

Brush / water jet

Drying

Ultrasound cleaner


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Laparoscopic instruments

Complex in design and delicate in construction +ve pressure due to CO2

Drive tissue blood into the channels

Problems

Lodging of bioburden in the crevices

Gentlest methods need to be used for

cleaning and sterilization


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Substances harmful for Instruments

Saline

Bleaching powder

Iodine based preparationsAbrasive cleaners- Vim powder etc

Laundry detergents

Surgeons hand scrubSoap


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DISINFECTIONkill or remove the pathogenic

micro organismSPORES NOT KILLED

Low

Reduces overall number of

veg micro organism

Does not destroy TB bacilli

spores

Application OT table,

floor etc.

Intermediate

Kills TB bacilli, most

virus, & fungi but only

some spores

Application OPD,

where breach of skin /

mucosa is not there

High

Kills most forms of

microbial life including

TB bacilli & most of

the spores

Application scopes

delicate instruments

etc. in minor surgical

procedures


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Methods of Disinfection

Low temperature steam 73oC x 20 mins

Boiling water 100oC x 5 mins

Formaldehyde air tight chamber at 50oC x ?

Gluteraldehyde 2% - effective against most

bacteria, virus including hepatitis B & C / HIV,(Degree of disinfection time used)

Ortho phthalaldehyde 0.55% (OPA)


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Factors affecting efficacy of

disinfectant

Prior cleaning

Moisture

Direct contact with the items

Time of contact

Temperature


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Sterilization

Kill all microbial life including bacteria / virus / fungi / spores

Techniques

Steam

121o x 15

mins

ETO

Heat

sensitive

instrument

(Make sure

no soiledinstrument

Hot air

Inefficient

good only for

grease /

ointment, oil

etc.

Low

temperature

steam

(73oC)+

formaldihide

Heatsensitive

instruments

Not very

popular

-Irradiation

(for

industrial

use)

Paracetic acid

Denatures

protein

Destroy cell

membrane50-56oC x 12

mins

Kills spores


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Formalin Chamber- The Bane of

Laparoscopy

Size used: 9 x 9 x 20

Tablets: 4, 6, 8, 10, 12,14.???

Minimum exposure time: 24hour

Organisms

Streaked petridish

Dried on instruments Bacterial spores

Ganjawala D, Shah M , Zaver i D.

Ef f icacy of formalin chamber for disinfection of instruments

Presented to Western I ndia Regional Orthopedic Conference, 2000


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Formalin Chamber - The Baneof Laparoscopy

No Standardization

How much leak

Chamber- How many times opened in 24hrsHow many tablets

Exposure How many minutes

Temperature

Dont shove instruments in a chamber and hop

from one hospital to another


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Vegetative forms -Streaked petridish

Dried soiled instrument

Spores (Clostridia)

4 6 8 10 12 14

Number of Tablets

No Effect

No Effect

How Good Is Formalin Chamber ?

Ganjawala D, Shah M , Zaver i D.

Ef f icacy of formalin chamber for disinfection of instrumentPresented to Western I ndia Regional Orthopedic Conference, 2000


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R i g h t p l a c e f o r t h i s


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Gluteraldehyde 2%(Cidex / Glutarex)

Efficacy depends upon

When activated (Normal Shelf Life -14 days)

Time of contact (min-25 minutes)

Complete submergence Number of cycles

Instruments wet or dry

Amount of bio-burden pH of Cidex

Temperature


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A Word About Cidex

Thoroughly clean & dry the instruments before putting incidex water on instrument changes the pH of cidex

Use sterilezed stainless steel tray for cidex

Avoid using plastic tray for cidex

Check efficacy before use

Allow cidex to drip back into the tray

Use gloved hands to pick up the instruments

Lifter should not touch the tray wall (Un sterile!!)

Rinse instruments thoroughly in sterile water (at least 3times)

Sterilize the sterile water tray!

Dry all the instruments before use


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Dont Do This


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Proper and improper use of cameraProper and improper use of camera

covercover


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Plasma Sterilizer -The Best


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Autoclave Cidex ETO Gas

plasma

Formalin

chamber

Sterile

sleeve

Camera x ++ +++ + ++

Light cable + ++ +++ + ++

Telescope +++ ++ +++ x x

Tubings /diathermy

x + +++ +++ + x

harmonic scalpel

cable

x ++ +++ + ++

Heat sensitive

hand instruments

x ++ +++ +++ x x

Heat resistant

hand instruments

+++ ++ +++ +++ x x

Trocars +++ ++ x +++ x x


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Heat tolerant endoscopes and accessories

- Steam sterilization is the first choice

Heat sensitive endoscopes and accessories

- ETO / gas plasma / low temp. steam + formaldehyde

Insufficient instruments / time to sterilize

- Immersion in 2% glutaraldehyde

- At least 10 min

- > 20 min if mycobacterial infection suspected

- At least 3 hrs required to kill spores

J Hosp Infect. 2000 Aug; 45(4):263-77

Decontamination of minimally invasuve surgical endoscopes and accessories

Ayliffe G; Minimal Access Therapy Decontamination Working Group


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Issues for and against reuse

Does it affect procedural outcomes?Can disposable instruments be ever cleaned

/ sterilized adequately?

Reuse of disposable instruments

R f Di bl L i I


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reusing Disposable Laparoscopic Instrument did not change the

operative and postoperative outcomes or the infection rate

Efficacy and safety of reuse of disposable laparoscopic instruments in laparoscopiccholecystectomy: a prospective randomized study, Colak T, Ersoz G, Akca T, Kanik A, Aydin S;Surg Endosc. 2004 Aug;18(8):1161-2

None of the patients had infectionat the wound site or intra-abdominally

High-level disinfection with 2% alkalinized glutaraldehyde solution for reuse of laparoscopicdisposable plastic trocars, Gundogdu H, Ocal K, Caglikulekci M, Karabiber N, Bayramoghu E,Karahan M, J Laparoendosc Adv Surg Tech A. 1999 Feb; 9(1): 117-8

disposable laparoscopic instruments with a relatively complex structure isnot effective and may result in nosocomial diseasetransmission

Is it possible to resterilize disposable laparoscopy trocars in a hospital setting?, Ulualp KM,Hazaoglu I, Ulgen SK, Sahin DA, Saribas S, Ozturk R, Cebeci H, Surg Laparosc EndoscPercutan Tech. 2000 Oct;10(5):340-1

What the literature says?

Reuse of Disposable Laparoscopic Instruments


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Minimal Access Surgery

Aim is less morbidity & good cosmesis

Not this

N i l T b l i f ti


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Infect Control Hosp. Epidemiol, 2001 Aug22(8):474-5

Nosocomial Myco bacter ium c helonac infect ion in laparosco pic surgery.

Rodrigues C, Mehta A, Jha U, Bharucha M, Dastur FD, Udwadia TE

Indian J Gastroenterol. 2001 Nov-Dec;20(6):247-8

Port-s i te infect ion with Myco bacter ium ch elonei fo l lowing laparosc opic appendicectom yBhandarkar DS, Bhagwat S, Punjani R

Scand J Infect Dis. 2002;34(12):928-9

Port-s i te tuberculos is: a rare com pl ic t ion fol low ing laparoscop ic cholecystectom y

Jagdish N, Sameer R, Omprakash R.

Surg Endosc. 2003 Jun;17(6):930-2 Epub 2003 Mar 07.Port-si te tuberculosis after laparoscop y: report o f eight cases

Ramesh H, Prakash K, Lekha V, Jacob G, Venugopal A, Venugopal B

Nosocomial Tubercular infection

a totally avoidable situation

A whopping cost of Rs. 23,800 per nosocomial non-tubercular infection

(Baroda 1999)


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What is right?

Are we doing it right?

Consequences of not doing it right

How can we do it right?

Sterilization of Lap Instruments


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-> 350 surgeons from

around the country

- Audience poll with

electronic keypads

4944

2 4

0

10

20

30

40

50

60

70

80

90

100

Formalin Gluter. ETO Autoclav.

MASStatus in I ndia

October 2002, Mumbai


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1621

2736

0

10

20

30

40

50

60

70

80

90

100

Formalin Gluter. ETO Autoclav.

MASStatus in I ndia

October 2002, Mumbai


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Thorough cleaning is an important primary step

Essential to follow rigid protocols for instrument

cleaning and sterilization

Only well-established methods of sterilization / highlevel disinfection should be used

Some current practices should be abolished

- formalin chambers- reuse of disposable instruments

It is necessary to establish stringent regulations for

the instrument manufacturers

Conclusions


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How many of us would allow either of theseinstrument sets to be used if we were

undergoing an open cholecystectomy?

Food for thought


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Ideal sterilization ???Search is on !!!


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05- Cleaning, Maintenance & Steralization in Laparoscopic Surger

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