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SurgicalInstruments Contributors CONSULTING EDITOR NANCYGIRARD,PhD,RN,FAAN Consultant,Boerne;ClinicalAssociateProfessor,AcuteNursingCareDepartment, UniversityofTexasHealthScienceCenter,SanAntonio,Texas GUEST EDITOR KATHLEENB.GABERSON,PhD,RN,CNOR,CNE,ANEF NursingEducationConsultant,OWKConsulting,Pittsburgh,Pennsylvania AUTHORS KATHLEENB.GABERSON,PhD,RN,CNOR,CNE,ANEF NursingEducationConsultant,OWKConsulting,Pittsburgh,Pennsylvania THEODOREHAINES,MD,MSc AssociateProfessor,DepartmentofClinicalEpidemiologyandBiostatistics, FacultyofHealthSciences,HealthSciencesCentre,McMasterUniversity, Hamilton,Ontario,Canada CYNTHIAK.HALVORSON,RN,MSN,CNOR PerioperativeClinicalEducatorandConsultant,Maur,Switzerland MARYGRACEHENSELL,RN,BSN,CNOR ORManager,AlleghenyGeneralHospital,Pittsburgh,Pennsylvania PATRICIAANNHERCULES,RN,MS MissouriCity;Director,SystemClinicalEducation,MemorialHermannHealthcare System,Houston,Texas AMYL.KENNEDY,RN,MSN,CNOR Director,ProgramofSurgicalTechnology;ProfessorofSurgicalTechnology,Harrisburg AreaCommunityCollege,Harrisburg,Pennsylvania LINDAE.SABIN,RNC,PhD ProfessorofNursing,SchoolofNursing,UniversityofLouisianaatMonroe,Monroe, Louisiana;Ridgeland,Mississippi RAMONSHABAN,BSc(Med),BN,PGDipPH&TM,GCertInfCon,DipAppSc(Amb), MCHlth(Hons),MEd,RN,EMT-P,IPN,CICP,FRCNA ResearchCentreforClinicalandCommunityPracticeInnovation,GriffithInstitutefor HealthandMedicalResearch,GriffithUniversityandPrincessAlexandraHospital, Brisbane,Australia iv Contributors MICHAELSINNOTT,MBBS,FACEM,FRACP SeniorStaffSpecialist,DepartmentofEmergencyMedicine,PrincessAlexandraHospital, Woolloongabba,Queensland,Australia STEPHANIESMITHSTANFIELD,RN,BSN,CNOR NorthBrownsvilleSurgeryCenter,Brownsville,Texas BERNADETTESTRINGER,PhD ProjectProgramManager,OccupationalHealthandSafetyAgencyforHealthcareinBC (OHSAH),Vancouver;AdjunctProfessor,FacultyofHealthSciences,SimonFraser University,Burnaby,BritishColumbia,Canada SurgicalInstruments Contents Preface:TheToolsoftheTrade ix KathleenB.Gaberson FromFingerstoMiniaturizationandRobots:AnOverviewoftheHistory ofSurgicalInstrumentation 1 LindaE.Sabin This retrospective historical analysis examines the history of surgical in- strumentsinrelationtothedevelopmentofsurgeryasadisciplineandsci- ence.Nursingimplicationsareincludedforreadersdedicatedtoresearch fortheimprovementinpatientoutcomes.Akeytosearchingforacontem- porary answer to a problem is found best by examining what has hap- penedinthepast. InstrumentReadiness:APatientSafetyIssue 15 PatriciaAnnHercules Operatingroominstrumentandequipmentreadinessandavailabilityare necessary to safeguard patient care. Using available data and real-life stories,thisarticledefines,givesanhistoricaloverview,andoutlinesthe existingprofessionalstandardsonthisissue.Itelaboratesoncontributing factorssuchasavailability,substitutions,stress,anddistractions.Itcon- cludes that the health care profession should take a closer look at this asapatientsafetyissue. ReviewofBestPracticesandLiteratureonInstrumentCounts 27 CynthiaK.Halvorson Withaheightenedemphasisonpatientsafetyandaloweredtolerancefor theoccurrenceof‘‘neverevents’’thereisaneedforimprovedpractices. Evidence-based knowledge bridges this gap by providing direction for best practices that ensure consistent and sustained safe patient care and optimal outcomes. Perioperative nursing has a long-standing and well-respectedpositionofadvocatingforsafepatientcare.Withintimate knowledge of the counting process, perioperative nurses, as key stake- holdersinthemultidisciplinaryapproach,mustcontributetothebodyof evidenceregardingbestpracticesforeffectivesurgicalcounts. TheHands-FreeTechnique:AnEffectiveandEasilyImplementedWorkPractice 45 BernadetteStringerandTheodoreHaines Thehands-freetechnique,wherebynotwopeopletouchthesamesharp itemsimultaneouslyduringsurgery,isaneffectiveworkpracticerecom- mendedtoreducetheriskofblood-borneexposure.Thistechniquecan be implemented using receptacles, tables, or the surgical field. Compli- ance with the technique can be increased using a newly developed video/DVDavailableforviewingontheInternet. vi Contents ‘‘ScalpelSafety,’’not‘‘SafetyScalpel’’:ANewParadigminStaffSafety 59 MichaelSinnottandRamonShaban Scalpelinjuriesaccountforbetween7%and12%ofallsharpsinjuries.Ef- fortstoincreasetheawarenessofpotentialhazardsofsharpsinjuriesand relatedpreventioneffortsbeganintheearly1980s.Researchshowscon- vincingly that a single-handed scalpel blade remover combined with ahands-freepassingtechnique(HFPT)isasafealternativechoicetothe safety scalpel. The concept of ‘‘scalpel safety’’ is based on providing nursesthefreedomofchoicetoselectthebestsafetydevicefortheirin- dividualneedsonacase-by-casebasis.Teammemberscannowchoose betweenasafetyscalpelandasingle-handedscalpelbladeremovercom- binedwithaHFPTtoachievethecorrectbalancebetweenpatientsafety andstaffsafety. InstrumentationforRoboticSurgery 69 MaryGraceHensell Robotic surgeryis performed with a computerized systemthat interacts withthesurgicalfieldbymeansofamechanicalarmorarms.Thisarticle discussesthecomponentsofthesystemandtheappropriateinstrumen- tation for robotic surgery. Because of a unique feature of the robot arm drapes,theyareconsideredpartoftheinstrumentation,witheconomicim- plications. The proper use and care of robotic instruments is also discussed. TeachingSurgicalInstrumentation:InnovativeTechniques 83 AmyL.KennedyandKathleenB.Gaberson Introducing surgical instrumentation to the novice perioperative nurse, nursingstudent,orsurgicaltechnologystudentischallengingandreward- ing. This article explores effective teaching approaches. It reviews three learningdomains,selectedlearningandteachingprinciples,andprovides guidance forselecting appropriate learning activities. Finally,itsuggests evaluationstrategiestoassessthatlearning. SurgicalInstruments:ALaughingMatter? 89 StephanieSmithStanfield Amongthesourcesofhumorintheoperatingroomareanecdotesabout thenamesorfunctionsofsurgicalinstrumentsorequipment.Thisarticle presentsacollectionofsuchjokesandstories,arrangedinvariouscate- gories,contributedbyperioperativenursesandothermembersofthesur- gicalteam. Index 95 SurgicalInstruments Preface: The Tools of the Trade PeoplehaveusedtoolssincetheStoneAge.Thefirststone,wood,andbonetoolsun- doubtedly were used for tasks necessary to sustain life—killing predator animals and later hunting animals for food, removing animal skins and joining pieces together to use for clothing and shelter, cutting pieces of flesh, and grinding grains. Once tools weredevelopedforthesepurposes,ancientpeoplesprobablyadaptedthemforsimilar uses, including cutting the human body in an attempt to relieve pain and heal illness. Finally, tools were designed specifically for such surgical uses, and eventually the surgicalinstrumentsofthemodernageweredeveloped.Assurgicalpracticeandtech- niquescontinuetoevolve,newsurgicalinstrumentsaredevelopedandexistinginstru- mentsaremodifiedfornewuses.Withanever-increasingarrayofsurgicalinstruments invariousmaterials,sizes,shapes,andtechnologies,onemaytakethesetoolsofthe tradeforgrantedastheyareusedtotreatdisease,correctdeformities,restorefunction, andrelievepain.Butasmoreinstrumentoptionsbecomeavailable,oneneedstorecog- nizetheirimportantroleinimprovingpatientandstaffsafetyandreducingoperativetime. Thisissueonsurgicalinstrumentsincludesarticleswithvariousperspectivesthat maystimulaterenewedappreciationfortheadvancesintechnologythatmakesophis- ticated,complexsurgicaltechniquespossible.Atthesametime,oneneedstorecog- nize some inherent risks associated with the use of surgical instruments, examine evidence that supports or refutes some traditional handling techniques, and learn newwaysofhandlingandcaringforinstrumentssothattheymaybeusedeffectively andsafely. Inthefirstarticle,DrLindaSabin,anursehistorian,revealsafascinatinghistoryof surgicalinstrumentation,startingwiththeuseofourownbodyparts—mouths,hands, andfingers—asimplementsforremovingforeignbodies,relievingpain,orincisingand draininganabscess.Thishistoricalanalysisprovidessupportfortheconceptthatall surgicalinstrumentsfunctionasextensionsoftheseoriginaltools.Shealsosupplies documentation that the function of surgical instruments evolved to support changes inthepracticeofsurgery. Next,PatriciaHerculespresentsacompellingargumentthatinstrumentreadiness isabest-practicestandardforsafeperioperativepatientcare.Herarticle,‘‘Instrument Readiness: A Patient Safety Issue,’’ proposes that the safety of patients undergoing surgicalinterventiondependsonverificationthatsurgicalinstrumentsareimmediately available,functional,sterile,andreadyforusewhenneeded. CynthiaHalvorson’sarticle,‘‘ReviewofBestPracticesandLiteratureonInstrument Counts,’’identifiesandreviewsextantresearchevidencesupportingbestpracticesfor surgicalinstrumentcountsanddiscussesimplicationsandrecommendationsforpre- venting adverse events related to incorrect counts. Because incidents of retained foreign bodies during surgery persist despite widespread use of manual count protocols, they now are classified as ‘‘never events’’ and reportable sentinel events. Evidence-basedknowledgeprovidesdirectionfordevelopingandimplementingeffec- tiveprotocolsforreportingandreconcilinginstrumentcountdiscrepancies. Although many surgical team members may regard percutaneous injuries during surgeryasaninevitableoccupationalhazard,DrBernadetteStringerandDrTheodore PerioperativeNursingClinics5(2010)ix–x doi:10.1016/j.cpen.2009.12.004 periopnursing.theclinics.com 1556-7931/10/$–seefrontmatterª2010ElsevierInc.Allrightsreserved. x Preface Hainesadvocatefortheconsistentuseofhands-freemethodsofpassinginstruments to prevent such injuries. They review the evidence on the effectiveness of this work practice as a safety measure to decrease bloodborne exposure risk from percuta- neous injury. They also discuss an effective method of educating surgical team memberstoincreasecompliancewiththistechnique. Inanarticlealsorelatedtothepreventionofinjuriesfromscalpelsandothersharps, DrMichaelSinnottandRamonShabancallforanemphasisonscalpelsafetyrather than reliance on use of scalpels with active safety features. They present evidence thattheuseofso-calledsafetyscalpelsdoesnotinfactreduceriskofscalpelinjuries to surgeons, perioperative nurses, and scrub technologists, and they call for a new paradigmofscalpelsafetyinvolvingthechoiceofscalpelwithactivesafetyfeatures or a single-handed scalpel blade remover combined with hands-free passing tech- nique. They propose that this choice should be made on a case-by-case basis and shouldconsiderboththepatientandstaffmembersafety. Inherarticle,‘‘Instrumentation forRoboticSurgery,’’MaryGraceHensell uses her experience with robotic surgical systems to write about the challenges of using and caringforroboticsurgeryinstruments.Sheexplainsthecomponentsofroboticsystems andemphasizestheneedtoconsiderdrapesfortheroboticinstrumentarmsasinstru- mentcomponents.Sheoffershelpfulsuggestionsforcaringforroboticinstrumentsand provideslistsofbasicroboticinstrumentsetsforvarioussurgicalprocedures. Amy Kennedy’s article, ‘‘Teaching Surgical Instrumentation: Innovative Tech- niques,’’ provides guidance for educators who must introduce surgical instruments to the novice perioperative nurse, nursing student, or surgical technology student. Weexplainhowknowledgeofthethreedomainsoflearningisimportantfordesigning instruction for learners, and emphasizes that learning objectives should be chosen carefully to match the level at which learners will be expected to demonstrate the desired learning outcomes. Offering examples from her experience as professor anddirectorofasurgicaltechnologyprogram,sherecommendsteachingtechniques that effectively introduce and sequence information and skill practice related to use andhandlingofsurgicalinstruments. The final article is a collection of jokes and humorous stories related to surgical instruments,compiledandorganizedbyStephanieStanfield.Thesejokes,anecdotes, and funny stories were submitted by perioperative nurses and other surgical team members in response to a request posted on the Association of Operating Room Nurses e-Chapter Web site. Sharing such jokes and stories has long been part of thecultureoftheperioperativeenvironment,helpingustobuildcamaraderie,relieve stress,andmakeworkmoreenjoyable. Thesearticlesprovidearangeofperspectivesonthepast,present,andpotential future of the use and care of surgical instruments in perioperative nursing practice. May we never again take for granted these tools of the trade, but instead, strive to use them in ways that produce optimum patient outcomes and promote safety for surgicalstaffmembersaswellaspatients. Kathleen B. Gaberson, PhD,RN,CNOR, CNE,ANEF OWK Consulting 213SharonDrive Pittsburgh, PA15221, USA E-mail address: [email protected] From Fingers to Miniaturization and Robots: An Overview of the History of Surgical Instrumentation Linda E. Sabin, RNC,PhDa,b,* KEYWORDS (cid:2)History (cid:2)Surgicalinstruments (cid:2)Surgicalnursing Surgeryasapracticehasancientrootsbeginningwithprimitiveattemptstohelpthe sickbyopeningthebody,piercingit,orchangingitinsomewayinanattempttohelp apersoninneed.Althoughthisancientcrafthasenduredtomoderntimes,itisimpor- tantfornursestorememberthatthepracticeofsurgeryasitisknowntodayonlyhas beenarespectedscientificdisciplineforalittleover150years.Inaddition,likenurses, surgeons suffered some of the same frustrations in gaining full recognition for their contributiontomedicinebecauseoflongperiodsoftimewhentheirpracticedidnot progress.1(p477) Nursesneedtoappreciatehowsurgicalinstrumentsweredevelopedinrelationto thehistoryofsurgerytoanticipatewhatislikelytohappeninthefuture.Kirkupnoted that the dramatic changes in surgery and instrumentation were related directly to the development of anesthesia, antisepsis, asepsis, and other scientific advances, Thelongperiodsofslowadvancementinthefield,however,didprovidethetimeto solveissuesrelatedtoanatomyandotherbasicsthatallowed19thcenturysurgeons to take advantage of the allied developments. A key concept in understanding this historyistorecognizethatallsurgicalinstrumentsfunctionasextensionsoftheorig- inaltoolsthatcamefromthehumanbody:mouths,hands,andfingers.2(ppxi,42–3)Itis alsoimportanttorecognizethatthefunctionoftheinstrumentsevolvedwiththeprac- ticeoftheartofsurgery.Itisimpossibletoseparatethestoryofthetoolssurgeonsuse fromthehumansagathatstimulatedtheneedforsurgery. a School of Nursing, University of Louisiana at Monroe, 700 University Avenue, Monroe, LA 71209,USA b 503CharmantPlace,Ridgeland,MS39157,USA *SchoolofNursing,UniversityofLouisianaatMonroe,700UniversityAvenue,Monroe,LA71209. E-mailaddress:[email protected] PerioperativeNursingClinics5(2010)1–13 doi:10.1016/j.cpen.2009.11.005 periopnursing.theclinics.com 1556-7931/10/$–seefrontmatterª2010ElsevierInc.Allrightsreserved. 2 Sabin ANCIENTSOCIETIES As noted previously, the earliest instruments for surgery were mouths, hands, and fingers. Fingers are capable of probing, manipulating, and retracting, and fingernails wereusedforcuttingandscraping.Wristsandhandsarecapableoftwisting,pounding, and pulling on body parts. Mouths can be used to suck out perceived poison or blood.2(pp42–3)Onecanpicturetheplightofprimitivepeopleusingwhattheyhadtore- moveforeignobjects,attempttobreakaboilorabscess,ortreatillnessesthatcaused painandfevers.Beforetools,bodieswerealltheyhadavailable.Thesefirstpatients experienced all oftherisksof surgery that remainedproblemsuntil the19thcentury AD:pain,riskofhemorrhage,andriskofinfection.Althoughthereisevidencethatprim- itive people attempted to relieve pain by such means as drugs, alcoholic drinks, acupuncture,andmind-alteringherbs,painneverwasbanished.Thereisalsoevidence thathemorrhagewasrecognizedearlyasaproblemandwastreatedwithtourniquets, pressure,andcautery.Whenthehistoryofsurgicaloutcomesisexamined,itisatribute tohumanresiliencethatpeopleeversurvivedmajorsurgerypriortothemodernera.3(p38) Aspeopleevolved,theydevelopedcrudetoolsmadeofanimalbone,antlers,horns, andstone,andbegantousethemtocutthehumanbodyandtreatillness.Toolsprob- ablyweredevelopedforotherdailyactivities andwereputintousewhenasurgical need arose. The practice of using tools designed for a purpose unrelated to human surgery procedures would continue until modern times. Some of the earliest tools thathavesurvivedinphysicalformorinartisticimageswereknivesorcuttingblades, saws, scissors, tweezers, clamps, and crude drills. One of the earliest metals used wascopper.Organicmaterialsalsowereusedsuchasshellstocutfleshandshark teethtouseaslancetsandscarifiers.Canalsfromlonganimalbonesandlonghollow plantstemswereusedasconduits.Kirkupclassifiedthemajortypesoftoolsinterms of structure and form: probes, needles, spring forceps, catheters, scissors, clamps, retractors,andthoseinstrumentsthathavemixedforms.2(pp80–2) There is considerable evidence from ancient writings, art drawings, and physical remainsthatoneoftheearliestsurgicalprocedurespracticedthroughouthumansoci- eties was trephination. The procedure consisted of drilling or cutting of holes in the skull to heal illness. Primitive healers performed trephination with the aid of knives, lancets,andothersharpobjects.Evidenceindicatesthatthissurgerywasperformed torelieveillnessessuchasheadachesandepilepsy.Researchershavefoundreports andskullsverifyingthepracticeinsuchwidelyseparatedregionsasPeruandEgypt. Early alloyed metals and organic materials were used to fashion knives and hand- operateddrillingtoolstoopenbonesinthehead.Onestudyexaminedtrephinedskulls fromprimitive Peruviantribes andnotedthat70%oftheskullsshowedevidenceof healing,indicatingthatpatientshadsurvived.2(p5),4(p8) AncientEgyptiansurgeryprogressedtothelevelofspecialties,witheachgroupof doctorsresponsibleforapartofthebody.Forexample,thephysicianinchargeofthe intestineswouldprovideenemasandsurfacetreatments,andthephysicianincharge oftheheadwoulddothetrephining.Anancient(1500BC)papyrusdiscoveredinthe 19thcenturydescribessurgical casesand strategiesused,suchasthepatientwith a‘‘tumorandabscess.’’Thisdisorderwastreatedwitha‘‘firedrill,’’whichwasafire- stickusedforkindlingawoodfireinthisperiod.TheEgyptiansurgeonhadahotpoint toprobeanabscess.3(p98),5(p17),6(p26) Hippocrates (400 BC) did not differentiate between physicians and surgeons, but wrote about a great variety of human disorders and their treatment. He wrote more aboutsurgerythananyothertopic.Hippocratesrecognizedthefourmajorelements believed to make up the body that were accepted in his era: water, earth, fire, and FromFingerstoMiniaturizationandRobots 3 air.Theseelementshadcorrespondingbodilycharacteristics:wet,dry,hot,andcold. The characteristics led to the theory of humors related to the fluids observed in the human body: blood, yellow bile, black bile, and phlegm. Many of the early surgical treatments were aimed at either enhancing or reducing those humors that were consideredthecauseofillnesswhentheywereoutofbalance.Surgicalinstruments described by Hippocrates were bronze or copper and of various natural materials suchasanimalhorn.2(p9),3(pp210–7),5(pp39–41) Manyofhiswritingswereaboutwarwoundsandcareofbrokenbonesincludingthe useofironrods.AccordingtoHippocrates,warandsurgerywouldalwaysbelinked because of theinevitable wounds that followed human conflict. His surgical writings alsoaddressedmorecommonproblemssuchasanalfistulaandincludedsomeinter- estingsurgicalequipment.Thetreatmentrecommendedforthefistulawastointroduce aballofanimalhornintotherectumandleaveitthereunlessthepatientneededtopass astool.2(p79)Hetaughtthatobservationwasofprimeimportanceindeterminingwhat thepatientneedswere.Healsowasavisionarywhotaughtthatdiseaseshadspecific causes,withmanyproblemscomingfromthenaturalworld,andthatrecoverycouldbe assisted with surgery and medicine.2(p79) It is noteworthy that in Hippocrates’ time, women were neveraccepted aseithersurgeonsornurses, andtheonly persons al- lowed to work with instruments in surgery besides the male surgeons were their apprentices.Theseassistantsalsogavethebedsidecare.7(pp54–5) Galen(130to200AD)followedHippocraticideasbutredefinedsomeoftheearlier teachingsandaddedtoboththeelementalandhumoraltheories.Hefocusedontheo- logicalexplanationsrelatedtodiseaseandstressedhisexpandedviewsofhumoral theoryofillness.Healsobelievedinobservationofthepatientandtheuseofmedicine andsurgicalprocedurestotreathumoralimbalances.Theprimarysurgicaltreatments usedintheGalenicapproachwerebleeding,cupping,blistering,purging,andcoun- terirritation. All of these painful processes were aimed at relieving excess humors believed to cause disease. Inflammation also was believed to cleanse the body of bad humors, so counterirritation could include scratching or scarifying the skin to cause reddening or small areas of bleeding. Nurses need to remember that these strategies were still in use in the United States well into the 19th century and often were employed as a defense against communicable fevers. Nurses at the bedside heatedthetoolsforblisteringorhotcupsforthecounterirritation.Theyalsocleaned upafterthebleedingprocedures.Intimesofepidemic,aphysicianmighthavemany callstomake,anditwasuptothosecaringforthepatienttofollowthedoctorwith care and comfort, as well as cleaning up from whatever was performed while the doctor moved on to the next case. Thisapproach to medicine and surgery was not challengedforover1500yearsafteritsdevelopment.3(pp251–9),8(pp5,10) THEDARKPERIODINSURGICALHISTORY FollowingtheadvancesofancientcivilizationsandtheGreeks,therewasalongperiod of history when little surgery was performed in the Western world outside of a few university surgical centers such as Salerno (Italy) and Paris (France). Much of the surgicalskillandpracticewaslostintheMiddleAgesbecauseofthedominanceof theCatholicChurch,whichtaughttheprimacyoftheHolySpirittointercedeinillness andforbadetheeducatedmonksandpriestsfromspillingblood.Onlythesimplestof proceduresrelatedtoGalenictheorywereusedinthisperiod.Monkshadmaintained much of the practical medical knowledge after the fall of Rome but were limited by Papaledictsovertime,andbythe12thand13thcenturiestheyhadtosendbarbers
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