LECTURE: Cleaning and Sterilization of GILLS Equipment, Thursday, August 27, 2020

This Zoom call information is only good for Thursday August 27, 2020

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The Lecture this week is being presented by Daniel Robertson from Delft University - Netherlands

The concept of doing something to prevent infection during surgical treatment dates to the Egyptians who used pitch and tar.1 The use of steam for sterilization started when a French physicist Denis Papain invented the pressure cooker. 1 However, the modern sterilization methods developed after Louis Pasteur wrote extensively about germs in 1860 and Joseph Lister used carbolic acid spray to disinfect surgical instruments. 1

The sterilization techniques have had several improvements since then and include sterilization with steam, irradiation, with glutaraldehyde. More recently, sterilization of instruments can be achieved using high temperature / high pressure, ultraviolet light, and the most used chemical for sterilization is ethylene oxide. It can be used on almost all instruments, both metal and non-metal.

The Center for disease control and prevention has given several guidelines for disinfection and sterilization and how to check them using tests like Bowie Dick test. 2 Laparoscopic surgery requires the use of delicate optical and electronic equipment that would be damaged by heat, so other methods of handling this equipment have been devised.


THE DEFINITIONS
It is important to understand the various terminology used for description.3

One more set of definitions are necessary for Laparoscopic Surgeries. 4

The need for sterilization of the instruments also depend on the organisms that the process is capable of tackling and the various levels are as follows:

The disinfectants are classified according to their capabilities as:

The guidelines for minimum requirements are as follows. 5

THE STEPS OR PROCESS

The various steps of the Cleaning and sterilizing process could be summarized as in the following diagram:

Unlike in the open instruments with the Laparoscopic instruments blood and tissues enter the various channels and contaminate them.

The cleaning process starts right in the Operating room and here the GILLS has the minor advantage that the positive pressure pushing blood and tissues into the various instruments and channel are not there with GILLS.

We also need to realize that the following substances that are commonly used in the Operating rooms are harmful to the instruments.

It is also important to realize that the resistance of the organisms vary too. 6

The common disinfection methods are the following:

A study in 1995 showed that the regular steam sterilization and short flash sterilization was sufficient to kill all the pathogens in closed trocars with meat inoculated with pathogens. 7 With the autoclaves in addition to the heat the latent heat generated by water becoming steam also contributes to killing the pathogens. 8
Dismantling and pre–cleaning are important before disinfecting. The commonly used disinfectants are Glutaraldehyde and Peracetic acid.

A good chemical disinfectant is Hydrogen per oxide.

There are many factors that affect disinfection of the instruments. It is important to check every tenth cycle with chemical test strips.

The following is the SOP for using Chemical disinfectants:

The following is the summary of the various techniques that are available.

The following are the indicators used:

Ethelene oxide sterilization is one of the commonly used method.

Low temperature steam with Formaldehyde is another alternative that is less expensive compared to ETO.

The Formalin chamber is the most used and discouraged method of sterilization.

The effectiveness depends on the number of tablets used and this study checked after 24 hours.

The recommendations from a study are as follows: 4

A study comparing the results of sterilization with cleaning and dismantling versus assembled sterilization found that the difference was almost tenfold higher in the latter group except for ETO sterilization. 10

SPECIFIC FOR GILLS

The critical part of the GILLS equipment is the abdominal ring that goes inside the body. It is made of stainless steel and could easily be autoclaved. It is good to have a few of them. The entire apparatus could be autoclaved at the beginning of the day and the portion that fits to the OR table could be left just cleaning by spirit.

Most of the places if they can autoclave the connecting portion or just clean with spirit. The hand instruments are generally cleaned and disinfected in Cidex solution and stored overnight in the formalin chambers.

This image has an empty alt attribute; its file name is Gnanaraj150-80x80.jpg

J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope. 

References (click to show/hide)

  1. Available from: https://www.flushinghospital.org/newsletter/history-of-instrument-sterilization/ [accessed on August 10, 2020]
  2. Available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/sterilizing-practices.html [accessed on August 10, 2020]
  3. Available from: https://www.slideshare.net/ShashwatJani/standard-techniques-for-sterilization-of-laparoscopy-instruments-by-dr-shashwat-jani [accessed on August 10, 2020]
  4. AMASI Guidelines. Available from: https://slideplayer.com/slide/12783058/ [accessed on August 10, 2020]
  5. William A Rutala, David J Weber, Disinfection and sterilization: An overview AJIC Vol. 41 Issue 5, May 2013 DOI:https://doi.org/10.1016/j.ajic.2012.11.005
  6. Available from: https://link.springer.com/chapter/10.1007%2F978-1-4612-2480-8_6 [accessed on August 10, 2020]
  7. C R Voyles 1, D L Sanders, J E Simons, E A McVey, W B Wilson. Steam sterilization of laparoscopic instruments. Surg Laparosc Endosc. 1995 Apr;5(2):139-41.
  8. Perkins JJ. Minimum standards for sterilization. In: Perkins JJ. Principles and methods of sterilization in health sciences. 2a ed. Springfield: Charles C Thomas; 1983. p. 154-67.
  9. Available from; https://www.slideshare.net/doctorrao/disinfection
  10. Marshburn PB, Rutala WA, Wannamaker NS, Hulka JF. Gas and steam sterilization of assembled versus disassembled laparoscopic equipment. Microbiologic studies. J Reprod Med. 1991; 36(7):483-7.

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