- 1. 3 Great Guys. Ignaz Semmelweis Louis Pasteur Joseph
Lister
2. Sterilization & Disinfection in Laparoscopic Surgery
Practical Guidelines Dr.S.Easwaramoorthy MS FRCS (Eng) FRCS (Glas)
Hon FRCS (Edin) Consultant surgeon, Lotus hospital, Erode, TN MRCS
Examiner, RCS of Edinburgh EC Member, ASI TN & P Chapter &
IAGES South Zone 3. Expensive telescope/Camera Delicate hand
instruments Long narrow lumen /Hinges Tubes and wires etc 4.
Laparoscopic equipments are considered As Critical equipments 5.
Spaulding Classification of Medical Devices BASED ON RISK OF
INFECTION Critical equipments Enter normally sterile body tissue:
e.g., surgical instruments -Sterilization Semi- critical devices
Contact mucous membranes: e.g., flexible endoscopes -Sterilization,
if not feasible- Minimally high level disinfection Non- critical
devices Contact intact skin: e.g., stethoscopes, electrocardiogram
electrodes -Intermediate or Low level disinfection 6. Guidelines
for prevention of surgical site infection, 1999 Critical equipments
require Sterilization/High level disinfection 7. Definition No Type
Vegetative TB bacilli Spore 1 Low level disinfection + - - 2
Intermediate level disinfection + + - 3 High level disinfection + +
(+) 4 Sterilization + + + 8. Aim of Sterilization Reliable Safe
Cost effective To protect our patients from Germs To protect our
staffs from Germicides! To protect our instruments from Damage!! 9.
Sterilization Cycle Surgery Storage/Transport Soaking Washing
Sterilization 10. Recommendation-1 Need: Good Quality water
Detergent Enzyme preparations 11. Washing / Cleaning Disassemble
Visual Check Manual, mechanical or ultrasonic cleaning Rinse &
Dry LubricationAssemble 12. Alfa MJ, Nemes R. Manual versus
automated methods for cleaning reusable accessory devices used for
minimally invasive surgical procedures. J Hosp Infect. 2004
Sep;58(1):50-8 Brush & Flush Junctions between insulating
sheaths and activating mechanisms of laparoscopic instruments
Articulations and grooves of forceps Long narrow lumen of sheaths
13. Machine washing & Ultrasonic cleaning Ransjo U, Engstrom L,
Hakansson P, Ledel T, A test for cleaning and disinfection
processes in a washer-disinfector. APMIS. 2001 Apr;109(4):299-304.
Tunnel type Batch type Cavitation effect 14. Recommendation 2 15.
Sterilization of Laparoscopic Instruments Steam sterilization
Ethylene Oxide Chemical Disinfection Formaldehyde Cabinets? Newer
methods.. Marshburn PB, Rutala WA, Wannamaker NS, Hulka JF. Gas and
steam sterilization of assembled versus disassembled laparoscopic
equipment. Microbiologic studies. J Reprod Med. 1991
Jul;36(7):483-7 Ayliffe G; Minimal Access Therapy Decontamination
Working Group. Decontamination of minimally invasive surgical
endoscopes and accessories. J Hosp Infect. 2000 Aug;45(4):263-77.
16. Steam Sterilization Porous load Vacuum autoclaves Wrapped
instruments With long narrow lumens Temp & Time; 121oC 15min
134oC 5min Useful for Mechanical instruments Telescopes Voyles CR,
Sanders DL, Simons JE, McVey EA, Wilson WB. Steam sterilization of
laparoscopic instruments. Surg Laparosc Endosc. 1995
Apr;5(2):139-41. 17. Ethylene Oxide Sterilization Temp &
duration 54oC 150min 37oC 5 hours (Aeration cabinet >24hrs) Use
for Heat sensitive items Monitor Indicator strips Dangers to Staffs
Inhalation injury Contact injury Expensive Alfa MJ, DeGagne P,
Olson N, Hizon R. Comparison of liquid chemical sterilization with
peracetic acid and ethylene oxide sterilization for long narrow
lumens. Am J Infect Control. 1998 Oct;26(5):469-77. 18. High Level
Disinfection Germicides Prewash & rinse Dwelling time :
45min/20/12 Shelf life : 2 weeks/4/ 4 Indicator strips Rinsing
protocol Health hazards to Staffs 2.4% Glutaraldehyde 3.4%
Glutaraldehyde OPA(ortho-phthalaldehyde) Peracetic acid Hydrogen
peroxide Superoxidised water 19. Factors affecting Sterilization
Number of organisms ( Bio burden) Types of organisms Concentration
of disinfecting agent Presence of organic material (e.g., serum,
blood) Contact time pH Biofilms Temperature 20. Recommendation 3
21. Monitoring the effectiveness of Sterilization Physical
Indicators Temp, Time and Pressure Chemical Indicators Bowie Dick
tape Brownie Tube Biological Indicators Bacillus Stearothermophilis
Bacillus Subtilis 22. Order of Resistance to
Sterilients/Disinfectants Bacterial Spores -Bacillus
Sterothermophilis & Subtilis -Clostridium Sporogenes
Mycobacteria Non-lipid or Small viruses -Polio, Rhino &
Coxackie Fungi -Trichophyton,candida Vegetative Bacteria -Staph,
pseudomonas, Salmonella Lipid or medium sized viruses -Herpes, HBV,
HIV Most resistant Least resistant Pirions 23. National Survey on
sterilization methods 1% 7% 53% 39% Formalin Chamber Ethylene Oxide
2%Cidex Autoclave 53% 24. Formalin Chamber Disinfection Bio
Indicator: Bacillus Stearothermophillis Bacillus Subtilis
Mycobacterium bovis 25. Variables Contact Time 3 hrs 5 hrs 8hrs
Temperature 28 o C 18 o C Control Time Temp Humidity 26. Using
formalin Chamber Use tight fitting formalin cabinet Pre washing and
drying is essential Disassembled trocars and Instruments Total of
45 gm HCHO Contact time : 5 hours & > Temperature : 280 C
& > Guidelines: 27. Newer methods of Sterilization Gas
Plasma sterilization Steris System Hydrogen peroxide 30 min at 500C
For heat sensitive items Small trays/Special packing Peracetic acid
30 min at 500C For heat sensitive items Point of use system 28. Gas
Plasma Sterilization Advantages: Safe ( no toxic residuals) Fast (
cycle time is 45-73 min ) No aeration necessary Used for heat
sensitive items Disadvantages: Cellulose (paper), linens and
liquids cannot be processed Small chamber Caution for instruments
with long/narrow lumens Requires synthetic packaging
(polypropylene) and special container tray Vapourised H2O2 4 phase
sterilization Vacuum phase Injection phase Diffusion phase Plasma
phase Plasma is Collection of electrons, Positive ions, neutrals
4th state of matter 29. Emerging Pathogens: Hepatitis C C.Difficile
H.Pylori Antibiotic resistant germs MRSA/VRE/MDR-TB SARS
virus,Avian Flu Pirion: CJD CJD: Immerse in NaOH for 1 hr Steam
sterilization 121oC 1 hr 30. Disposable Laparoscopic devices Can we
Resterilize? 1.Roth K, Heeg P, Reichl R. Specific hygiene issues
relating to reprocessing and reuse of single-use devices for
laparoscopic surgery. Surg Endosc. 2002 Jul;16(7):1091-7 2.Chan AC,
Ip M, Koehler A, Crisp B, Tam JS, Chung SC . Is it safe to reuse
disposable laparoscopic trocars? An in vitro testing. Surg Endosc
2000 Nov:14(11) 1042-4 3.Gundogdu H, High-level disinfection with
2% alkalinized glutaraldehyde solution for reuse of laparoscopic
disposable plastic trocars. J Laparoendosc Adv Surg Tech A. 1998
Feb;8(1):47-52 Involves regulatory, ethical, medical, legal and
economic issues 31. Reprocessing the Disposable Instruments For
Economy Issue Environmental Issue Against Risk of Cross infection
Difficult to clean Inadequate disinfection Prions Material and
Mechanical failure Patient Safety Issue Legal Issue Who is to be
blamed? 32. 2006 Kaiser Permanente Health Plan, Inc. *Reprinted
with permission from: Muscarella LF, Automatic Flexible Endoscope
Reprocessors, Gastrointestinal Endoscopy Clinic of North America,
2000 April;10(2):245-257 Reprocessing Algorithm* Reusable? Discard
after initial use Thoroughly cleaned? Heat sensitive? Pressurized
Steam or Dry Heat Sterilization GasPlasma Sterilization Long, thin
lumens? Just-In-Time Liquid Sterilant No NoNoNo Yes Yes Yes Yes 33.
Sterilization & Disinfection of Laparoscopic Equipments
Practical Guidelines Soak them early and wash them well Cleaning is
critical Choose the appropriate sterilization method Choose the one
that suits you Monitor the Sterilization Process Ensure reliability
& Safety. Maintain Wound Infection Register. Always be on the
look out for any trouble.
