Surgical instruments

A surgical instrument is a specially designed tool or device used to perform specific actions during various medical procedures and operations. Over time, many different kinds of surgical instruments have been invented. Some surgical instruments are designed for general use in surgery, while others are designed for a specific procedure or surgery.

 

Most surgical instruments are made from stainless steel although other metals are also used. Most are also designed to be reusable and because of this they need to be able to withstand thorough cleaning and sterilisation (known as decontamination) before reuse.

 

Effective decontamination of re-usable instruments is essential for the prevention of the spread of infection both in subsequent patients and for staff handling the instruments.

 

Current procedures used in the NHS are extremely effective at decontaminating surgical instruments from pathogens, such as bacteria and viruses, reducing the risk of transmission of disease and infection to patients and staff.

 

However, in 2000 the Spongiform Encephalopathy Advisory Committee (SEAC) identified a theoretical risk of transmission of variant Creutzfeld-Jacob Disease (vCJD) from instruments used for surgical procedures. The disease-causing agent of vCJD is an abnormal prion protein, rather than a bacterium, virus or fungus. Unfortunately, this abnormal prion protein appears more resistant to the techniques used for the decontamination of surgical instruments.

 

In patients with vCJD, the abnormal prion protein is mainly concentrated in the brain and spinal cord; however it has also been found in some of the other body tissues, such as the tonsils, spleen and lymph nodes. As the disease can take many years to develop, it is also a concern that the abnormal prion protein may be present in the body tissues of seemingly healthy people. It is theoretically possible that during surgery on such individuals, this prion protein may contaminate surgical instruments and may not be adequately removed during decontamination, presenting an infection risk to subsequent patients.

 

Adenotonsillectomy procedures (the removal of tonsils and/or adenoids) were identified as carrying a high risk for the transmission of vCJD between patients via reusable surgical instruments. This type of surgery is often performed on children and young people, presenting a small, and as yet, theoretical risk of developing vCJD later on.

 

As a result, all adenotonsillectomy surgery discontinued within the UK in 2000 for a short period.

 

In 2001, single-use instruments were introduced by the Department of Health in response to concerns by SEAC, but were withdrawn shortly afterwards due to major problems with their supply and quality.

 

NHS Trusts in England and Northern Ireland returned to using reusable instruments, accepting the theoretical risk of vCJD. However, in Wales, adenoid and tonsil surgery ceased for all but emergency cases on the recommendation of the Chief Medical Officer (WAG) until surgery with single-use instruments could be a feasible proposition.

 

In 2003, the Welsh Assembly Government announced the recommencement of routine tonsil and adenoid surgery in Wales using a set of highly specified single-use surgical instruments procured after detailed comparison and analysis of such instruments from various suppliers. All adenotonsillectomy surgery in Wales has to be undertaken using only these specified single use steel surgical instruments and these are monitored through the NPHS Surgical Instrument Surveillance Programme (SISP).

 

The mechanism to deliver safe surgery in Wales, and free of risk from vCJD, resulted in the establishment of the NPHS Surgical Instrument Surveillance Programme (SISP) in 2003.

 

The surveillance programme monitors all tonsillectomy and adenoidectomy surgery performed by NHS hospital Trusts in Wales (and associated private hospitals) with the specified single-use steel instruments. The aim was to record what happened during surgery and to determine if surgery with single-use instruments was as safe as surgery with the equivalent reusable instruments, and thereby, provide reassurance of safe practice to the public and healthcare professionals. Careful monitoring of their introduction and of their continued use in Wales is essential.

 

The SISP has been fully established for over four years and during this time the surveillance has gathered information on over 182,000 single-use tonsillectomy instruments with approximately 19,000 operations recorded in the database to date.

 

More information about SISP will be available from the NPHS Health Protection website shortly.