What musical instruments require surgical implants

Introduction. 1.1 History of instrument manufacture Materials of surgical instruments Standardization Surface quality 10


1 Introduction. History of instrument manufacture 3.2 Materials of surgical instruments 7.3 Standardization 9.4 Surface quality 0.5 Instrumentation 0.6 Basic rules

2 2 Chapter Introduction An essential part of the work of the OR nursing staff and the surgical technician assistants (OTA) is, in addition to the important activity of the unsterile room assistant, to take over the instrumentation during operations. For this, it can be expected that the nursing staff in the operating area know the instruments and their intended use and can correctly prepare the necessary instruments for each planned operation. Precise preoperative diagnostics mean that the operations can be precisely planned. As a result, the preparation can usually be specified in standards and can be read easily. The preparation of the container sieves is only a small part of the work of the instrument operator. Before the materials are prepared in a sterile manner for an operation, the sterility of the instrument containers is checked, and the number and functionality of all instruments are tested. All materials that are used in and on the patient are prepared, documented and approved for use by the operating theater staff. The nursing staff can be expected to name the instruments, make them available in the correct manner, and hand them to the surgeon in such a way that they can be used immediately. It is desirable that the instrument operator knows the course of the operation so well that he knows in advance which instrument will be required. Insight into the surgical field to recognize the anatomical structures helps to draw conclusions about the progress of the operation. In this way, the required instruments can at best be handed over without being asked. Each instrument has been manufactured for its specific use and it can be recognized by certain criteria for which use it is suitable. The names of the instruments result either from their function, their inventor, their manufacturer, but also from their shape, the organ or their properties. Since in some clinics individual instruments have also been given proper names, it is particularly difficult for new employees to take over the instrumentation. If its function can be derived from the equipment of the instrument, however, it is much more comprehensible. In difficult surgical situations in particular, it must be expected that an instrument can be used without a name. The reprocessing criteria must be known, even if the reprocessing is usually carried out in the central sterile goods supply department (CSSD), because this knowledge results in responsible handling of the valuable instruments. They represent a significant financial value that can be preserved for a long time through knowledge in many areas. > We can only implement without problems what we understand and know. You can only work efficiently if you know what you are doing and keep track of every situation. In most cases, instruments are provided in specially equipped sieves in the container and, if necessary, expanded with individual instruments. Each sieve is equipped according to the house standard and this standard is

3 3. History of instrument manufacture binding. It should be noted that the weight of the container must be easily manageable by each employee. This book is intended to provide insights into the manufacture of instruments, the naming of the individual instruments, information on preparing the instrument tables and help to ensure that the instruments are handed over without complications and stress-free. Only a few instruments can be named as examples and the names do not always correspond to those mentioned in the catalog, especially since different manufacturers use different names. Continuous technical innovation leads to the production of multifunctional instruments and mechatronic systems, which cannot be mentioned here. History of instrument production Hannelore Schlautmann The history of instruments goes hand in hand with the development of surgery. What does the word "surgery" actually mean? The word comes from the Greek and means: "to make by hand". Since the beginning of human history, healing men and women have endeavored to rid others of illnesses and to treat injuries. With all of their senses - sight, touch, taste and hearing - they have tried to recognize and treat diseases, and they have often used instruments to help them. Stone Age bone finds show healed fractures, which were probably stabilized with splints. Skull trepanations have been successfully performed by healers, as demonstrated by the healed drill edges on skull finds. Extensive medical knowledge was already available in the pharaohs' empires; around 2500 years ago, over 200 different instruments for performing operations were known there. From the time around 700 BC come from the Edwin-Smith Papyrus and the Ebers Papyrus. They contain initial descriptions and instructions for wound treatment and wound healing. The writings of the Greek Archimatheus from the year 00 BC. are some of the earliest sets of rules for medical conduct. The Amazons of Greek mythology had their breasts amputated in order to better pursue their craft of war with a bow and arrow, so there must have been instruments and surgical methods for this. Instruments were made of stone and bone. Archaeological finds show that as early as 500 BC Plant fibers, animal tendons and the biting tools of large ants were used in various cultures to close wounds. Hippocrates of Kos was around 460 BC. Born on the Greek island of Kos and died around 370 BC. in Larisa. He is considered the most famous doctor of ancient times and the founder of medicine as a science. 6 writings are assigned to him, but they are between 400 BC. and

4 4 Chapter Introduction 00 n.chr. which of them were written by himself is unclear. Hippocrates explains illnesses with an imbalance of the four body fluids (blood, mucus, yellow and black bile) and suggests a change in living conditions, diet, medicines and surgical interventions such as bloodletting and cupping for healing. After the fall of the Greek Empire and at the beginning of the rise of the Roman Empire, more and more medical knowledge came to Rome with Greek doctors. Greeks like Heliodorus and Japyx were very influential. During the countless campaigns of Rome, doctors gained great knowledge, and military doctors became the best surgeons. The motto of the Roman generals was: "The best surgeons for the best legions". An eight-volume encyclopedia "De medicina", which was written by the Roman doctor Cornelius Aulus Celsus (around 25 to 50 BC), shows the surgeons' high level of knowledge. Excavations from Pompeii give us an insight into the history of instruments. The city was founded in an eruption of Mount Vesuvius on August 24th in the year 79 BC. buried under a six-meter-high layer of ash, lava and rubble. In the year 77 a large package with surgical instruments was found during excavations in a house. Instruments made of metal have already been used here, which are not dissimilar to those in use today. The first double-ended instruments also date from Roman times. But medicine was not only developed in the West, doctors researched and healed, and wars were waged in the Orient. We know from early Arabic writings that a short time after the introduction of Islam, medical knowledge was already at a high level; there were hospitals, doctors and nurses who had to provide evidence of training and who had to follow certain standards. In Cairo, for example, For example, in the Qalawun Hospital, a hospital for almost 8000 patients, cataract operations were carried out with sharpened metal tubes in the early Middle Ages. During the Middle Ages, medicine in Europe included the experience of the ancient naturopaths and the medical knowledge of classical antiquity (around 200 AD, Galen made a decisive contribution to a renaissance of the teachings of Hippocrates). Above all, however, it was unconditional belief in saints that was supposed to cure diseases. Medical knowledge came to Europe with the crusaders, but its transmission was made difficult by church dogmas and decrees. In the eyes of its representatives, church teaching contradicted research and experimentation on people. The dissection of corpses was forbidden to protect the human soul and targeted learning about the relationships in the human body was made more difficult. The result was scholastic medicine (theoretical textbook medicine) with its theoretically highly educated, but practically only conditionally capable and successful doctors who, however, enjoyed a high social reputation. Far below them in the social hierarchy were surgeons and bathers, who acquired practical knowledge during the frequent wars

5 5. Acquired the history of instrument manufacture, as well as barbers and blacksmiths who provided the common people with surgical interventions such as tooth extractions and abscess splitting. The executioners were the least respected, but because of their work, they often had excellent anatomical knowledge. In the course of time, however, the resistance of the Church eased and research and discovery were carried out. Evidence of this is, among many others, the anatomical drawings of Leonardo da Vinci (452 ​​to 59) and numerous surgical textbooks written in the 6th and 7th centuries. Instruments for medical use were made by gunsmiths and cutlers. While natural materials such as bones and stones were used in the early history of surgery, bronze was added later in the form of cast and wrought bronze. The more metal finishing developed, the more the composition of the instruments changed. Instruments made of brass and copper were followed by forged ones made of ferrous materials, which were protected from corrosion by metallurgical processing, an important requirement in the introduction of asepsis. Due to a further requirement, namely to manufacture instruments that were easy to clean, elaborate decorations made of ivory, precious stones and precious metals, as they were previously common, had to be dispensed with. In the 9th century, Ignaz Philipp Semmelweis (88 to 865) was the first to discover the cause of childbed fever and introduced thorough hand washing and disinfection of hands with chlorine for doctors and students. Joseph Lister (827 to 92) found that germs contained in the air caused sores and introduced the disinfection of the entire operating area, the instruments and the bandages with carbolic in order to reduce the growth of germs. He is considered the founder of antiseptics. After these pioneering discoveries in the field of hygiene and after pain could be successfully combated during operations with ether, chloroform and nitrous oxide (842 to 844), a rapid development began in the field of surgical techniques and, at the same time, instrument manufacture. Medical development in the 9th century was shaped by many doctors Theodor Billroth (829 to 894) Robert Koch (843 to 90) Bernhard R. K. v. Langenbeck (80 to 887) Robert Liston (794 to 847) Cesar Roux (857 to 98) Curt Schimmelbusch (860 to 895) Ignaz Philipp Semmelweis (88 to 865) Joseph Lister (827 to 92) Rudolf Virchow (82 to 902)

6 Chapter 6 Introduction You have developed and shaped important instruments such as hooks (Langenbeck, Roux), clips (Billroth) and scissors (Liston) and given them their names. These instruments are still part of the basic set of instruments today. In the 20th century, the advancement of technology also changed surgery. Many technically sophisticated devices made activities easier, the development of robots operated by the surgeon changed the operations and the tasks of the OR team. Nevertheless, operations are always carried out "by hand" Robots have to be controlled, intestinal anastomoses sewn by hand or performed mechanically using a stapling device. However, this is not possible without preparatory steps by the surgeon. In trauma surgery, saws, hammers and chisels are still used, which look quite similar to the ancient models. Surgery and handicrafts, tools and instruments are always associated with each other in their development and can only be viewed together. Like any good craftsman, a surgeon needs manual dexterity, technical understanding and creativity. In order to be able to work successfully in his profession, every craftsman has individual tools in which he invests a lot of money and which he treats with care. This is particularly true in the medical field. The selection, use, care and precise knowledge of the instruments are part of everyday life for all doctors and nurses in the functional area of ​​clinics and medical practices. With the industrial manufacture of instruments, new job profiles from the professions cutlery and precision mechanic appeared in 939 that of the surgical mechanic. He manufactures and maintains medical-surgical and cosmetic instruments, implants and medical devices. Surgical mechanics work in medical technology workshops, but also in industrial companies that manufacture medical instruments (Fig.). The direct contact between the surgeon and the instrument manufacturer is still important, because the requirements for surgical instruments are still largely defined by the users. This is how ideas come from practice for practice. Today, ever better instruments and devices enable ever larger and more complex operations. Fig. Statue of a surgical mechanic (source Aesculap AG, artist: Roland Martin) The following are among others: Erich Lexer (867 to 937) Harvey Cushing (869 to 934) Ferdinand Sauerbruch (875 to 95) Michael debakey (908 to 2008) Denton A. Cooley (920)

7 7.2 Materials used in surgical instruments for wound closure Closure of wounds has always been a concern of doctors. Already 500 BC wounds were closed with plant fibers, linen thread or animal tendons. In ancient times and in the Middle Ages, people used gut strings for musical instruments and as bowstrings, but also to close open wounds. In the 6th century, catgut, a thread made from sheep's intestines, was used. In 908 the first industrial suture material production was carried out in the B. Braun company. But it was not until the 1970s that the first braided (multiple filaments), fully absorbable, synthetic suture material was developed, and in the years 98 to 984 a monofilament (single filament) synthetic absorbable suture material was also developed On the world market there is a very large range of stainless steel types made from a wide variety of alloys. However, only very few meet the high standards for the manufacture of medical and, in particular, for the manufacture of surgical instruments. Because these are subject to the highest loads in use and must perform their task correctly. To ensure this, high quality standards apply to the production of the surgical instruments. So z. For example, it is expected that tweezers and clamps will retain their elasticity for a long time; chisels and scalpels should be able to cut over the long term and not break. During use, the instruments are exposed to a wide variety of chemical (body fluids, cleaning agents and disinfectants), physical (pressure, leverage) and thermal (disinfection, steam sterilization 34 C, high-frequency surgery approx. 000 C) influences. The challenges that this poses for manufacturers in the search for and development of appropriate materials and manufacturing processes are enormous. Surgical instruments are made from a variety of metals, metal alloys, plastics, and ceramic materials. All these materials are tailored to their respective intended use in accordance with the latest state of technology and research, and are certified according to DIN, ISO and EN (Section 3). Plastics and hard tissue can be found e.g. B. as hammer handles, on ear specula, endoscopes, as insulation on instruments, as glue and sealing material use. We find ceramic materials in implants for trauma surgery and orthopedics, and glass in optics. The main part of the materials, however, are made up of the various metals. All are subject to international standards and are specially processed and alloyed according to their use, i. That is, they contain metals, carbon or other chemical substances in different proportions. These additives influence, among other things, their strength, elasticity, rust resistance, electrical conductivity and of course their price.

8 8 Chapter Introduction The most frequently used steels for instruments and implants are chromium, nickel and molybdenum, which are responsible for rust and corrosion resistance, titanium but also copper is processed. Copper is used in the jaw parts of some needle holders, but also as an additive in steel connections.Titanium is increasingly used in different alloys because of its special hardness, but also because it does not cause allergies. When processed, titanium looks matt, bright metallic, shiny. Instruments and implants made of titanium are light but still strong, corrosion-resistant, flexible and slightly magnetic. Due to the complicated manufacturing process, titanium parts are about 0 times more expensive than comparable steel parts. Titanium was discovered in 79, but large-scale industrial production has only been possible since 940. Titanium alloys are often characterized according to the US standard ASTM (American Society For Testing and Materials) comparable to the German DIN standard. > Pure titanium has the material number The most common titanium alloy on the market is Ti6Al4V. We encounter titanium as an implant in dentistry (cheaper than gold, lighter than steel), orthopedics (as a joint replacement and osteosynthesis material), neurosurgery (more favorable magnetic properties than steel) and as microsurgical instruments (which do not lose their delicate properties even in the autoclave Sharpen). A titanium coating is also used on instruments used in plastic surgery and cardiac surgery. After grinding, the instruments are coated with titanium in order to retain their special sharpness for longer. In addition to the classification according to material number, each steel is also given a short name that is based on what the steel is to be used for. It is also common to classify steels according to their chemical composition. Chemical abbreviations for material abbreviations: Cr Chromium Mn Manganese Mo Molybdenum Ni Nickel N Nitrogen S Sulfur V Vanadium Ti Titanium An example for understanding: The steel with the material number 430 and the short name X5CrNi80 is the well-known V2A steel The X stands for a high-alloy steel ( Stainless steel) The number 5 for the carbon content, here 5%

9 9.3 Standardization The letters Cr and Ni for the chemical elements chromium and nickel The number combination 80 for the amount of 8% chromium and 0% nickel added to the pig iron The terms austenitic, ferritic and martensitic steel provide information on the stress and strain of the corresponding types of steel so martensitic steels z. B. used because of their hard character in the manufacture of scissors, knives and cutting pliers, among other things, austenitic steels, however, are specially heat treated, which gives them z. B. gives resistance to alkalis and acids. Austenitic steel is used to manufacture containers, bowls, retractors and the like. Some instruments have a special hard metal insert made of a chromium-tungsten alloy, which increases the service life and functionality due to its hardness. These instruments are marked with a gold handle (chapter 4). Implant steels are used for steel implants (e.g. endoprostheses, plates, screws), but also for the instruments with which the implantation is prepared, such as drills or milling machines. Here, too, particularly pure austenitic steels are used, since implants have to meet special requirements. They have to withstand high dynamic loads, they must not be magnetizable and they must not offer any contact surface to any tissue fluids..3 Standardization Standardization is the basis for standardization and quality assurance. It is not an invention of the modern age. Bricks were standardized in ancient Egypt, the Romans had standard dimensions for their water pipes and in the 5th century standardized individual parts were used in shipbuilding in the Republic of Venice. In order to ensure that the various high-quality steel types used in industry have comparable qualities, they are subject to a basic standard, the DIN Surgical instruments are processed in a standards committee "Precision Mechanics and Optics" (NAFuO) NA 027. The German Institute for Standardization e. V. guarantees with its test procedures the comparability of the different worldwide standards, i. This means that DIN standard 7442 for instrument steel in the Federal Republic of Germany is the same standard as in Singapore, provided a manufacturer has undergone the German standardization process. The DIN standard 7443 applies to stainless steel for surgical implants, which are subjected to different tests than those for general instruments. At the European and international level there are other organizations that focus on the standardization and thus the comparability of

10 0 Chapter Introduction have made raw materials, manufacturing processes, finished products and applications their task at the European level this is the EN (European standard) and at the international level we speak of ISO (International Standards Organization). When purchasing new goods, the DIN or ISO numbers provide clear information on materials, design and test requirements, among other things. They make it easier for B. the technical comparison at international level. Every standard must be reviewed every 5 years. Depending on the result, the standard will be confirmed, revised or withdrawn..4 Surface quality So that the instruments do not dazzle the surgeon from the bright operating room light during the operation, the surfaces of the instruments should be matted. After an instrument has been manufactured, it is given this matt finish either by sandblasting or matt brushing. During sandblasting, the polished surface of the instrument is dented by the bombardment with tiny glass beads and becomes matt. The gold-plated rings at the working end of an instrument show that this instrument has a hard metal insert (chapter 2) in the instrument mouth. This edition is made of pure gold. This prevents z. B. Corrosion can occur due to chemical reactions during reprocessing..5 Instrumentation Margret Liehn The instrumentation of a surgical procedure requires a lot of knowledge. The instrument operator is familiar with the anatomy as well as the planned course of the operation. From the anatomical position, the structure of the organ and the planned operation, it can often be deduced which instruments are needed in particular, how they should be shaped and which special grooves are required. In order to be able to hand over instruments quickly, purposefully and with foresight, the site must be visible and the instruments must be clearly structured and accessible. However, you have to practice beforehand to work equally with both hands, because with one hand an instrument is handed over, with the other hand the one previously used is removed. Most people have one preferred hand and the other, mostly the left, has many things to learn first. The following exercises can help to train the second hand (the information applies to right-handers): Brushing your teeth with your left hand Using the knife while eating with your left hand Eating the soup also with the spoon in your left hand

11 .6 Basic rules Use of scissors with the left hand, right-handed scissors can also be used with the left (!) Brush the hair with the left hand Here there are many examples that could help to train the second hand to to facilitate handing out with the left hand during instrumentation..6 basic rules Every employee must have knowledge of the contents of the instrument container; if necessary, an internship in the CSSD helps during the familiarization period. Instruments are prepared in a standardized way for the planned operation (Chapter 7). The structure of the instrument table as well as the side tables is regulated by binding standards for every employee, which facilitates intraoperative detachment, which can be possible at any time. Basic sieves contain the instruments that are always required, so the content varies in the specific surgical disciplines. In addition, there are special sieves, if necessary individually packaged additional instruments and disposable materials. All instruments that are required in a standardized way for the planned operation are ready on the instrument table, everything that may be required is on the additional table. The sieves are laid out on one or more additional tables and only what is needed is removed. If the planning changes intraoperatively, the instrument operator must have instruments ready during the ongoing operation and, if necessary, request new instrument containers. In the operating theater departments, it is handled differently, whether the instrument operator with his used gloves can reach into the clean sieve during the procedure in order to have additionally required instruments ready, or whether a pair of forceps has to be laid out. Since all instruments prepared for the operation must be processed in the same way in the CSSD, both are possible. The functions as well as the names of the instruments are known, because everyone on the surgical team must speak the same language so that there are no avoidable delays or even errors. Many instruments look deceptively similar and yet have different names and tasks. Knowing the shape and the profile often makes the task clearer, but it can still happen that one surgeon uses the same instrument differently than another surgeon. If this goes hand in hand with the intended use of the instrument, this is not a problem. In addition, there are the preferences of the individual surgeons for certain, known tools that should be taken into account. In the best case scenario, the required instrument is handed over without being requested by the surgeon, but always promptly and in such a way that the surgeon immediately grips the rings or the handles of the instrument

12 2 Chapter Introduction can without having to re-grasp. To do this, the instrument must be observed until it has reached the surgeon's hand. If he can work immediately without turning the instrument, the instrumentation was correct. This requires some practice, because the surgeon usually faces the instrument operator and it is difficult at first to make it clear how the instrument has to be handed over in order to be able to be used immediately.