In the motion picture Major League, the egotistical game announcer constantly belittles his sidekick in the booth with the phrase, "Less is more." I believe that this same mantra easily applies to the cataract surgical tray of the 21st century.

With the advent of new surgical techniques and the need to maximize both efficiency and surgical outcomes, we need to revisit how we use our trays. Our goal now should be to produce the best surgical result in the shortest time possible, creating a happier patient, in the short and the long term.

The swifter case times can result in better outcomes, reduced risk of complications and more satisfied patients. Here�s how I�ve been managing this important aspect of surgical planning.

First: observe your assistants

I decided to observe my assistants several years ago as I watched different scrub techs at our hospital fumble through the various tiny instruments on my tray in semi-darkness, trying to distinguish between a chopper, Y hook, iris spatula, cyclodialysis spatula, etc. (Hey, after age 40, and in the dark, they do all look alike!) On top of that, the instruments were carefully protected in those rubber finger mats, where you can�t really see what the instruments are without picking them up out of the bottom and looking at them, one at a time.

Most of the instruments on the tray were being used less and less frequently. I had quit suturing routinely back in the early 90�s, and had abandoned the superior rectus suture about the same time. Phaco and clear corneal incisions removed the need for a whole host of other instruments. No longer did I routinely need large and small needle holders, Wescott and Vannas scissors, tying forceps, curved corneal scissors, Gill knife, cautery tip and cord, lens loop, muscle hook, etc.

Not only did these extra instruments clutter the tray, making it difficult to quickly find the instruments I most often needed, but we were needlessly exposing instruments to repeated autoclaving, reducing their lifespan. But the problem was that sometimes I did need to suture a wound, or even face the dreaded conversion to an extracapsular approach. On occasion, those infrequently needed instruments could become an eyesaver.

Creating a second tray

We toyed with the idea of wrapping the infrequently used instruments in "peel-packs." Unfortunately, when we really needed a specific instrument, that day�s circulating nurse, who primarily worked in orthopedics, had a tough time finding what I wanted in a timely fashion (i.e., right now!).

We then moved to our current concept of the "second tray." The second tray, packaged in a sterile manner, has one of almost every instrument I might need in the event of an unconventional event during surgery. If we do need to suture, all the instruments I need are in that second tray. The only instruments peel-packed are backups for what we commonly use.

Our current "main" tray is incredibly simple. It contains two diamond knives (for the side port and main incisions), dressing scissors, a lid speculum, chopper, phaco handpiece, and an I&A tip. Disposables include two syringes, two 27g. cannulas, and a bent capsulorrhexis needle. Add viscoelastic and an IOL/injector and the tray is complete.

Putting the instruments to work

My current procedure, using the instruments I mentioned, is efficient and produces excellent results.

After prepping and draping, the scissors are used to cut a slit in the drape parallel to the lid margins. The lid speculum is placed, allowing isolation of the lashes under the drape. With the microscope positioned, and while the patient looks at the light, I make a side port incision with a 1-mm wide diamond knife. This knife is sharp at the tip, but the sides of the shaft are dull, allowing the knife to fixate the globe while the single plane corneal wound is constructed with the other hand.

Both knives are then withdrawn. Nonpreserved 1% lidocaine is injected through the sideport incision. (Over 99% of our cases are done under topical.) Viscoelastic is then injected through the corneal tunnel to quickly displace aqueous. I use the bent needle to construct a relatively wide capsulorrhexis, followed by hydrodissection of the cortex from the capsule.

If chopping (I also do the phaco flip technique), I bury the phaco tip into the central nucleus and perform the "quick chop" maneuver. Irrigation and aspiration of the cortical remnants follow. Viscoelastic is reintroduced to inflate the capsular bag, and the implant is injected into the eye. The viscoelastic is removed, and the wound sides are hydrated. The lid speculum and drape are removed, and the patient is rolled out while the room is quickly turned over for the next case.

Silence is golden

During the procedure, my scrub tech and I rarely talk about the surgery. She watches the progress on the monitor and knows what I need, usually without asking. By the way, we don�t even have an assistant�s scope on our microscope. It�s very difficult for the scrub tech to try to keep everything straight and also watch the case through the scope. Watching the case via the monitor is easier for her, as well as for everyone else in the room. Because she knows what I need next, I�m able to keep my fixation on the eye where it should be.

Here�s another neat trick I learned from David Brown, M.D., and his Surgicare Director, Gina Stancel, from Fort Myers, Fla. Remember those annoying rubber finger mats I mentioned? Those blue rubber pads with the vertical extensions that keep delicate instruments from touching each other? They do help to protect the instruments, but they�re not user friendly when it comes to finding the instrument you need and getting it out of the tray.

Gina recommended inexpensive baking trays (you can get them at Wal-Mart) with an equally inexpensive foam liner added to the base. The instruments for the day are simply and carefully laid out on the tray.

You can visualize everything, and the instruments are easier to grasp. Of course, you can�t sling it around too much, but that was never a good idea with the old system either.

I highly recommend the Statim autoclaves distributed by several companies. These relatively small autoclaves can hold a typical cataract tray and completely cycle through in 9 minutes. They are much cheaper than the big autoclaves, and maintenance is much simpler.

Alternating trays

To achieve our goals, we use three complete "main" trays, which we alternate throughout the day. The trays are sterilized in the autoclave, then removed by the scrub tech and placed on the surgical back table in the operating room.

After a sterile drape is placed over the phaco machine table extension, the tray is transferred onto the drape, and I use instruments from that location. Instruments are irrigated clean by the scrub tech as the surgery proceeds.

At the close of a case, the tray is taken back to the autoclave for sterilization. A fresh tray is retrieved and the cycle continues until we�ve completed all of our cataract cases for the afternoon, usually about 10 cases.

The right setting

Besides streamlined instrument trays, another big factor has contributed to our success � getting out of the hospital and into a surgery center.

I formed a multispecialty surgery center with four other doctors in our community last year. Now I have the same scrub nurse and circulator almost every day. (We do have good backups for vacations and illnesses.) Things stay properly cleaned and maintained, and stuff just doesn�t get lost when one person is responsible.

Also, since we�ve moved to the surgery center, diamonds don�t break as often. I handle diamonds a little differently than is usually recommended. Because I trust my scrub tech completely, she hands me the diamond knives, one in each hand, with the diamonds exposed.

I make the incisions and hand the blades back in the same manner. I�ll grab the next instrument off the tray and proceed with the case while the tech immediately rinses and then retracts the blades.

Because of this immediate rinsing, no extra care is required to keep the diamonds clean. We�ve done this in more than 1,000 cases without seeing any evidence of staining or other changes in the diamonds.

Simplifying is the key

I hope this article will help you in simplifying your cataract surgical tray. You�ll achieve greater efficiency and a streamlined process. I�ve come to the conclusion that just as it is with life in general, less is in fact more in surgery. OM

How Instruments Fit into Our Multispecialty Surgery Center

Our surgery center is about 5,000 square feet, with two major operating rooms (O.R.s), one minor procedure room and a YAG laser room. Besides me, we have general, orthopedic and plastic surgeons at the center.

The center is new, so we�re only using one of the major O.R.s for now. However, because of increased efficiencies, including those I mentioned in the main article, we can perform up to six cataract surgeries per hour.

We can accomplish this because fewer surgeons are involved than you�d find at a typical hospital. The types of procedures are also limited, so keeping up with surgical instrumentation is easier.

For example, we don�t try to have a totally separate tray for every doctor in each specialty. The general surgeons sit down and decide what they really need in their trays to avoid the same problems we�ve tried to eliminate in cataract surgery.

Most instrument trays for all specialties fit nicely in a room very close to the O.R. Our surgeons remark that case turnover for them allows them just enough time to dictate the operative report and speak to the family. I�ve never heard that said in the hospital.

�Larry E. Patterson, M.D.

Why Put Instruments in a Baking Tray?

As mentioned in the accompanying article, we place the routinely used instruments on a foam mat in the baking tray. The instruments are simply laid out in a manner that is easy for the scrub tech to work with. I�ve experienced no instrument damage from this setup. We used to keep all the instruments in one large tray, and transfer the routinely used items onto a mayo stand. This newer process eliminates that extra transfer step.

�Larry E. Patterson, M.D.

Larry E. Patterson, M.D., is a cataract surgeon who operates at a new multispecialty surgery center in in Crossville, Tenn.