Curating the retina surgical tray

“Time inside the eye” is the main criterion when selecting tools.

By Jorge I. Calzada, MD, FACS

The key to high-volume and high-complexity vitreoretinal surgery is efficiency. A surgical case that wastes the time and efforts of the surgeon and staff can lead to many deleterious consequences: an anxious patient under the drapes if he’s under local anesthesia; surgeon and assistant stress; and miscommunication among surgical team members.

The key to achieving surgical efficiency is avoiding getting TIEd.

The “time inside the eye” (TIE) concept implies that the longer a surgery lasts, the likelihood of surgical difficulties and complications rises exponentially. The surgeon and surgical team that minimizes TIE per case positions themselves to increase — with less perceived effort — their volume of surgical cases and their volume of more complex surgical cases. Higher surgical volume will beget improved surgical-team skill sets and better overall surgical outcomes. As a corollary, the surgeon and surgical team must:

• Strive to reduce unnecessary surgical delays

• Distill the surgical goals of a procedure

• Eliminate superfluous surgical techniques or maneuvers

• Concentrate on what leads to the defined surgical goals in the most direct plan

• Divert from said goals only to verify that no complications have been incurred (e.g., viewing the retinal periphery to ascertain the presence of peripheral tears).

Within the provided conceptual framework, the surgical team should work to improve every detail of the procedure and operating room, especially the contents of the surgical tray.

Get standardized

Although it’s common for surgeons to desire much flexibility in their instrumentation choice, the more standardized the processes and instruments a surgical center can have, the fewer problems with maintaining the instrument inventory.

For example, our surgical center has agreed to stock only 25 g vitreoretinal instrumentation for standard cases. Not having to keep 23 g or 20 g instruments intrinsically improves inventory management and decreases staff errors or delays.

Instrumentation

For the sake of organization, we classify the vitreoretinal instruments that we use in our tray into the following:

• Ocular surface instruments

• Plug forceps

• Large ocular surface forceps (Bishop forceps)

• Small ocular surface forceps (0.12-mm toothed forceps)

• Small needle driver

• Visualization and illumination

• Flat irrigated handheld lens

• Wide-angle handheld lens

• Disposable 25 G endoillumination probe

• Noncontact, wide-angle visualization system (not usually used in our center)

• Vitreous cutters and vitrectomy cassette disposables

• Retinal surface instruments

• Disposable membrane peel forceps

• Disposable retinal scissors

• Disposable aspiration cannula

• Retinal laser probes

• Disposable straight and curved endolaser probes

• Anterior-segment instruments

• Phacoemulsification and IOL implantation instruments

• IOL manipulation hooks (Sinskey and Kuglen hooks)

• Foreign-body forceps

• 20 g diamond-coated reverse-action foreign body forceps

• Scleral buckling instruments

• Orbital retractors

• Suture clamps

• Large scleral needle drivers

• Muscle hooks

Just some of Dr. Calzada’s instrument choices.

This list covers the majority of cases encountered on a regular basis.

Foreign-body forceps, since used infrequently, are not on our standard trays. Inclusion of anterior-segment instruments on the retina tray depends on whether the retina surgeon performs anterior-segment techniques with or without the involvement of an anterior-segment surgeon. We do not regularly keep a full set of anterior-segment instruments in the retina tray.

Disposables vs. reusables

One important issue in acquiring surgical instruments is whether to use disposable or reusable instruments. The main benefits of reusable instruments are quality and cost amortization over many cases. The drawbacks of reusable instruments are high initial cost of purchase, the need to sterilize and damage to delicate tips over time.

Modern manufacturing techniques allow disposable instruments with very high-quality handles and tips. Since the highest expense in most surgical centers is personnel and time, we feel that these costs often offset savings attributed to reusable instrumentation. Therefore, all retinal forceps, scissors, endolasers and knives in our center are disposable. We standardize a quickly accessible location inside the operating room where we keep these instruments, and they are only opened if the surgeon specifically requests them during the procedure. We do not open any disposables in advance, regardless of how a case has been booked, since many times intraoperative needs are different than assumed preoperatively. Needle drivers and larger ocular surface forceps are sturdy enough to be used repeatedly without difficulties and are rarely encountered as disposable. An additional benefit of disposable instruments over reusable instruments is that every case is performed with nearly equivalent instruments. If an instrument is dropped or bent, or if it’s defective from the pack, then all that is required is opening a new set.

With respect to a dropped or contaminated reusable instrument, replacements are always required. Reusable instruments may also decline slowly over time in functionality, making the surgeon work harder to achieve the surgical goal without asking for a replacement instrument.

Visualization, organization

Visualization optical systems are critical for vitreoretinal surgery, both for macular dissections as well as peripheral vitrectomy techniques. Noncontact visualization lenses attached to microscopes provide excellent surgical views, but in our opinion these do not match the intraoperative view through contact lenses. That said, the main disadvantage of contact lens systems is the need for a trained assistant who can hold the lenses. In the absence of a trained assistant, noncontact lenses are required. As mentioned in the introduction, high surgical volume provides the opportunity to train assistants properly.

And a few more of Dr. Calzada’s instruments and surgical necessities.

The Mayo stand should be organized with only those instruments that are regularly used during the procedure. Including rarely used implements creates confusion and clutter.

On replacement and evaluation

For surgeons who are comfortable with their techniques, it’s too easy to avoid trying new instruments. But, to challenge our preconceived notions and to explore new ideas and techniques is the basis for advancement in the art of surgery.

To drop the security blanket sheltering the known and customary, try new instruments at meetings, in wet labs or in the operating room.

New purchases: Cost/benefit analysis

As mentioned above, the biggest cost drivers in modern operating rooms are time and personnel. Failing to consider these bigger dynamics when evaluating new instrumentation costs is shortsighted.

An instrument that requires less time to clean and maintain will decrease surgical and personnel time to do so; hence it often will be cost efficient. Yet it is often difficult to make any calculations to see just how cost efficient an instrument is. While management staff can create spreadsheets showing instrument costs and amortization, they rarely provide the larger context of time efficiency per instrument. Surgeons and management staff should not forego cost analyses. Rather, use such numbers as guides and comparisons while considering time and personnel efficiency when making purchasing decisions.

Conclusion

We are at a high point in the history of vitreoretinal techniques and instrumentations. Proper surgical instrument selection and OR organization is needed for surgical teams to take advantage of this technology, while keeping budgets and costs within profitability margins. This allows surgical centers to thrive and continue providing high level surgical care to patients. OM

About the Author
	Dr. Jorge I. Calzada is a vitreoretinal surgeon and president of Charles Retina Institute in Memphis, Tenn. He specializes in macular diseases, complex retinal detachment repair and pediatric retina surgery.