by Anne Reed

This article looks at types of surgical instruments to determine:

• When repair is more economical than replacement.
• What repairs are possible on minimally invasive instruments.
• How to decide when to replace an instrument.

There is great irony that in this time of heated debate over the recycling of single-use devices to cut costs, hospitals nationwide are discarding thousands of dollars worth of good reusable instruments annually. An old rule of thumb still prevails in the minds of buyers: If the repair cost of an item exceeds a minimum of 50 to 70% of its replacement cost, then it's smarter to buy a new one. Old habits die hard. Because of enhanced technologies in the repair industry and greater access to replacement parts than ever before, much of their equipment does not need to be replaced.

We all function under the misconception that new is better, and often that's true, especially when technological advances render a product obsolete. However, in the case of surgical instruments where physical properties rarely change, or endoscopes in which most functioning parts can be replaced, we shouldn't assume that "if I replace this item, I will also be upgrading it at the same time." The nature of the repair industry in the US has evolved considerably, bringing with it a number of opportunities unavailable until just a few short years ago. Consequently the criteria for deciding whether to repair or replace an instrument must also change with the times.

Historical Perspective
The technology of modern surgical instrumentation developed in Europe, more specifically in Germany. For generations, highly skilled cutlery craftsmen meticulously hand-forged instruments to the custom specifications of the physician/customer. During the industrial revolution, instruments were assembled in mass quantities to be offered for sale. Owing to a heritage rich in expertise and the use of the finest in raw materials, the technology of instrument manufacturing ultimately became embedded in Germany.

Early in the twentieth century, American surgeons began purchasing most of their instruments from Europe. Unfortunately, there were no support services stateside, so when an instrument was damaged or needed sharpening, the doctor had only two recourses - either throw it away and order a new one, or send it by boat to the European manufacturer for repair. It would take from a few months up to two years for the refurbished instrument to be returned, and with the limited number of instruments available to most doctors, this was more that a mild inconvenience.

Gradually, as the market for instrumentation in the US expanded, more European companies set up operations here to be near the customer base. This improved turnaround expectations, but because manufacturers' central focus was the initial production, early instrument repair efforts were seldom treated with high priority, and replacement was encouraged.

With this void in the service market, buyers looked for independent repair alternatives to create a new level of service that the manufacturers didn't offer. Today, as the industry has grown, so have the capabilities, and with greater access to replacement parts and repair technology, the practice of preserving an instrument indefinitely is more common than ever before.

Consider that surgical instruments are forged out of the most durable of metal alloys like titanium and martensitic 400-series stainless steel. Little can go wrong that can't be repaired economically, yet oftentimes, after an instrument has given a year or two of service with a minimum of maintenance work, buyers will elect to replace it when it breaks down. Usually, if the repair cost exceeds 50% of the replacement cost, replacement is automatic, but if executing the repair would restore the instrument back to its original condition, the facility would save the difference and still have the equivalent of a functionally new instrument with a renewed life expectancy. Compound this by the number of instruments a hospital owns, multiplied by the number of times a repair could "rescue" the instrument, and the savings would be substantial.

It's a change in mindset to seek repair first. There is a time when an instrument should be replaced and a reputable repair company will always give this advice. However, if the objective is to maximize the life of the facility's equipment, without compromising patient care or surgeon concerns, then one might consider an enlightened approach to equipment preservation for the ultimate in cost effectiveness.

Minimally Invasive Instruments
Endoscopic instruments for use in Urology, Arthroscopy, Laparoscopy, Gynecology, Bronchoscopy, ENT, and General Surgery are among the most costly in inventory, and by their very design, inherently easy to damage. There are more moving parts that are likely to break than in most instruments, and far more materials that are subject to disintegration. A knowledgeable repair source is a valuable asset. Until recently, minimally invasive surgical (MIS) instrument repair was virtually unknown because most of the original suppliers were distributors who purchased them from a variety of small instrument makers in Germany. Therefore, the only refurbish option immediately available was a trade-in-progam. Now, more of the MIS instruments are offered directly by the original manufacturers, but even so, service efforts are often limited to reinsulation, resharpening, and tube realignment.

Owing to a revolution in parts availability in the last five to six years, however, repair opportunities have exploded, and because most MIS instruments are made up of a number of replaceable components, the potential for preserving them is practically infinite. Though repair costs sometimes seem high when compared to the cost of general instrumentation repair, MIS instruments are categorically more complex, and repairs require a higher degree of skill and expertise.

Deflecting bridges retail for as much as $1,500, and new working elements cost between $1,200-$2,800, yet they can be repaired for an average of $100-$500, including parts. Assuming the repaired instrument provides the same anticipated shelf-life promise of the new instrument, then the hospital would realize an enormous capital savings by maintaining their existing equipment. Similar savings of up to 90% of the replacement cost are realizable on the full line of MIS instruments including forceps, scissors, graspers, punches, trocars, cannulas, sheaths, bipolar tubal forceps, retractors, obturators, hooks, spatulas, probes, etc.

Objective repair opinions are essential to the success of a genuine equipment preservation effort. When sinuscopy instruments, for example, become stiff and dull, and won't perform like new, the most common reaction has been to replace the entire tray at a cost of about $15,000. A qualified repair provider would give the hospital the same result - functionally new instruments with the same expected life span - at about $2,000, an 86% savings.

There comes a time when replacement is the intelligent choice. Older laparoscopy forceps could not be dissembled for cleaning. Sterility measures encourage the use of the newer style which can be taken apart, therefore, replacement should be considered. Some facilities have elected to utilize single-use forceps, but again, with the enhanced repair capabilities now available, disposables are no longer the most economic choice. Resectoscope systems of the 1970's have evolved into continuous flow systems, which represents a significant technological improvement that surgeons would appreciate.

In answer to new sterilization methods, manufacturing techniques, like hard anodizing and nickel plating, have given MIS instruments an inherently longer life. Many instruments, if not processed correctly, will corrode over a period of time. Once the metal deteriorates and functional integrity has been compromised, then replacement becomes necessary.

Barring genuine instrument decomposition or replacement for purposes of technological upgrade, the repair opportunity for most MIS instruments is almost limitless. To maximize the facility's substantial investment in them, their care, upkeep, and preservation should be a high priority. Though repair prices reflect the higher value of MIS instruments, the reward in decreased capital expenditures will be noticeable.

Rigid Endoscopes
The rigid endoscope, one of the most fragile and sophisticated instruments in the operating room, is subject to more frequent damage than most other equipment because of its delicate lens system. Most damage results from fluid invasions or trauma to the internal optics system. While complicated by nature, approximately 90% of these parts can be replaced at a charge far less than expensive repair/exchange options. To capitalize on the potential efficiency of an original investment in the endoscope, the hospital or surgery center is economically better served to repair it until it has sustained damage genuinely beyond repair or has become technically obsolete.

Most scopes can be repaired. Even a scope that is completely broken in half can be repaired to a like-new condition at a cost of up to 60% less than a replacement. However, most users would assume that a scope so severely damaged would be beyond salvation, and that's a misconception some suppliers would encourage. In fact, damage to this extent usually renders a trade-in allowance void. In the last five years, endoscopic repair technology has so matured, that hospitals can enjoy the use of their scopes almost indefinitely. Even 10-year-old scopes with anodized or plated aluminum or brass bodies can continue to give service, since the optics systems relative to today's science, remain the same.

Obsolescence
Laparoscopes fitted with out-dated achromatic or first-generation rod lens systems can be upgraded to newer, highly-defined rod lens endosopes. In the interest of optimum patient care, these models should be replaced. Ureterenoscopes, originally produced with a rod lens system, have been redesigned into semi-rigid fiber scopes that better withstand torque and give the surgeon finer manipulation capabilities. An investment in this new and certainly improved model would be a sound one.

Some manufacturers have upgraded older standard sterilizable scopes to newer models that are fully autoclavable. Given current sterility issues and anticipated sterility mandates, this could be a good opportunity to upgrade and take advantage of available trade-in allowances or rebates when these break down. Occasionally, vendors will introduce upgrades that automatically render all other components of an existing operating system obsolete, and conscientious health-care buyers could assume they have no choice but to invest in the new unit in its entirety. While the manufacturers may have indeed introduced a breakthrough in some facets of the equipment, this is a situation where it pays not to be on the leading edge of the marketing curve, since, given the pressures of the marketplace, the supplier may be forced to retrofit adapters so the new technology remains compatible with older components that never really changed. If this sounds complicated, it's not. It can be a matter of re-engineering locks, mountings, etc. to match the existing mechanics; a conversion that could have been done in the original manufacturing process. Furthermore, equipment performance may have yet to be determined beyond clinical trials.

Obsolete is relative. The obsolescence of an instrument is often subjective, and therefore relative to the income opportunity available in the sale of a replacement.

Flexible Scopes
Like rigid endoscopes, with today's enhanced repair technologies, there is very little that cannot be repaired on a flexible unit, providing another opportunity to capitalize on your original investment. Most working elements can be replaced for significant savings.

Replacement considerations could be given to those older scopes that were manufactured with round 40-micron fibers which allow more light-carrying fibers to be packed into the image bundle. As a result, resolution is greatly enhanced and distracting moiré pattern is virtually eliminated. Technical improvements have also been made in video endoscopes, so when there is CCD chip damage, one might consider upgrading. It's important to keep in mind, however, that even with some of these improvements, the decision to replace instead of repair that flexible scope could still be a matter of personal choice. If a surgeon is accustomed to working with the older model and isn't convinced the upgrade will improve his diagnostic or surgical capabilities, then perhaps it's unnecessary to invest in the new equipment. But it's still important for the enlightened buyer to know all available options so they can preserve their equipment and protect their budget. Flexible scopes represent a major capital expenditure; consulting with a reputable repair vendor before considering replacement is a practical and prudent strategy.

Power Equipment
More and more hospitals are benefiting from repair providers who help negate the effects of randomly "obsolete" power equipment. Most of the equipment no longer serviced by the OEM can effectively be made fully functioning by a competent repair source at a fraction of its replacement cost. This option is even more attractive when one considers that the replacement of some power hand pieces also necessitates the purchase of all new support components like cords, consoles, and attachments. Suddenly, the investment in new equipment has multiplied considerably, and if there's no real technical gain in the newer system, then repairing the broken hand piece is wise.

Repair options in the power equipment market are somewhat limited because many patterns, even current releases, are subject to OEMs' replace-or-exchange-only policies, even though the broken piece can usually be returned to fully operational status at a cost far below the replacement. It just doesn't make good fiscal sense to essentially "total" the unit on which damage is incidental; therefore, the vigilant buyer will seek second opinions for the repair of motor drives, attachments, burr guards, duraguards, instrument power cords, shavers, etc. to help curb capital expenditures. Even some battery packs can now be refurbished.

As with other equipment decisions, if a new unit can only be expected to provide the same performance capability and life expectancy of the repaired unit, all other conditions being equal, then the repair choice, again, is obvious. Furthermore, preventable factors contributing to power equipment failure, such as over/under lubrication, immersion, etc., are often identified during the repair analysis, and armed with this information, the facility can take steps to troubleshoot the abuse to help reduce repair frequency.

General Instrumentation
General instruments, the workhorses of the operating room, need routine care and maintenance to ensure their stamina. Regular sharpening and alignment will not only ensure optimum surgical effectiveness, it will also keep them functioning. While users can expect a long life, there will ultimately come a time when most general instruments should be retired:

• Cracked box locks on ring-handled instruments prevent the jaws or tips from aligning properly.
  
• Needleholders have an indefinite life span because the tungsten carbide inserts can be replaced repeatedly, however, if the jays are stressed, or the metal becomes too pitted, replacement is recommended.
  
• Instruments with a cutting edge or shearing action can be sharpened over and over until the blades no longer have enough surface to overlap properly. To prevent premature replacement, only experienced repair technicians should sharpen instruments so they don't remove more of the edge than absolutely necessary.

Despite their durability, most general surgical instruments will eventually succumb to the stress of metal fatigue caused by user abuse or the repeated assault of corrosive chemicals, but it's important not to reject them based on cosmetic value alone.

Repair vs. replace opportunities abound. Some products that were sold with a lifetime guarantee are no longer protected by the supplier who found it economically unrealistic to continue honoring that warranty indefinitely. Furthermore, as manufacturers continue to bring new equipment to the marketplace, they often discontinue production and service support to their older models. Surgeons who have come to depend on these instruments, and have even tailored their surgical techniques to them, are especially disheartened to learn they can't acquire a replacement when theirs breaks down. Whether it's a scope, an instrument, or a power unit, it can generally be repaired. Even replaced equipment, not useable for a trade-in allowance, can often be refurbished to serve as back-up.

Ultimately, buyers should understand that a surgical tool is only the sum of its parts - carbide inserts, ratchets, jaws, inner cables, lenses, fiberglass-ceramic tips, etc. As long as these parts can be changed out, then the instrument can be reborn with a renewed life expectancy equal to that of a replacement. It is only when the major components of the unit have become so fatigued that the instrument is no longer capable of supporting any replacement parts that one should consider discarding it.

The inclination, of course, is to buy new. While hospitals everywhere are struggling with cost-saving issues, the most fundamental of cost-saving practices - that of maintaining and preserving one's reusable assets - has been overlooked. Today's sophisticated repair industry can, indeed, breathe new life into damaged equipment. Now there are repair solutions available that weren't accessible a few short years ago, and this provides buyers with far more control over the fate of their equipment.

A solid preventive maintenance program, combined with sterile processing procedures that don't violate the instrument, will contribute greatly to the preservation of these assets. Enlightened, conscientious managers who initiate and promote a dedicated equipment preservation effort can protect their investment with confidence well into the next century.