Endoscopes are an important medical tool. There are a variety of different endoscopes, including rigid and flexible varieties, tailored for specific procedures and uses within the health care arena. The proper cleaning and disinfection of these devices has been a big topic in the news recently regarding patient safety concerns. The importance of these devices regarding treatment and diagnosis procedures remain and that is one reason experts are working to outline specific cleaning procedures for all types of scopes. TechNation reached out to manufacturers and technicians to find out the latest about rigid endoscopes.
The panel of industry experts for the roundtable discussion includes Kelly Klink, Product Manager, Rigid Endoscopy and Fiber Optic Repair Divisions, Mobile Instrument Service and Repair Inc.; Marci Morgan, Lead Scope Technician, Scopeplus + Labs Inc.; Darryl Rock, Business Unit Vice President, Surgical Endoscopy and Systems Integration, Olympus Corporation of the Americas; and George Wright, President and CEO, Integrated Endoscopy.
Q:What are the latest advances or significant changes in rigid endoscopes and in the rigid endoscope market in the past year?
Klink: Manufacturers are answering the call for smaller endoscopes which significantly reduce patient trauma, blood loss and recovery time. While the make-up of the optic system is relatively the same, (glass rods, spacers, etc.) they are becoming smaller by design.
Morgan: In my opinion there have not been many changes in a long time. Most scope manufacturers continue to use the same rod lens systems for over 10 years. Each manufacture has about three different lens systems they use based on scope diameter and length. One example is a rod lens that is used in 4 mm cystoscopes made by one of the biggest and most popular companies. I have used this same diameter and length lens for these scopes for more than 15 years. There are also a few major manufactures that share the same lens system. Yes, you can take one system out of one manufacturer’s scope and put it in the other. Once you have a bright, clear and focused image there are not many things to improve on. Why reinvent the wheel. Glues have changed to autoclavable types that will take the 272° temperatures. Eyepiece material and colors also have been tweaked a little. Yes HD and 3D scopes are out there, but with the cost I don’t see many of them.
Rock: The rigid endoscope market has seen only a few significant changes over the past 25 years. More recently, 4K Ultra High Definition (UHD) rigid endoscopes are advancing imaging technology along with 4K Imaging Platforms. The new glass lens telescopes used in the new 4K system offer four times the resolution and color reproduction than HD telescopes. Olympus will introduce the 4K UHD in the coming months for both 5 mm/10 mm telescopes to be followed by 4 mm arthroscopes and sinuscopes.
Wright: One significant technology advance in the rigid endoscope market is the introduction of the first single-use arthroscope, providing a new option for facilities that may help them better manage costs and eliminate cumbersome, time-consuming reprocessing requirements. The development of high-quality, single-use surgical instruments is increasing rapidly in ORs and ambulatory surgery centers, especially in the field of orthopedic surgery. Several factors are driving increased demand for single-use devices, including ease-of-use, lower cost, instrument accuracy, and the elimination of infection risk.
Q: How will those changes impact rigid endoscope maintenance?
Klink: Smaller naturally means more delicate, which creates a challenge in handling the scope for everyone from the sterile processing technician to the surgical technician and physician. Having the correct storage, transport and cleaning resources on hand is vital. Education on proper care and handling for everyone who touches them from the end user (physician) to the sterile processing staff is an absolute must to help reduce damage.
Morgan: Scope repairs years ago were somewhat easier in that the scopes were not autoclavable. The glues were not as strong so opening the scope took less time and heat. Internally, there are very few changes. The lens systems haven’t changed. External things like gold plating and colored rings have always been replaced. The new glues are more expensive and take time to cure, but you adjust repair procedures to this change. Mechanically each manufacturer’s scope is made different. Each has its own special way to disassemble. Most repair facilities have their own set of procedures, tools and fixtures for this.
Rock: The all-in-one design of the ENDOEYE videoscope helps to reduce the number of points along the imaging chain where the image can degrade over time. 4K Technology will provide significant improvements in clarity and visualization resulting from the increase in resolution.
Wright: Single-use rigid endoscopes eliminate two key issues associated with reusable endoscopes — reprocessing and maintenance/repairs. Reusable endoscopes must be cleaned and sterilized or high-level disinfected after every use, and extensive documentation, handling, storage, and inventory requirements must be followed. In addition, reusable endoscopes get damaged during use, handling and reprocessing. As a result, they are sent out for repair an average of six times a year, and lifetime repair costs can amount to more than twice the purchase price.
Q: What technologies are worthy of the initial investment? How can a facility with a limited budget meet the rigid endoscope needs of today?
Klink: The high-definition video equipment on the market today can give even the most basic type of endoscope an incredible image. So while the endoscope plays a major part, the HD image displayed on screen is much more a function of the video equipment. A good way to upgrade is to sell older equipment and apply the proceeds to the purchase price of newer, more advanced models. Working with a reputable leasing company can also help make upgrades more affordable. Finally, taking a hard look at repair costs and providers can also free up funds. For example, repair-exchange programs are incredibly convenient, but if you do not need the rapid replacement, you are overpaying for repairs. Those savings can be applied to expanding or upgrading inventory.
Morgan: Scopes have not changed much over the years. Most urological and orthopedic procedures have used the same scope and instrumentation for years. There are some new very expensive scopes out there. Scopes with flexible distal ends and robotics are there but again I don’t see many. Some surgical procedures are now preformed with smaller diameter scopes and sheaths. They basically take the same lens design and grind it to a smaller diameter. This allows a procedure to use a 3 mm scope rather than a 4 mm. Reduced stress on the patient with a smaller diameter sheath is a plus. On the downside, the scope is repaired more often because of the smaller size. It breaks quicker.
Rock: Facilities are beginning to expand their scopes to look at the overall cost of ownership of equipment such as endoscopes, and not just the cost to acquire new technologies. This allows physicians to consider technologies that will help them achieve long-term goals. Facilities with limited budgets are looking for device manufacturers to provide technologies that can be maximized across multiple specialties. Universal platforms are a great solution.
Wright: Maintaining an adequate inventory of endoscopes to meet surgical demands requires a significant investment for facilities. Single-use arthroscopes provide an option that eliminates the need to invest in large inventories of more expensive reusable scopes. This is particularly useful in ambulatory surgery settings, where closely managing costs is crucial for profitability.
Q: What else do you think TechNation readers need to know about purchasing and servicing rigid endoscopes?
Klink: Too often, purchases are not thought through. Taking time to carefully assess your real needs is key. Look at your inventory and what gets used. Review your caseload and build a forecast of your needs so you can optimize your inventory and approach to repairs and maintenance. And most of all, get custom education from your repair supplier. OEMs and third parties have textbook classes. Demand a program that is tailored to your facility so you can make the class more relevant to staff. If rigid scopes are maintained and cared for correctly, they will last many years and the supporting equipment (video cameras, processors, monitors, etc.) is where the investment should be focused.
Morgan: Occasionally we see repairs come in from manufacturers you have never heard of. It can be a problem if no replacement parts are available. If the eyepiece is broken and there isn’t a replacement around, we have to make a drawing and send it to the machine shop. This could add 2-3 hours to the repair. Make sure the scope is readily used in the industry and serviced by local, qualified repair facilities. If it has to always go back to the manufacture, they are now in control. We can take a 10-year-old scope, rebuild it with new tubing, light fibers and lenses. It’s now a perfect scope ready for surgery. The manufacture tells you it’s not serviced anymore. They sell you a brand new scope with the same components inside that was just deemed not repairable or serviced anymore.
Rock: Many vendors provide rigid endoscopes, but not all scopes are created equal. High-quality instruments typically provide more value with better visualization and long-term quality than low-cost, low-quality products. Service also is something that can’t be taken lightly. Many facilities invest in high-end technology, but then trust third-party entities to repair that technology instead of taking it back to the OEM. Service by the OEM is critical because only the OEM can provide original parts that are designed to be used with each specific rigid or flexible endoscope. Using the OEM for service will ensure the longevity of the equipment and maximize the investment.
Wright: When purchasers look at making an investment in rigid endoscopes and are considering either reusable or single-use scopes, it is important that they consider the total cost of ownership. A Millennium Research Group study found that the greatest costs associated with rigid endoscopes are attributable not to purchase price, but to scope backup/inventory requirements, repair, refurbishment, sterilization and OR downtime — contributing an additional 650 percent above the purchase cost over the life of the device.
Q: What are the most important things to look for when deciding whether to go with an original equipment manufacturer or a reputable third-party rigid endoscope provider?
Klink: Quality – Does the provider return the scope to its exact original specifications and designs or simply do the minimum needed to make it work again? Parts – Are new parts used when a replacement is needed or are parts salvaged from other scopes? Reliability – What specific experience do they have with the equipment you use? Relationship – Will they provide you with the education and tools you need to keep your repair budget in check? Are they a hands-off type of company (call me when it’s broke) or are they hands-on, and work with you and – your staff to resolve issues and reduce repairs? There are some providers that propose bundled offers. It’s important to look it over closely, understand the real cost for the components you need and make sure it fits your vision. Most times facilities are purchasing equipment they may never utilize to get a discount on a large purchase. But in the end, they may find that some of those items never get taken out of the box.
Morgan: Chevrolet does not make tires. They buy them from tire manufactures. Most scope manufactures buy tubing, light fibers, glues and lenses from many different sources and have them assembled by another source that puts their name on it. I have heard company reps say they can’t buy the same lens we use. Why have I repaired scopes for 25 years and always get perfect images? Is the doctor seeing a different picture with my repair? I have meet with many German lens designers and manufactures over the years. They make lenses and sell them all over the world. We order them with a specific diameter, length and focal distance. Most manufacturers don’t even fix your scope, they give you another scope that someone broke or dropped that has been refurbished. Why not get the same scope you own, refurbished and sent back to you?
Rock: The term “Original Equipment Manufacturer” says it all. The original manufacturer has the parts, as well as the product history and intelligence to produce and maintain the highest quality product. Many OEMs, including Olympus, do not provide proprietary parts to third-party vendors, so once a third-party vendor has worked on a scope it is no longer validated by Olympus. This also will play a vital role in how the endoscope is reprocessed under CDS standards. OEMs are FDA “regulated” and held to specific standards which are set and routinely monitored. Most third-party vendors are instead FDA “registered,” which does not hold them to the same standards. Olympus takes pride in the quality of its devices and utilizes patented processes to maintain the highest quality standards in manufacturing and repair that, in our experience, third-party vendors cannot duplicate.
Wright: We believe the answer is not whether an OEM or third-party manufacturer is the issue but, more importantly, the technology behind the rigid endoscope. Things like high-quality lenses, elimination of outmoded fiberoptic technology, the use of state-of-the-art LED illumination, and the elimination of potential cross contamination from accumulated bioburden are much more important issues. When looked at in this context, the new technology found in the single-use arthroscope is perhaps the best answer.
Q: Is it possible to keep up with the latest rigid endoscope advances and improvements without buying brand new? What are some of the newer technologies available?
Klink: There are many times that model upgrades put on the market really have no functional or internal changes from the prior model produced. Similar to the automotive marketplace, a new scope might boast a new look on the outside, but under the hood, it’s largely the same components. Video arthroscopes have been a mainstay for a long time. Until a few years ago, they were largely unchanged in their basic design. What is new on many models is a magnetic drive focus assembly. It gives the orthopedic surgeon a smooth rotation and takes minimal effort to fine tune an image.
Morgan: As stated earlier there are HD and 3D scopes in the market. I don’t see many of them. The most common scopes are 2.7 or 4 mm diameter for ENT, orthopedics and urology. That hasn’t changed in 20 years. The lens systems are still the same. Most of the advances have come in video and recording devices.
Rock: New technologies enable facilities to offer patients the newest advancements in health care. Customer upgrade programs help facilities afford the newest technologies. For example, Olympus’ 3D imaging is a cost-effective upgrade for facilities who own the latest Olympus 2D imaging system. The modular design of the EXERA III Universal Platform (compatible with all current rigid endoscopes) provides an economical upgrade path from 2D to 3D imaging since a facility can add the necessary items to their system after purchasing the base 2D system.
Wright: Over time, endoscopes get damaged and degraded in optical quality due to frequent use, handling and reprocessing. In fact, most surgeons performing endoscopic surgery rarely get to use a brand new endoscope. Single-use endoscopes leverage technology used to mass-produce small, high-definition glass lenses for cellphone cameras, as well as patented, inexpensive, and durable LED technology to produce a low-cost, single-use endoscope with high-definition optics. As a result, single-use arthroscopes provide a first time experience for every surgeon, every time.
Q: How can purchasers ensure they are making a wise investment in a rigid endoscope? How can they ensure they will receive the necessary literature and training tools?
Klink: Look at need first. Understand what physicians want and need for their caseload. Then, involve people who are behind the scenes including people responsible for reprocessing and maintenance. A team approach works best. We’d suggest including language in the purchase agreement that stipulates the type and frequency of education sessions and access to documentation for staff. We think quarterly assessments of staff and processes and facilities are key to long-term repair management. If you cannot get this from your OEM, ask others in the market to step in.
Morgan: If they are buying a new scope get one from a reputable company. Make sure the company has been making these for a long time. Don’t buy the first of the line. I know of a company that specializes in ENT. They came out with a urological line of scopes. I got three calls asking if I knew where they could get it repaired. Hmm …
Rock: The initial attraction of a low-priced product can be tempting, but there is more to consider than acquisition price. Added benefits, such as on-site training, education, and support necessary to learn and maintain the equipment can be costly afterthoughts. Olympus provides a variety of educational resources for customers included with their purchase. Additionally, service plans help health care providers protect their investments by extending the useful life of their endoscopes, and maximizing procedural uptime and clinical performance. Full service agreements offer a fixed annual repair rate, eliminating the guesswork for repair budgets. Literature and training tools also are provided by OEMs to support customers’ needs for education and training of proper use, care and handling of these products.
Wright: Purchasers should research all options and consider the most recent technology advances in order to make decisions based on their specific needs and budgets. Speak with the manufacturer to ensure that all literature and training tools are obtained, and keep them on file for future use.
Q: What else would you like to add or do you think is important for biomeds to know about rigid endoscopes?
Klink: Rigid endoscopes are workhorses. If repaired, reprocessed correctly and handled with care, they can last many years. OEMs discontinue models from time to time and inform facilities that they no longer support/service them. That shouldn’t make your facility have a knee-jerk reaction and fear that you need to purchase new equipment. We routinely see well-maintained older rigid endoscopes arriving for repair that are 10 plus years old. If the inventory of rigid scopes is adequate and the needs of the surgeons are being satisfied, the investment should be more focused on the supporting equipment that enhances the rigid endoscope and the surgical view it provides to the surgical team.
Morgan: If they have the opportunity to go and see a local repair facility, then go. Find out if they really do it. Everyone uses other facilities in some way. Most of us are friends and help each other. Make sure they specialize in something. Either they do scopes, cameras or related instrumentation. I have had biomed technicians, doctors, OR and SPD staff at my repair facility many times. They all have left with a better knowledge and understanding how things are made and what’s inside. They actually handle items better now that they have learned more about lenses and light fibers.
Rock: Olympus understands downtime due to equipment repairs can result in lost revenue for health care facilities so we recently put into place the Olympus Uptime Guarantee. This agreement guarantees next-day equipment replacements for Olympus full service agreement customers at no charge. These are the types of programs and support that OEM vendors provide to customers to ensure their total cost of ownership is in line with budget needs.
Wright: Endoscopic surgery has rapidly evolved into the gold standard for efficient, lower-risk surgical procedures. However, recent infection outbreaks have increased awareness about patient safety issues connected with inadequately reprocessed scopes. In addition, a recent study in the American Journal of Infection Control showed that repetitive use and reprocessing causes alterations to the surface of endoscopes, with the incidence of endoscope contamination directly proportional to the number of times it was used and reprocessed. The results suggest the necessity of limiting the duration of time reusable scopes may be used. Some have called single-use instruments the “way of the future” because they have the potential to minimize the risk of infection transmission, improve operating room efficiency, and help hospital and ASC control costs.
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