In this talk, we will introduce a new surgical tool developed to aid in no-touch technique for assembly of shunt components. As we all know, infection is a common and serious complication of shunts. Numerous studies have reported on a multitude of risk factors and management strategies to reduce infection rates. Structured protocols with high compliance has been shown to reliably reduce infection. Many protocols include stipulations on the handling of shunt components including double gloving, changing gloves, and not touching shunt components by hand. The occurrence of holes in surgical gloves has been detected in up to 12-33% of gloves and in up to 30-40% of cases. There has also been a demonstrated association between infection and handling of the shunt system using breached surgical gloves. When the proximal catheter is connected to the shunt valve, the catheter is often already carefully placed in the ventricle in the valve placed under the scalp. This task is cumbersome without touching either component by hand. Tools commonly used are shotted mosquitoes or antibiotic-soaked gauze. The idea of making a specialized tool was initiated by a former fellow, Brian Hanick. At the Hospital for Sick Children, Dr. Drake heads a large engineering and 3D printing lab specializing in surgical robotics, which provided this specialization to create an elegant instrument now in use at the hospital. The tool we designed can be held like a clamp and equipped with a special cylindrical tip that grasps the catheter and eases it onto the valve tip in one movement. The front or top end of the tool is about 5 mm long and wide enough to allow the tip of the catheter to slip over the nub of the valve without buckling. The back or bottom end is tapered and provides enough friction to keep the catheter from slipping back without damaging the catheter. The tool was designed for a 3 mm diameter catheter, but functions similarly with larger or smaller diameter catheters as well. Here is a video demonstrating its use. To ensure that there are no micro tears or other kinds of damage, we performed electron microscopy on 24 shunt catheters placed on and off the valve three times using the tool. We put a sharpie mark at the distal end of the catheter where the jaws come together, as indicated by the star. This location is most likely for the catheter to be pinched and sheared during manipulation. Here are six representative pictures of six catheters. The sharpie mark is denoted by the stars. None of the catheters showed any damage. For efficacy testing, we asked a group of non-surgeon volunteers who were unfamiliar with shunt surgery and unbiased to either of the tools to use a standard shotted mosquito or the new tool to perform the shunt assembly task on a 3D printed skull model. They were instructed not to touch either component with their hands and given five minutes of practice with the tools prior to testing. Thirteen people were tested. The volunteers took twice as much time to complete the task with the shotted mosquitoes and the new tool. They also had to readjust their grip on the catheter three times as much using the old shotted mosquitoes versus the new tool. For the new tool, they averaged two attempts, whereas with the shotted mosquitoes, they averaged over six attempts. We also asked our staff, residents, and fellows to give their feedback on the tool. All agreed it would be a tool they would use in their practice. All but one preferred the new tool to their current practice. The one person who disagreed prefers use of double gloved hands. Finally, all found it easier to use than the standard tool. Since the survey, this new tool has been sterilized and used in the operating room. We have received positive feedback and the tool is in frequent use. In terms of next steps, we have just obtained a provisional patent on our novel tool in recent weeks. We are in the process of determining optimal channels for manufacture and distribution of the device. The tool can be made available as stainless steel forceps, as described in this presentation, or alternatively as a set of plastic tips that can be attached to an existing tool. The question of whether use of the tool will reduce operative time and infection rates has yet to be determined and can be retrospectively compared after we have collected a larger number of cases. In the meantime, we hope to be able to share this simple and inexpensive solution with the neurosurgical community. Thank you.

surgical tool

no-touch technique

shunt components

Dr. Drake

Hospital for Sick Children