There's a hole in my bucket: The cost of disposable instruments

Received September 16, 1996. * Reprint requests: William W. Hurd, M.D., Depar tment of Obstetrics and Gynecology, Indiana Universi ty Medical Center, 550 North Universi ty Boulevard, Room 2440, Indianapolis, Indiana 46202-5274 (FAX: 317-274-7417; email: whurd@iunet.iupui.edu). The opinions and commentary expressed in Editor 's Corner articles are solely those of the authors. I ts publication does not imply endorsement by the Editor or American Society for Reproductive Medicine. According to an early American folk song, even the apparent ly simple task of fixing a bucket is much more involved than it first appears. You must first obtain wood, an ax, a sharpening stone, water to whet the stone, and the pump must be primed with water from an intact bucket. Likewise, efforts to reduce the cost of medical care may be more difficult than they initially appear and may invoke complicated circular arguments. A case in point is the issue of the use of disposable ins t ruments for laparoscopy. Disposable instruments have become available for laparoscopy only in the last few years. In the early 1970s, as gynecologic laparoscopy gained popularity, s tandard reusable ins t ruments and systems for laparoscopic surgery were designed by a few large manufacturers . The design of laparoscopic ins t ruments changed little over the next 20 years, probably because the profit margin for these ins t ruments was small. The laparoscopic market was confined to gynecologists, and the demand was limited to a narrow range of procedures. Then, in the early 1980s, a quiet laparoscopic "revolution" began. A small group of intrepid gynecologists began to use the laparoscopic approach for more than jus t diagnostic laparoscopy and sterilization procedures. "Operative laparoscopy" was applied first to infertility procedures and soon after was used for general gynecologic and oncologic procedures as well. Perhaps the most important event, from a market opportunity viewpoint, may have been the "discovery" oflaparoscopy by general surgeons and the development of the laparoscopic cholecystectomy (1, 2). For this procedure, an entire new generation of disposable ins t ruments was developed. At the same time, perhaps in par t as a result of this impetus, operative laparoscopy by gynecologists was transformed from a procedure performed only by a select few, to a common approach for multiple gynecologic problems. The number of companies developing and marketing newly designed disposable ins t ruments exploded to meet the rapidly increasing needs of laparoscopic surgeons. Disposable ins t ruments have since replaced reusable ins t ruments in many operating rooms for a number of reasons. The-most obvious advantage may be the dependable sharpness of disposable instruments, particularly trocars and scissors. The disadvantage of dull scissors is obvious, and dull trocars require more force to insert through the abdominal wall (3). Certainly, it makes sense that sharp scissors may be safer than dull scissors. However, it has yet to be proven that extremely sharp disposable trocars are any safer than properly sharpened reusable trocars or tha t a reduction in force required for trocar insertion improves safety.