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OBJECTIVE: Advancement in new technology has been necessary for the development
Takeshi Mikami, M.D.
of surgical hemostasis. The purpose of this study was to assess novel bipolar forceps
Department of Neurosurgery,
Sapporo Medical University, plated with gold-polytetrafluoroethylene (PTFE) composite film.
Sapporo, Japan METHODS: Novel bipolar forceps with gold–PTFE composite film were invented and
compared with commercially available forceps with 50-µm gold-plated tips in terms
Yoshihiro Minamida, M.D.
of their physical properties and coagulation performance. The contact angle was meas-
Department of Neurosurgery,
Sapporo Medical University,
ured to determine the degree of wetting tension. Then the surface roughness, electric
Sapporo, Japan resistance, and changes in local temperature on the surface of the tip were recorded.
Coagulation performance of the two sets of bipolar forceps was determined comparing
Izumi Koyanagi, M.D. the amount of protein in the adhered coagulum on the tips and comparing the ease
Department of Neurosurgery, with which the coagulum could be removed.
Sapporo Medical University,
Sapporo, Japan RESULTS: This gold–PTFE composite film-plated metal has a significantly higher con-
tact angle than conventional gold-plated metal, and the plating maintains the matrix
Kiyohiro Houkin, M.D. metal property. The amount of coagulum sticking was smaller than with the ordinary gold-
Department of Neurosurgery, plated forceps. The ease of removal was also superior with the gold–PTFE composite
Sapporo Medical University, film-plated forceps.
Sapporo, Japan
CONCLUSION: The concept of promotion of protein repellence is important for achiev-
Reprint requests: ing reduced adherence of protein to neurosurgical instruments. This protein repellent
Takeshi Mikami, M.D., plating is indispensable to achieve safer and more accurate microneurosurgery.
Department of Neurosurgery,
Sapporo Medical University, KEY WORDS: Bipolar forceps, Gold polytetrafluoroethylene composite film, Neurosurgical operation
South 1 West 16, Chuo-ku,
Sapporo 060-8543, Japan. Neurosurgery 60[ONS Suppl 1]:ONS-157–ONS-161, 2007 DOI: 10.1227/01.NEU.0000249252.86417.85
Email: tmikami@sapmed.ac.jp

Received, April 26, 2006. ipolar forceps, introduced by Greenwood nology for plating the tip of bipolar forceps. In
Accepted, August 31, 2006. (9) in 1940, are an invaluable tool for this report, we introduce the characteristics
neurosurgical operation. Further im- and performance of these novel bipolar for-
provements made possible precise control of ceps with gold–PTFE composite film during
bleeding and fine dissection (1, 4–6, 11, 12, experimental coagulation.
14–18). Occasionally, however, problems of
charring and tissue adherence occur (4, 13),
and recently, the possibility of prion disease MATERIALS AND METHODS
from surgical instrument contamination has
arisen (3, 7, 8, 19, 20). Adherence of protein to Two types of bipolar forceps with 1.0-mm
the tip of the coagulation device is a problem wide tips were assessed. These consisted of a
that must be resolved immediately. trial tip plated with gold–PTFE and a commer-
The metal polytetrafluoroethylene (PTFE) cially available tip plated with 50-µm gold
composite film has superior water and protein (KH-2001; Codman/Johnson & Johnson,
repellence (3, 10). This composite film is elec- Tokyo, Japan) (Fig. 1). Before starting coagula-
troconductive, heat resistant, extremely tion, the bipolar forceps were washed with
durable, and has antifouling properties (10). deionized water and ethanol and then dried at
Because PTFE’s protein repellence contributes 50⬚C. The coagulation was carried out with a
to the reduction of adherence to bipolar for- Malis bipolar coagulator (CMC-III; Codman &
ceps during coagulation, we applied this tech- Shurtleff, Inc., Raynham, MA).



Physical Properties of the Material

A metal 1 cm2 sample of the material used for the tips of each
product was prepared before the measurement of wetting ten-
sion. Wetting tension is the maximum liquid surface tension
that will spread, rather than bead up, on the film surface.
Wetting tension is specific for any given system and is deter- B
mined by the interactions across the three interfaces. It is a
measurable property that reflects the surface energy of the film.
To determine the degree of wetting tension, the contact angle of
a water drop (1.5 mm in diameter) on the surface of the FIGURE 1. Photographs depicting the gold-plated bipolar forceps (A) and gold
gold–PTFE composite film and gold-plated film was measured PTFE composite film plated bipolar forceps (B).
at 25⬚C in air saturated with moisture (CA-X; Kyouwa
Kaimenkagaku, Saitama, Japan). The contact angle is the angle Adherence of coagulum to the tips was assessed by measur-
between the surface of a solid and the surface of a liquid ing the ultrasonic irrigation time necessary to remove the coag-
droplet on that surface, and it is the primary measurement to ulum. The coagulation of the blood was carried out at 15 Malis
determine wetting tension. Measurement was repeated five units (1.6 W) for 20 seconds. The tip with adhered coagulum
times with each type of material. was held in 5 ml 1% Triton-X 100 at a distance of 5 mm from the
The surface roughness of the tips was measured by a laser ultrasonic processor, and the rinsing was performed (output,
scanning electron photomicroscope (1LM21W; Lasertec, 2.0 W). The time it took for detachment of the adhered coagu-
Yokohama, Japan). Two-dimensional z axis images and three- lum was averaged over 10 procedures and was expressed in
dimensional images were obtained in addition to the usual seconds.
scanning electron microscopic images. From these electron
micrographs, the average roughness (Rz) was calculated at 10 Statistical Analysis
points. Details of the method of calculation were reported pre-
Data are expressed as the mean ⫾ standard deviation.
viously (13). Measurement and calculation were repeated five
Correlations were analyzed using a two-factor analysis of vari-
times with each type of material.
ance. The items measured were contact angle, roughness of the
Electric resistance was measured using a digital instrument
surface, and electric resistance, and the time it took to remove
(digital multimeter 753306; Yokogawa, Tokyo, Japan). We meas-
the stuck coagulum was analyzed using the Mann-Whitney U
ured electric resistance between the tip of the bipolar forceps
test. The level of statistical significance was set at a P value of
and the arm. Measurement was repeated five times with each
less than 0.05.
type of material.
Changes in local temperature on the surface of the tip were
measured using a thermograph (TH5100; NEC, Tokyo, Japan). RESULTS
One hundred microliters of human whole blood preincubated
at 37⬚C were put on a slide glass, and the tips of the bipolar for- Physical Properties of the Material
ceps then were placed in the blood with a gap of 1 mm. Table 1 shows the physical properties of the gold-plated bipo-
Measurement was started from 30⬚C, and increases in heat lar forceps and gold–PTFE composite film-plated bipolar for-
were measured. After coagulation finished, we left the bipolar ceps. A water drop on the surfaces of the bipolar forceps is
forceps as they were and measured the decrease in temperature shown in Figure 2. The average contact angle of the sample
in a similar manner. Measurement was repeated five times with piece of each material differed: 74.9 ⫾ 2.1 degrees for the gold-
each type of material. plated film, and 142.6 ⫾ 3.6 degrees for the gold–PTFE plated
film. There was a significant difference (P ⫽ 0.009).
Coagulation Performance The surface of both materials was examined by laser micro-
scope and the data were calculated. Mean roughness (Rz) val-
Details of the method were previously reported (13). We
ues of the two samples were significantly different for each
used human whole blood for evaluation of adherence in this
study. One hundred microliters of human whole blood preincu-
bated at 37⬚C were put on a glass slide. The coagulation was TABLE 1. Physical properties of gold-polytetrafluoroethylene
performed at constant electric power (15 Malis units ⫽ 1.6 W) composite film plated bipolar forcepsa
for 8 to 20 seconds. After the coagulation, the adhered coagu-
Gold plated Gold–PTFE P value
lum was removed by an ultrasonic processor in a solution of 5
ml 1% Triton-X 100, and the protein content of the solution was Contact angle (degrees) 74.9 ⫾ 2.1 142.6 ⫾ 3.6 0.009
assayed by a bicinchoninic acid protein assay reagent (Pierce, Roughness (Rz) 0.07 ⫾ 0.03 0.97 ⫾ 0.10 0.009
Rockford, IL). The coagulation at each condition was repeated Electric resistance (Ω) 0.6 0.6 NS
five times and the amount of coagulum was expressed as the a
PTFE, polytetrafluoroethylene; NS, not significant.
average milligrams of protein in these five procedures.

ONS-158 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 www.neurosurgery-online.com


achieved because the mate-

rial itself resists water and
protein. Metal–PTFE com-
posite film is prepared by
electrodeposition in a metal
sulfamate plating bath in
which fine PTFE particles are
suspended by using a
cationic surfactant. It has the
FIGURE 2. Photographs depicting a water drop on the surfaces of the bipolar same hardness as matrix
forceps with gold plate (left) and gold–PTFE composite film plate (right). metal and it achieves a high
Different configurations of wetting tension were obtained. d e g re e o f a t t a c h m e n t t o
underplating metal. This
process is not difficult and FIGURE 3. Graph demonstrating the
material (P ⫽ 0.009): 0.07 ⫾ 0.03 µm in the gold-plated forceps the resources are readily amount of protein in the coagulum
and 0.97 ⫾ 0.10 µm in the gold–PTFE composite film-plated available. In the manufactur- and the duration of coagulation time.
forceps. Electric resistance of both types of bipolar forceps was ing process of the bipolar for- Values represent the average of five
0.6 Ω; thus, there was no significant difference. ceps, the gold–PTFE compos-
coagulation procedures. The amount
Local temperature on the surface of both tips suddenly ele- of protein was significantly lower on
i t e f i l m w a s p l a t e d o n the gold-plated forceps tips. The
vated to 81.2 ⫾ 5.6⬚C until 10 seconds of electricity time, and stainless steel instead of gold asterisk denotes a P value of less than
plateaued thereafter. When the electricity power continued for plating. The estimated cost 0.05.
30 seconds, the temperature of both tips rose to approximately for the gold–PTFE composite
89.3 ⫾ 2.9⬚C. After coagulation ended, the temperature of both film plated forceps is the
tips gradually decreased to 35.8 ⫾ 1.5⬚C after 130 seconds. same as that of the gold-
There was no significant difference between the two forceps. plated forceps. The actual
selling price for these two
Coagulation Performance different forceps is similar.
The amount of adhered coagulum, measured by its protein Ceviker et al. (5) reported
content, increased as the coagulation time became longer. The previously that a Teflon-
adhered coagulum was significantly less on the gold–PTFE- coated bipolar coagulator
composite film–plated forceps (P ⬍ 0.0001) (Fig. 3). The mean reduced adherence. However,
ultrasonic irrigation time for coagulum removal from the gold–- given its low electric conduc-
PTFE-plated forceps (7.42 ⫾ 0.78 s) is shown in Figure 4. It was tivity, Teflon cannot be used FIGURE 4. Bar graph demonstrating
significantly shorter (10.84 ⫾ 1.79 s) than that for the gold-plated to cover the entire surface of the time for removal of coagulum by
tips (P ⬍ 0.002). the forceps, so Teflon-coated ultrasonic rinsing. Values represent
bipolar forceps have both the average of 10 procedures. There
were significant differences in time
DISCUSSION nonconducting coated parts
between the two materials tested. The
and uncoated conducting asterisk denotes a P value of less than
We previously reported that the chemical and physical prop- parts. Also, Teflon comes off 0.05.
erties of forceps have a significant impact on the extent of easily because of its poor sur-
adherence during bipolar coagulation. Electric and thermal fea- face tension. Although the wetting tension of metal–PTFE com-
tures at coagulation depend on the characteristics of tip mate- posite film plating is as low as that of Teflon, the plating main-
rial, which include heat and electrical conductivity, ionization tains the property of a matrix metal. Moreover, metal–PTFE
tendency of metals, electrical distribution of the tip surface, composite film has a high coefficient of friction because of the
and the wetting tension of the material (13). The recent inven- roughness of its surface. The coefficient of friction is a dimen-
tion of nonstick bipolar forceps with cooling technology sionless scalar value that describes the ratio of the force of fric-
(IsoCool; Codman & Shurtleff, Inc., Raynham, MA) was made tion. Consequently, the grasping power of the material is supe-
from the viewpoint of heat conductivity. We focused on wetting rior to the conventional gold-plated forceps.
tension in this study, and this concept guided the development We confirm that the PTFE composite film-plated bipolar for-
of these novel bipolar forceps. ceps can withstand conventional sterilization; however, parti-
Polytetrafluoroethylene (E.I. du Pont de Nemours & cles of the PTFE may come off as a result of daily cleaning
Company, Inc., Wilmington, DE) is a material resembling before reuse of the forceps. After more than 10 gas steriliza-
Teflon, and metal–PTFE composite film plating has high wet- tions, particles began to come off, and the tip showed some
ting tension and superior water repellence (2, 10). The results of changes in color. Improvement in durability is feasible in the
our experiment showed that when this material was used as future by application of a supplementary diluted metal coating.
the tip of the bipolar forceps, a more ideal coagulation could be Otherwise, there is a possibility of disposable use of this tip.



CONCLUSION Acknowledgments
We thank Hajime Kiyokawa, Ph.D., Kiyokawa Plating Industry Co., Ltd., and
Starting from the concept of protein repellence, we developed Tomohiko Asahara, Ph.D., Codman/Johnson & Johnson, Tokyo, Japan, for their
novel bipolar forceps. The PTFE composite film used has a high technical support in the preparation of the bipolar forceps. None of the authors
wetting tension and superior water repellence. Therefore, it did has a financial interest in the bipolar forceps used in this study.
not adhere easily, and coagulum that became stuck came off
easily. Moreover, this composite film has a high coefficient of COMMENTS
friction because of its roughness, and the grasping power of the
material is superior. These characteristics result in an improved
performance. We think that this technology is superior and will
M ikami et al. meticulously present their objective data comparing
the use of gold-polytetrafluoroethylene (PTFE)-coated bipolar
forceps with standard bipolar forceps. They assessed a number of vari-
be widely used in the future for microneurosurgery. ables not limited to, but including, protein adherence, electric resist-
ance, and roughness of the surface of the bipolar tips. They also pres-
ent a subjective evaluation of the clinical use of the PTFE-coated
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ONS-160 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 www.neurosurgery-online.com


T he authors describe a modification to bipolar forceps that may

interest all neurosurgeons. Sticking of a bipolar forceps is a prob-
lem in brain tumor surgery and could be disastrous in vascular neuro-
an inconvenience and can prolong operative time. The modification
described in this report should reduce sticking and require less fre-
quent cleaning. My only question is where do I get one?
surgery. Sticking can be reduced by frequent cleaning of the forceps tips Patrick J. Kelly
(I usually have it cleaned after each coagulation); however, this can be New York, New York

Govard Bidloo, 1649–1713, Ontleding des Menschelyken Lichaams. Amsterdam: By de weduwe van Joannes van Someren, de erfgenaamen van Joannes van Dyk,
Hendrik en de weduwe van Dirk Boom, 1690 (courtesy, of the U.S. National Library of Medicine, National Institutes of Health, Bethesda, Maryland).