INSTRUMENTATION ASSESSMENTS

NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE

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

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

NEUROSURGERY VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-157

MIKAMI ET AL.
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-
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
gold–PTFE composite film and gold-plated film was measured
at 25⬚C in air saturated with moisture (CA-X; Kyouwa
Kaimenkagaku, Saitama, Japan). The contact angle is the angle
between the surface of a solid and the surface of a liquid
droplet on that surface, and it is the primary measurement to
determine wetting tension. Measurement was repeated five
times with each type of material.
The surface roughness of the tips was measured by a laser
scanning electron photomicroscope (1LM21W; Lasertec,
Yokohama, Japan). Two-dimensional z axis images and three-
dimensional images were obtained in addition to the usual
scanning electron microscopic images. From these electron
micrographs, the average roughness (Rz) was calculated at 10
points. Details of the method of calculation were reported pre-
viously (13). Measurement and calculation were repeated five
times with each type of material.
Electric resistance was measured using a digital instrument
(digital multimeter 753306; Yokogawa, Tokyo, Japan). We meas-
ured electric resistance between the tip of the bipolar forceps
and the arm. Measurement was repeated five times with each
type of material.
Changes in local temperature on the surface of the tip were
measured using a thermograph (TH5100; NEC, Tokyo, Japan).
One hundred microliters of human whole blood preincubated
at 37⬚C were put on a slide glass, and the tips of the bipolar for-
ceps then were placed in the blood with a gap of 1 mm.
Measurement was started from 30⬚C, and increases in heat
were measured. After coagulation finished, we left the bipolar
forceps as they were and measured the decrease in temperature
in a similar manner. Measurement was repeated five times with
each type of material.
Coagulation Performance
Details of the method were previously reported (13). We
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
performed at constant electric power (15 Malis units ⫽ 1.6 W)
for 8 to 20 seconds. After the coagulation, the adhered coagu-
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
assayed by a bicinchoninic acid protein assay reagent (Pierce,
Rockford, IL). The coagulation at each condition was repeated
five times and the amount of coagulum was expressed as the
average milligrams of protein in these five procedures.
ONS-158 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007
A
B
FIGURE 1. Photographs depicting the gold-plated bipolar forceps (A) and gold
PTFE composite film plated bipolar forceps (B).
Adherence of coagulum to the tips was assessed by measur-
ing the ultrasonic irrigation time necessary to remove the coag-
ulum. The coagulation of the blood was carried out at 15 Malis
units (1.6 W) for 20 seconds. The tip with adhered coagulum
was held in 5 ml 1% Triton-X 100 at a distance of 5 mm from the
ultrasonic processor, and the rinsing was performed (output,
2.0 W). The time it took for detachment of the adhered coagu-
lum was averaged over 10 procedures and was expressed in
seconds.
Statistical Analysis
Data are expressed as the mean ⫾ standard deviation.
Correlations were analyzed using a two-factor analysis of vari-
ance. The items measured were contact angle, roughness of the
surface, and electric resistance, and the time it took to remove
the stuck coagulum was analyzed using the Mann-Whitney U
test. The level of statistical significance was set at a P value of
less than 0.05.
RESULTS
Physical Properties of the Material
Table 1 shows the physical properties of the gold-plated bipo-
lar forceps and gold–PTFE composite film-plated bipolar for-
ceps. A water drop on the surfaces of the bipolar forceps is
shown in Figure 2. The average contact angle of the sample
piece of each material differed: 74.9 ⫾ 2.1 degrees for the gold-
plated film, and 142.6 ⫾ 3.6 degrees for the gold–PTFE plated
film. There was a significant difference (P ⫽ 0.009).
The surface of both materials was examined by laser micro-
scope and the data were calculated. Mean roughness (Rz) val-
ues of the two samples were significantly different for each
TABLE 1. Physical properties of gold-polytetrafluoroethylene
composite film plated bipolar forcepsa
Gold plated Gold–PTFE P value
Contact angle (degrees) 74.9 ⫾ 2.1 142.6 ⫾ 3.6 0.009
Roughness (Rz) 0.07 ⫾ 0.03 0.97 ⫾ 0.10 0.009
Electric resistance (Ω) 0.6 0.6 NS
a
PTFE, polytetrafluoroethylene; NS, not significant.
www.neurosurgery-online.com
 NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE

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.

NEUROSURGERY VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-159

MIKAMI ET AL.
CONCLUSION
Starting from the concept of protein repellence, we developed
novel bipolar forceps. The PTFE composite film used has a high
wetting tension and superior water repellence. Therefore, it did
not adhere easily, and coagulum that became stuck came off
easily. Moreover, this composite film has a high coefficient of
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
be widely used in the future for microneurosurgery.
REFERENCES
1. Bergdahl B, Vallfors B: Studies on coagulation and the development of an
automatic computerized bipolar coagulator. Technical note. J Neurosurg
75:148–151, 1991.
2. Brenner A: Electrodeposition of Alloys: Principles and Practice. New York,
Academic Press, 1963.
3. Brown P, Preece M, Brandel JP, Sato T, McShane L, Zerr I, Fletcher A, Will RG,
Pocchiari M, Cashman NR, d’Aignaux JH, Cervenakova L, Fradkin J,
Schonberger LB, Collins SJ: Iatrogenic Creutzfeldt-Jakob disease at the millen-
nium. Neurology 55:1075–1081, 2000.
4. Casotto A, Piattelli M: A new device for electrocoagulation of small vessels.
Acta Neurochir (Wien) 71:151–160, 1984.
5. Ceviker N, Keskil S, Baykaner K: A new coated bipolar coagulator: technical
note. Acta Neurochir (Wien) 140:619–620, 1998.
6. Dujovny M, Vas R, Osgood CP, Maroon JC, Jannetta PJ: Automatically irri-
gated bipolar forceps. Technical note. J Neurosurg 43:502–503, 1975.
7. Fichet G, Comoy E, Duval C, Antloga K, Dehen C, Charbonnier A, McDonnell
G, Brown P, Lasmezas CI, Deslys JP: Novel methods for disinfection of prion-
contaminated medical devices. Lancet 364:521–526, 2004.
8. Flechsig E, Hegyi I, Enari M, Schwarz P, Collinge J, Weissmann C: Transmission
of scrapie by steel-surface-bound prions. Mol Med 7:679–684, 2001.
9. Greenwood J: Two-point coagulation. A new principle and instrument for
applying coagulation current in surgery. Am J Surg 50:267–270, 1940.
10. Ibe T, Kiyokawa H, Chong Y, Yonezawa S, Takashima M: Electrodeposition
and surface properties of nickel-PTFE composite film. Materials Science
Research International 4:148–152, 1998.
11. Jacques S, Bullara LA, Pudenz RH: Microvascular bipolar coagulator.
Technical note. J Neurosurg 44:523–524, 1976.
12. Malis LI: Electrosurgery. Technical note. J Neurosurg 85:970–975, 1996.
13. Mikami T, Takahashi A, Hashi K, Gasa S, Houkin K: Performance of bipolar
forceps during coagulation and its dependence on the tip material: A quan-
titative experimental assay. Technical note. J Neurosurg 100:133–138, 2004.
14. Ohta T, Funatsu N, Kuroiwa T, Matsui T: Bipolar diathermy forceps with
automatic irrigation. Technical note. J Neurosurg 62:933–934, 1985.
15. Sakatani K, Ohtaki M, Morimoto S, Hashi K: Isotonic mannitol and the pre-
vention of local heat generation and tissue adherence to bipolar diathermy
forceps tips during electrical coagulation. Technical note. J Neurosurg
82:669–671, 1995.
16. Samii A, Dujovny M: Kirwan ”non-stick” bipolar forceps. Surg Neurol
45:297–298, 1996.
17. Sugita K, Tsugane R: Bipolar coagulator with automatic thermocontrol.
Technical note. J Neurosurg 41:777–779, 1974.
18. Vallfors B, Erlandson BE, Wieck BO, Hansson HA, Svensson J: Coagulation in
neurosurgery. Acta Neurochir (Wien) 55:29–34, 1980.
19. Yan ZX, Stitz L, Heeg P, Pfaff E, Roth K: Infectivity of prion protein bound to
stainless steel wires: A model for testing decontamination procedures for
transmissible spongiform encephalopathies. Infect Control Hosp Epidemiol
25:280–283, 2004.
20. Zobeley E, Flechsig E, Cozzio A, Enari M, Weissmann C: Infectivity of scrapie
prions bound to a stainless steel surface. Mol Med 5:240–243, 1999.
ONS-160 | VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007
Acknowledgments
We thank Hajime Kiyokawa, Ph.D., Kiyokawa Plating Industry Co., Ltd., and
Tomohiko Asahara, Ph.D., Codman/Johnson & Johnson, Tokyo, Japan, for their
technical support in the preparation of the bipolar forceps. None of the authors
has a financial interest in the bipolar forceps used in this study.
COMMENTS
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-
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
forceps. In summary, the authors found that protein adherence was sig-
nificantly decreased, which was confirmed in a clinical setting with
significantly less intraoperative charring and tissue adherence.
The authors are to be commended for their concise, well-organized
assessment of the PTFE-coated bipolar forceps. Certainly, any techno-
logical advancement that decreases the amount of tissue adherence to
bipolar forceps would be welcomed by the neurosurgical community.
We use Isocool bipolar forceps (Codman/Johnson & Johnson Profes-
sional, Raynham, MA), which have significantly decreased the amount
of tissue adherence we experience. A side-by-side comparison of PTFE-
coated and Iscool bipolar forceps would be interesting.
Robert F. Spetzler
Jeffrey Klopfenstein
Phoenix, Arizona
M ikami et al. have introduced two learning opportunities to the
readership. First, they have educated us regarding the physiol-
ogy and mechanics of surface tension and protein repellency as it per-
tains to coagulators. They have also provided basic science data regard-
ing a new modification of traditional coagulators. For both of these,
they are to be congratulated.
Edward C. Benzel
Cleveland, Ohio
M ikami et al. have developed a novel bipolar design incorporating
a tip plated with a protein and water repellant gold-PTFE com-
posite film. A variety of physical parameters were examined to deter-
mine the characteristics of this new bipolar forceps when compared
with conventional gold-plated tips. The authors found that the
increased microscopic roughness of the gold-PTFE film provides an
increased surface area for coagulation and, perhaps, tissue grasping,
while at the same time diminishing coagulum adherence. These factors
improve coagulation performance and the ease of cleaning. Although
this device is not yet available for purchase, the manufacturing process
is not difficult and the component materials are neither rare nor expen-
sive. The authors estimate that the eventual cost would be comparable
to that of gold-plated forceps. Of some concern is an apparent vulner-
ability to repeated sterilization. Particles of PTFE begin to shed after
only a few gas sterilizations. Perhaps disposable tips are the answer.
This group should be commended for applying modern material
design to improve upon a basic instrument used by neurosurgeons
every day. The subtle enhancements in utility provided by these new
bipolar tips may facilitate improved hemostasis and surgical efficiency.
These authors may have succeeded in building better microsurgical
mousetraps.
Joel D. Macdonald
Salt Lake City, Utah
www.neurosurgery-online.com
 NOVEL BIPOLAR FORCEPS WITH PROTEIN REPELLENCE

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).

NEUROSURGERY VOLUME 60 | OPERATIVE NEUROSURGERY 1 | FEBRUARY 2007 | ONS-161