By meeting the challenges of visibility in laparoscopic surgery, we improve performance, cut time and frustration, and unburden camera operators.

By Matthew Brunson Martin, MD, FACS

Visibility is essential to all surgery, which is why we put so much effort into ensuring that laparoscopic procedures have adequate lighting and ever-improving scopes and monitors. Visibility is still repeatedly impaired, however, when blood and/or smoke or steam from lasers and other tools cover the scope, blurring or obscuring the surgeon’s view. This recurring, frustrating problem triggers a time-consuming series of cleanings throughout surgery. We have long identified the need for solutions that allow surgeons to work uninterrupted, with a clear view. Now it appears this is possible, with the advent of scope-clearing technology that may improve surgical efficiency as well as enhance the experience for surgeons and staff.

Frustrating Interruptions

When visibility is impaired during laparoscopic surgery, we stop surgery, and the camera operator removes, cleans and re-inserts the scope. The scope can get blood on it again during re-insertion, in which case it is cleaned again. This process is especially cumbersome in advanced laparoscopic procedures that last longer than 30 minutes. If we clean the scope 6 times during a 45-minute procedure, taking 2 minutes per cleaning and reinsertion (more for obese patients), then we add 12 minutes to surgery. If OR time is $50 per minute, that’s an additional $600.

From the surgeon’s standpoint, when looking through the scope, our brain gets an understanding of the area of focus and all the surrounding anatomy. Every time the scope comes out and goes back in, we have to locate all those landmarks again and refocus. (“Where was I, and what was I doing?”) It takes additional time to get back into the procedure, and the repeated interruptions get very frustrating, especially when they happen at key moments. In addition, if the cleaning process doesn’t go swiftly and smoothly, tensions can escalate between the surgeon and camera operator.

Some clinical factors make this process particularly taxing. In bariatric surgeries such as gastric bypass, we’re working high on the abdomen, and it can be very tedious to remove the scope and then try to return it to the same spot. We have a similar situation in hiatal hernia repair, taking down the vessels around the spleen and dissecting up into the mediastinum. Removing the scope for cleaning at that point is very tiresome. Other procedures require cleaning more often because they produce more lens-fogging substances. Final removal of the gallbladder from the gallbladder bed generates a lot of steam, and condensation is a problem when we use the harmonic scalpel for colon mobilization. We know before we perform these surgeries that we can expect scope cleaning to slow us down.

Addressing the Problem

Over the years, the industry has looked for ways to keep scopes clean during surgery and reduce or eliminate removal and reinsertion. Cleaning fluids now have an enhanced ability to reduce fogging and repel fluids. We can utilize a povidone-iodine surgical scrub solution or choose from a range of branded options. Several manufacturers package solutions in single-use tools to make the cleaning process more efficient during surgery.

In addition, several devices are available to restore visibility without removing the probe. Surgeons can employ several probe sheaths with intra-operative flushing, for example. These are designed to repel and wash away material that could impair visibility without interrupting surgery. Another option is an in-abdomen lens cleaning device that covers the scope lens with a biocompatible transparent film. When blood or steam ruin visibility, the surgeon clicks the trigger, advancing the film along the scope and restoring a clear optical view.

Benefits of In Situ Cleaning

Of all the benefits offered by these cleaning options, I find that the greatest is the ability to clean the lens without removing the scope, so I use an in-abdomen lens cleaning device that I control. I am able to maintain visibility throughout surgery without removing the scope at all, so I can focus continuously on what I’m doing, without fighting through worsening visibility or interruptions. As a result, one of the biggest sources of frustration and tension in the OR is gone. Surgery takes significantly less time as well because we’re eliminating a few minutes for each cleaning and reorientation.

In addition to making surgery faster and less stressful, there is another significant advantage to not removing and reinserting the scope for cleaning: This approach is easier on the camera operator, which in turn benefits both the surgeon and the hospital.

As hospitals trim down OR staffs, the camera operators assigned to a laparoscopic surgery may spend most of their time working in other areas, so they are accustomed to using different scopes or use scopes only occasionally. Inexperienced technicians make mistakes while holding the camera, causing it to get dirty and require removal and cleaning. They feel pressure to perfectly remove, clean, and reinsert probes, knowing that the surgeon’s frustration is related to their performance. The operators’ frustration and anxiety can make their work suffer, so the problems snowball.

Because in situ cleaning controlled by the surgeon eliminates both of those concerns, I think camera operators are able to do their job better with higher confidence. The technology can make a good camera operator really great, and it can make a marginal operator acceptable – all while making them happier as well. Hospitals with a smaller pool of experienced laparoscopic camera operators don’t have to juggle OR staff to match those operators to complex surgeries. Laparoscopic surgeons can be comfortable with less experienced staff in the OR, while experiencing the visibility and uninterrupted work that has eluded us in the past.

– Matthew Brunson Martin, MD, FACS, is a surgeon at Central Carolina Surgery, PA, in Greensboro, North Carolina. He performs general and cancer surgery, laparoscopic bariatric, and advanced videoscopic surgery of the GI tract including laparoscopic colon resections and hiatal hernia reconstructions.