Some believe that the recent surge in single-incision laparoscopic surgeries has spurred the advancement of rigid and semi-rigid endoscopes. Others claim surgical pioneers are taking advantage of improved scope mechanics and hardware to push the envelope of minimally invasive surgery. Whichever came first makes for an interesting discussion, but no one can debate that articulating tips, full-HD displays and improved imaging sensors are the hottest things going in new endoscope designs.

The art of articulation
Daniel Herron, MD, FACS, chief of bariatric surgery at Mount Sinai Hospital in New York City and the director of laparoscopic surgery training at the Mount Sinai School of Medicine, readily admits that endoscopes with flexible tips optimize a surgeon's ability to access and visualize tissue through suboptimal port locations.

But he's also quick to point out a scope's primary limitation: a fairly steep learning curve. "That's true," says David Renton, MD, an assistant professor of surgery and director of minimally invasive surgery at the University of South Carolina in Columbia.

Dr. Renton is charged with teaching surgical residents how to manipulate a scope's articulating tip using two levers (which control left-right and up-down movements) at the base of the scope's handle. For surgeons, learning the intricacies of maneuvering steerable tips is all about breaking habits formed from the first time they handled a rigid endoscope. "You need to work the switches that work the scope's tip instead of intuitively tilting the entire shaft to shift the field of view in the surgical cavity," he says. "It definitely takes some getting used to."

At Mount Sinai, where Dr. Herron says he and his colleagues host more laparoscopic cases than any hospital in Manhattan, surgeons don't routinely use scopes with articulating tips. It's a matter of preference and familiarity that Dr. Herron believes reflects the preferences of most surgeons in most surgical facilities. He believes a majority of physicians employ 10mm rigid scopes for basic lap choles, while more advanced surgeons use 30-degree or 45-degree angled scopes for complicated hernias and bariatric surgeries.

Dr. Herron believes articulating tip technology is still a novelty, but will eventually become more commonplace as its clinical applications become widely accepted, its costs decrease and single-incision surgery continues its movement to the mainstream (see "A Minimalist Approach" on page 46). For now "a standard 30-degree, 10mm scope provides a high-quality image in standard resolution or high-def, and it's incredibly durable," he explains. "Those scopes are a very mature, very established device that's tough to improve upon."

CCD versus CMOS
For the past 15 years or so, charge-coupled device (CCD) image sensors have dominated the commercial camera market because they acquire high-resolution images in a small form, says Lee Nelson, an imaging consultant based in Falls Church, Va.

The sensors have more recently provided surgeons with clearer, more precise images of anatomy and are the current gold standard in medical imaging.

Complementary metal-oxide semiconductor (CMOS) sensors, however, are gaining a foothold in the surgical industry, developing into the next generation of image-capturing technology, says Mr. Nelson. "They operate better [than CCD sensors] in low-light conditions," he explains, "creating an equivalent image with less light energy directed into the patient."

Sending high levels of light into the surgical cavity isn't difficult to do, says Mr. Nelson. However, the additional heat generated by the light source as it's sent through the scope's components has the potential to damage the adhesives that hold the scope together. Because they operate effectively using less energy, "CMOS sensors have the potential to reduce the technological requirements of scopes and prolong the devices' lifespans," he says.

CMOS sensors also reach an extra degree of miniaturization, according to Mr. Nelson, who notes that some manufacturers have taken advantage of shrinking physical profiles to place imaging sensors at the endoscope's tip. Converting images to electronic signals where the images are generated — as opposed to CCD sensors that digitize images remotely through processors embedded in scope handpieces — shortens the distance that signals must travel along an optics system before being processed and generated on a screen for your surgeon to see.

"Every extra ounce of benefit that you can squeak out of a system results in a better image for the end user," says Mr. Nelson, who says the CMOS sensors' smaller size has let some manufacturers break the 5mm diameter threshold in their scopes' designs. Smaller scopes mean smaller incisions, less damage to internal organs and a furthering of the minimally invasive movement.

CMOS sensors are also less expensive to manufacture, which has some companies considering disposable endoscopes, says Mr. Nelson. Rather than cleaning and sterilizing a scope between uses, you could toss disposable devices after a single use, which could potentially reduce downtime between cases and eliminate infection control concerns relating to reprocessing.

High-def? Definitely
Yes, HD is great to look at. Yes, it's currently the closest thing to real-life imaging. But does it improve clinical outcomes? "Probably not," admits Dr. Herron. "But, hey, I can work off black-and-white images and operate pretty well. That doesn't mean I want to or should."

Dr. Herron remembers how much he prefers HD every time he operates in a room that hasn't yet received an imaging upgrade. "It's painful to go back to standard definition," he says, equating the experience to watching HDTV at home before trying to follow the grainy picture on your grandmother's old tube set.

To him, the benefits of HD go beyond crystal clear, beautiful images. "When viewing HD, surgeons worry less about the anatomical details they're trying to identify," he explains. "Is that normal tissue? Is it blood? With HD, they know." Improved visualization reduces a surgeon's stress level, meaning he's less likely to make mistakes, repeat steps or double back to check his work. "In other words," says Dr. Herron, "he can concentrate on providing quality care."

Brad E. Snyder, MD, assistant professor of surgery and director of clinical research for the Minimally Invasive Surgeons of Texas, a consortium at the University of Texas Medical School at Houston, thinks HD is a perk — at least for now. "What we have now is adequate," he says, although he expects high-def to become the norm within 5 years. High-def makes a huge difference in the amount of detail a surgeon can see, notes Dr. Snyder, and obviously "the better we see, the better the surgical outcomes. And really, that's what this is all about."