LESS PAIN, MORE GAIN Adjustable laparoscopes can ease the physical burden of laparoscopic surgery.

Articulating laparoscopes had never been on my wish list. The standard rigid scopes I'd used for years worked just fine. In fact, if I'd had the option, I probably wouldn't have switched. But when we upgraded to a 3D high-definition system, there was no choice: The improved visualization was only available with an articulating scope. And now? Now, there's no way I'd go back to using straight sticks. Here's why.

1. More angles
Of course the obvious improvement is that the articulating scope provides a significant range of mobility and a broader field of sight that you can't get with a rigid, non-adjustable laparoscope. The one we use moves 100 degrees in any direction, so you can actually turn it back almost entirely on yourself.

Yes, you get some range with a nonadjustable scope. They typically come with a tray and a set of 4 or 5 scopes — so you have a zero-degree option, a 15-degree, a 30-degree, a 70-degree and sometimes a 50-degree option. But the beauty of the flexible scope is that it's all-in-one. There are 2 triggers that allow you to go up and down and side to side. So, for example, you can go 50 degrees left and 30 degrees up at the same time. In other words, you're able to get those kinds of very odd angles that you can't get with traditional scopes. And once you get there, the camera can be locked into place, so it stays exactly where you want it to.

2. Sharper focus
The scope's chip-in-tip technology is another big plus. It's like an auto-focus camera, but better, because it never goes out of focus.

With the articulating scope we use, it's one piece, so it's completely static. The focal distance is from the tip of the lens to the actual tissue. That means it's completely in focus at all times. As opposed to an auto-focus camera, where you can see the image go from fuzzy to crystal clear, with this technology, there's no transitional phase. It's always crystal clear.

3. Added efficiency
The idea that articulation will produce better surgical outcomes by broadening the field of vision is intuitive, of course, but as yet unproven. The articulating scopes are too new for there to have been any definitive studies.

But there is one area where I can say for certain that the new scopes are providing better outcomes: They save time. And if you have a safe outcome in a shorter amount of time, that's a better procedure.

With conventional scopes, you often have to flip back and forth among the various scopes to visualize different angles. You might find yourself swapping out instruments every 30 seconds, every minute, every 5 minutes — however often you need a different view. That can add a significant amount of time to a procedure and be pretty cumbersome.

4. Space savings
For single-site surgery, the articulating scope is a lifesaver. If you have everything going into a single port, it can be impossible to do surgery because of instrument "sword-fighting." So you need to find ways to create space. With conventional scopes, the easiest way to do that is to push the camera up, and look down, so you keep the camera out of the way of your articulating instruments. When we use the articulating scope, we're able to create space by simply deflecting the camera tip.

PRODUCT SHOWCASE Sharona Ross, MD, test drives Olympus's new articulating laparoscope at last year's SAGES conference.

5. Improved ergonomics
There's growing concern about the ergonomic challenges related to laparoscopic surgery. With conventional scopes, sometimes I have to really lean out over the patient to get the angle I need. That can be hard on the shoulder and back. With the articulating scopes, I don't have to do that, because I can do the majority of my manipulation with a finger and keep the scope in the middle of the surgical site. There's more manual dexterity involved, so there might be more fine-motor complications, instead of lower-back issues, but I suspect this technology will be more ergonomically friendly overall.

COMPARISON SHOPPING
Articulation Is Worth the Investment

TOP TOOL Most general surgeons work with angles, making articulating laparoscopes invaluable additions to their arsenal.

The one advantage non-articulating laparoscopes have over articulating models: rigidity. I can use conventional scopes as a manipulator during surgery. I can use it to move structures and I can use it for support.

I can't do that with an articulating scope, because it isn't rigid. It's purely for visualization. But that's it — there are no other disadvantages. Everything you can do with straight sticks, you can do with articulating scopes, plus more.

Of course, some surgeons are trained on zero-degree angles; they're used to looking straight down at the surgical site. But most laparoscopic general surgeons are working with angles. The more complex the procedure, the more you realize the advantages that come with articulation.

Yes, there's a learning curve with articulating scopes, but it isn't massive. If you've been using laparoscopic equipment for a while, you understand the mirror image nature of laparoscopic surgery — that is, if you want to look up, you push the scope down, and so forth. It's the same thing with the articulating scopes. You just need to know you're going to need to pull the trigger back to go up and push the trigger forward to go down. Once you get that, the learning curve isn't very daunting.

The technology is pretty remarkable, and it took a while for these new scopes to hit the market, because it was a challenge to be able to use fiber-optics and not crack the fiber. They're a little more delicate than traditional scopes and of course, they're more expensive, but I've been using them for a year now and I haven't had any problems or complications. To me they're absolutely worth the investment.

— Kevin Audlin, MD