ROOM WITH A VIEW Laparoscopy is tough enough to perform, without additional visualization-related challenges.

Smoke, lens fogging, debris, lighting that's never perfect: too dark or too light, too bright or not bright enough. Add in the challenge of operating in tunnel vision and it's a wonder surgeons can see well enough to perform surgery at all. But they can, and perform it well, thanks in part to a few technologies that overcome the fundamental visualization limitations of laparoscopy.

1. Imaging upgrades
Laparoscopic instruments don't let surgeons "feel" the abdominal cavity. They can't determine if the anatomy they're manipulating is hard, soft or textured. You can tell the difference between a circle and square on a 2D picture, but can you tell the difference between a soft square and hard square? That's the sort of challenge surgeons face during laparoscopic cases, when the difference between healthy and unhealthy tissue is its physical properties. The laparoscopic surgeon's ability to operate hinges solely on how well he can see the minute details of anatomy.

The better the camera, the better the scope and light source, the better the picture. High-definition obviously improves a surgeon's view of intra-abdominal action, but is the technology the standard of care? Not necessarily.

Scopes with light sources of questionable quality and screens that force surgeons to work off analog images are still in use today, even with the availability of many high-def camera and lighting options designed to improve surgeons' views — not to mention super HD and 3D — that are light years ahead of older equipment. But not all facilities have invested in the latest imaging technology that gives surgeons clear, crisp views of surgery. If you haven't yet upgraded your ORs, it's time to reconsider doing so.

2. Lens protection
Laparoscope lenses that are blocked by surgical debris or condensation are an annoyance surgeons must often endure. Thankfully, there are countless systems designed to limit these common issues.

To keep scopes fog-free, ensure the camera lens is placed in a scope warmer before surgery and covered with an anti-fogging solution. Additional options include specially designed trocars that clean lenses as they pass through and a barrier system that fits over the tips of laparoscopes to keep lenses free of debris and clear of condensation.

Surgeons must also focus on keeping the lens clean when maneuvering inside the abdomen. Once the lens gets dirty or fogs, the only truly effective way to proceed is to remove it, clean it and put it back in, which is a time-wasting annoyance.

3. Smoke-screen solutions
Attempting to see through the smoke generated during abdominal cases is another inherent problem of laparoscopy. There are a number of different ways to rid the surgical cavity of smoke. The easy way: Venting it through a port. The practice works well, but if the CO2 that's pumped back into the abdominal cavity to maintain insufflation after venting is cold, the laparoscope's lens will likely fog. Units that warm the CO2 delivered to the abdominal cavity are helpful in these situations.

Smoke evacuation technologies work well, but perhaps not substantially better than focusing on not creating excessive smoke in the first place and occasionally venting the smoke that is produced. In my opinion, the best way to avoid smoke-related problems is to make less of it. New energy sources produce less smoke relative to cautery that was in widespread use just 10 years ago.

SKILL SET Surgeon technique is just as important as the technologies designed to keep views clear.

4. Tissue manipulation
Trocars inserted to approximately 5mm are the standard small trocar used on adults. However, mini-lap instruments designed for use through ports 3mm or smaller, or perhaps no port at all in the case of needlescopic instruments, are well-utilized in pediatric patients or during a single-incision surgery such as gall-bladder removal. When maneuvering instruments through a single port, surgeons often don't have an easy way to manipulate the gall bladder. Needlescopic graspers can be inserted without a port and used to grasp the gall bladder and move it around. The instrumentation is very useful in those situations.

Additionally, surgeons have the option of using soft-tissue retractors through trocars to move anatomy out of their line of sight. They insert the retractor through a 5mm port, anchor one of its articulating clips to the intra-abdominal wall, place its stainless steel bar under the soft tissue that needs to be moved and fasten the device's second clip to the peritoneal wall.

5. Improved insufflation
For the most part, maintaining adequate insufflation is no longer a major issue for laparoscopic surgical teams. But CO2 leakage can still occur around trocars, for example, during procedures involving the removal of anatomy through ports that often get slightly bigger during the process. Trocar systems designed to sustain insufflation equilibrium by detecting drops or peaks in pressure and automatically adjusting CO2 flow to maintain a preset pressure can help.

One of the best ways to prevent intra-abdominal pressure loss is with an insufflation system that can blow fast enough to replace leaked CO2. For instance, newer insufflation machines blow 30 to 50L per minute through high-flow tubing versus older models that blew at 10L a minute, which wasn't enough to adequately replenish lost CO2.

A focus on safety
Appendix and gallbladder removals are straightforward, high-volume procedures that most surgeons can accomplish with any working piece of equipment. But advanced laparoscopic procedures — complicated and prolonged cases that aren't done on a daily basis, such as lap adrenalectomy or lap paraesophageal hernia repair — require additional ammunition. It's not that gallbladders are safer than advanced cases, it's that complex procedures require more tools to accomplish safely, and every bit of visual-aid technology helps.

It might be hard to prove that operating without the crispest images or visibility-enhancing tools can slow surgeons down, but there's little argument that poor visualization is unsafe. When it comes to improving the views of laparoscopy, patient safety should be the primary concern.