PRE-TREAT THE SCOPE Keeping laparoscopes warm before insertion into the abdomen is key to reducing fog and condensation.

Even if you have the latest ultra-high definition imaging system, your surgeons will still struggle to see inside the abdomen if smoke, fog and debris are coating their lenses. Here are 3 proven solutions to keep laparoscopic lenses clean and clear during surgery.

1 Use a smoke evacuator or filter
For some surgeons, the idea of using a smoke evacuator isn't appealing, as they see it as cumbersome and noisy. Plus, they may already be using a simple and affordable option to clear smoke out of the abdomen during cases.

"I open up the valve on the trocar, and the smoke comes out," says David Renton, MD, FACS, assistant professor of general surgery at The Ohio State University Wexner Medical Center in Columbus. "There are filters out there, but smoke evacuators just sound like a jet engine behind you."

The increasing concern around the dangers of inhaling surgical smoke has more facilities seeking better alternatives.

"We have a false sense of security we're not hurting the patient," says Vangie Dennis, BSN, RN, CNOR, CMLSO, director of patient care practice, ambulatory surgery services at Emory Healthcare in Atlanta, Ga. "Plenty of studies show that it bonds with hemoglobin and can give them symptoms related to increased levels of carbon dioxide." To help prevent these effects, Ms. Dennis points to several active and passive devices meant to remove and filter smoke out of the abdomen.

An easy solution is passive smoke filters. These devices attach to the trocar and simply filter the smoke as it leaves the patient, without seriously impacting the pneumoperitoneum or creating a noise nuisance, says Ms. Dennis. The latest of these disposable devices uses a filter to trap and remove 99.9% of the smoke particles in the insufflation gas. "These work well, but there are cases that generate more surgical plume and require a device that can remove the plume without compromising the pneumoperitoneum," she says.

For those situations, there are several devices on the market that remove smoke through instruments that are placed via the trocars. Options include tubing that connects the trocar to an in-line filter and wall suction, laparoscopic suction/irrigation probes that are able to regulate the pull of the smoke or small battery-operated evacuators that connect to the trocar.

Each one has merits and disadvantages, says Ms. Dennis. "With the irrigation probes, you can adjust the probe to suction out the smoke without reducing the pneumoperitoneum," she says. "The flip side is you can still end up suctioning out too much, which causes instability of the CO₂ gas in the abdomen and can extend the case or create issues."

The battery-operated evacuators — which are about the size of a small juice can — can be costly and cumbersome, and can get in the way of an already-crowded surgical field, she notes. "When I evaluated it, it made a lot of noise and the physicians didn't care for it."

One of the latest innovations on the market promises to prevent smoke, fog and debris through updated abdominal access technology. The technology eliminates conventional insufflation, trocars and filtered tubing systems. Instead, the valve-free system uses a primary access port and an insufflation system to continuously filter smoke out of the CO₂ and recirculate the clean gas, says Dr. Renton.

TWICE THE FIGHT Using an anti-fog solution in addition to warming the insufflation gas is the optimal way to avoid fog during a case.

Ceana Nezhat, MD, medical director of the Nezhat Medical Center in Atlanta, Ga., says that while he used to use external smoke evacuators and filters regularly, he has mostly stopped using them in favor of the new insufflation system. "It's the latest technology and the best technology," he says. "It also works well with the robotic system to evacuate smoke."

While extremely effective and something "the docs love," there is one big downside to the new system. "It is very expensive," says Ms. Dennis. "It can cost more than $100 in disposables, and you also need to buy equipment that works with the special access port."

Another capital equipment solution is a new endoscopic video enhancer. The single console hooks up to your current endoscopic imaging system and minimizes the visual presence of smoke and condensation using its software designed for the military. Though smoke is still present in the abdomen, the manufacturer claims the system helps sharpen the haze-filled images for your surgeons.

"The best thing is to prep the scope. Even something as simple as wrapping it with a warm towel so it doesn't go cold will help."

— Vangie Dennis, BSN, RN, CNOR, CMLSO

2 Pre-warm and pre-treat scopes
Dr. Renton notes that there are 2 main ways to prevent the fogging and condensation that occurs when you move from the cold OR to the warm abdomen of the patient: warming the scope beforehand and using an anti-fogging solution on the camera tip.

To warm the scope beforehand, there are some options that range in price and complexity. You can use a simple basin filled with warm sterile saline to store the scope before insertion, while special thermoses and scope warmers currently on the market can create similar results more easily and consistently. Dr. Renton's favorite option: sheaths that you "crack" to activate and wrap around the scope to keep it warm. They're simple to use, he says, and don't require you to move in and out of the surgical field like some other options.

All of the techniques work, says Ms. Dennis. The important thing is finding something that's easy and consistent to use. "The best thing is to prep the scope," she says. "Even something as simple as wrapping it with a warm towel so it doesn't go cold will help."

There are also plenty of anti-fogging solutions on the market, says Dr. Renton. You apply these solutions before insertion into the abdomen, and they create a film on the tip of the scope that helps prevent fogging and condensation. These tend to be pretty affordable, notes Ms. Dennis. Her facility uses a single-use wipe that costs roughly $3 to pre-treat the scope.

Even though there are plenty of options, Dr. Renton notes they aren't 100% effective. "None of the solutions are perfect," he says. "But, usually some combination of warming and anti-fog solution helps."

In a study Dr. Nezhat authored (osmag.net/gE5QqG), he found that using a device to warm and humidify the insufflation gas in addition to applying an anti-fog coating to be the most effective solution, especially in robotic surgery. "It's always been a problem, especially if you use a smaller diameter scope," he says. "We combined the anti-fog solution and humidifying the insufflation, and it worked the best."

3 Remove smudges and debris
Debris can be one of the more difficult site impairments to take care of during laparoscopy, though companies are working on new options to keep scopes clear. Applying a surfactant substance on the lens can help protect against smudges, while Dr. Renton points to "smudge-resistant" trocars, which help wipe the scope clean every time it's inserted through the port.

Another option is sheaths that attach to the ends of the camera and direct CO₂ from the insufflator to flow over the lens to prevent fogging and repel debris. "But they're becoming less popular, since it makes the scope bigger and can require larger ports," says Dr. Renton.

The valve-less access system also purports to help keep the scope clear from smudges that occur when moving the scope in and out of the trocar. "There are no valves on the system, so there's nothing for the scope to touch as it's inserted," says Dr. Renton. "Liquid and debris often collect at the valves, and that then touches and smudges the camera."

Or you can go the gadget-less route, though it may require a little dexterity on the surgeon's part. "Some docs are proficient enough to wipe [the lens] on a clean organ or use their irrigation stream to clean it," says Ms. Dennis. "Though most of the time, you need to just remove the scope and wipe it off."

Talking to your docs to find what they need the most can help cut down on investments in gadgets while ensuring clear views all around. "With dwindling reimbursement, and every hospital and ASC watching their margins, sometimes you have to go back to basics," she adds. "You might not need to incur every little widget." OSM