CLOSE WATCH Surgeons need to see anatomical details to optimize their surgical performance.

Squinting through fog, smoke and debris during laparoscopy is like driving in a snowstorm with sketchy windshield wipers — visibility inside the abdominal cavity and on the road reduced to blurs. That can make even the most technically savvy physician look like a first-year resident. Here are 3 ways to eliminate common obstructions so your surgeons have the views they need to optimize laparoscopic outcomes.

TROCAR MISHAPS
Insert With Care

SURGICAL SITES Vedra A. Augenstein, MD, says starting procedures with optimal views is key.

Don't forget to focus on the start of laparoscopic procedures to ensure your surgeons have clear views of the action, says Vedra A. Augenstein, MD, a general surgeon in the Carolinas HealthCare System in Charlotte, N.C.

"Getting into the abdomen might be the toughest part of the case," says Dr. Augenstein. "It isn't talked about very much, because rates of poor outcomes during trocar insertion are very low, but until you're in safely, it can be challenging."

She says clear views are essential during the procedure, but they're also incredibly important when inserting trocars in order to avoid potentially fatal injuries. "It requires a high amount of skill to control entry into the abdomen," says Dr. Augenstein. "Even during a simple case like an umbilical hernia repair, trocar mishaps can prove devastating."

Although Dr. Augenstein often gains successful access using an open cut-down method to insert a small trocar that she dilates to a larger port, she says the obese and elderly present unique challenges during the beginning stages of abdominal procedures. Cutting through several layers of fat before reaching muscle in overweight patients is inherently difficult, and inserting a trocar can be problematic because the abdominal wall is thicker and heavier. The elderly, on the other hand, don't have little fat layers inside the abdomen to protect delicate organs from injury.

During difficult trocar insertions, Dr. Augenstein might opt for a specialized trocar that lets her visualize layers of the abdominal wall as she places the port. She makes a 1 cm incision in the fascia and inserts a zero-degree camera through the trocar, which lets her watch as its tip passes through layers of fat and muscle. "You know exactly where you are in the abdomen," says Dr. Augenstein. "The technique still depends on feel and knowing the best angle of insertion, but you're able to recognize the layers" and avoid delicate structures.

— Daniel Cook

1. Make the surgical smoke disappear. Pumping in new insufflation gas is the easiest way to rid the abdominal cavity of smoke, says Dmitry Oleynikov, MD, FACS, a professor of surgery and director of minimally invasive and robotic surgery at the Center for Advanced Surgical Technology at the Nebraska Medical Center in Omaha. But there are some issues associated with the practice. "If you're not using a central CO₂ system, then pumping in new gas means trading out the CO₂ canisters more frequently, which wastes time," he says, adding that pumping in fresh CO₂ can also fog the laparoscope's lens if the new gas isn't warmed or humidified.

Dr. Oleynikov doesn't use a smoke evacuator. His reasons for not doing so — added cost without improved visualization — echo a familiar refrain that doesn't necessarily reflect the advances newer devices offer, such as more powerful and quieter suction, and streamlined designs. He's tried "passive, active, big and small evacuators," but says all were limited to some degree. Instead, he simply vents smoke through ports and insufflates the abdomen with new CO₂.

2. Prevent lens fogging. To help clear the lens of fog, many devices humidify the insufflation gas as it enters the abdominal cavity. Dr. Oleynikov touts the use of closed filtration systems that filter particles out of vented CO₂ before the gas is recirculated and pumped back into the abdomen. That process removes particles that may inhibit the surgeon's view while also keeping the gas warm and humid. He's also an advocate of the many devices that preheat or pre-humidify insufflation gas before it enters the abdomen, although in his experience the gas is never quite warm enough or humid enough to combat lens fogging.

Another way to prevent lens fogging is to pre-warm the laparoscope or rub an anti-fog solution on the camera lens (similar to what swimmers or skiers put on goggles to maintain clear views of the action). In addition to coating lenses with an anti-fogging solution, Dr. Oleynikov warms his laparoscopes before use to reduce condensation on the lens that occurs when cold scopes are placed into warm abdominal cavities. He uses an electronic scope warmer, but says there are many ways to warm scopes, including bathing them in warmed saline solution.

He says a device that sends a high-flow of CO₂ across the tip of the scope to keep particles from sticking to the surface is helpful, but not always reliable. "It's a great gizmo, and when it works, it works great," he says. "But it's expensive, and in my experience, requires more effort than the benefit you derive from it."

3. Clean the lens. Removing and wiping down scopes several times during a case is a sure-fire way to clean the lens, but it can waste valuable OR time. Depending on the procedure , you may have to clean the scope every 2 to 3 minutes, says Dr. Oleynikov.

Trocars designed to clean laparoscopic lenses as they're passed through failed to impress Vedra A. Augenstein, MD, a general surgeon in the Carolinas HealthCare System in Charlotte, N.C., during a trial. "Once you get inside the abdomen, that's where lenses are impacted by condensation and spray during cauterization," she says. "Investing in something that doesn't do a perfect job of keeping the lens clear might not be worth it." She, too, often relies on the tried-and-true methods of removing the scope for cleaning or dabbing the lens against the abdominal wall to remove gunk. Dr. Oleynikov kiddingly wishes for a tiny wiper blade that whisks away the debris that sticks to the laparoscope's lens.

MODERATE TEMPERATURE Warming laparoscopes before procedures limits fogging of the lens.

Part of the routine
Keeping views of laparoscopy clear has diagnostic value: Surgeons can notice atypical lesions, and color variations and subtle pathology in tissue, says Ceana Nezhat, MD, FACOG, FACS, of the Atlanta (Ga.) Center for Special Minimally Invasive Surgery & Reproductive Medicine.

"It's ideal to work with a stain-resistant laparoscope lens, an insufflator that warms and humidifies gas, and an automatic smoke evacuation device," says Dr. Nezhat. "The technologies add to the efficiency, efficacy and safety of procedures."

Dr. Nezhat says ensuring pristine views of the surgical field is "as important as proper patient positioning and appropriate skin prepping," he says. "We check each day and before every case to ensure the scope's integrity is intact and the camera is properly balanced."

His techs and assistants set up and check the equipment before cases, but he reviews their work and takes full responsibility to ensure every device is in good working order.

"I would not attempt laparoscopy unless all the equipment is primed to provide me with optimal images," he adds. "It's part of my routine, and it should be part of every surgeon's routine."