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3 Simple Ways to Clear the View
Don't let smoke, fog or debris impede laparoscopic procedures.
David Bernard
Publish Date: December 20, 2013   |  Tags:   Waste Management
no smoke CLEAN START Laparoscope lenses must remain clean and clear for unobstructed views of the surgical site.

With all the talk of HD this and 3D that, effective and safe surgery is jeopardized by one simple truth: Docs can't operate if they can't see. Smoke, fog and debris cloud or smear the laparoscope's lens during abdominal cases, effectively blinding the surgeon and wasting valuable minutes as he repeatedly removes the scope for cleaning or constantly pauses to ventilate the surgical site. Thankfully, there are ways to ensure your surgeons maintain clear views of the action.

1 Eliminate the smoke
The smoke that's generated by electrocautery, laser tissue ablation or ultrasonic scalpel dissection in the close confines of the pneumoperitoneum can also impair the laparoscopic surgeon's view of the surgical site. Even high-definition scopes and widescreen monitors offer little benefit when a smoke-filled cavity casts a haze over the image, flattening depth perception and dulling color differentiation. "It is critically important to keep the field smoke-free," says Robert Baxt, MD, a laparoscopic hernia repair and abdominal wall reconstruction specialist based in Avon, Conn. "This explains the growing popularity of smoke evacuators in the OR."

In addition to the units and accessories that suction smoke away from open or skin-level sites, devices are available to clear the air inside the peritoneum by way of the trocars your surgeons are working through. "A passive, automatic smoke filter that continuously ventilates and filters the smoke doesn't require the surgeon to stop what he's doing, which is a big benefit," says William L. Barrett, MD, of CaroMont Surgical Associates in Gastonia, N.C. If trocar ports are at a premium, the evacuation devices can be inserted and removed as needed.

A smoke evacuator's suction capacity and filtration quality are major considerations in evaluating its effectiveness. But whether it's inobtrusive to a surgeon's technique, easy for surgical staff to set up and adjust, and acceptably quiet while running are also important factors in choosing a system. The most common barriers to adoption and implementation, however, are the least mechanical. "In outpatient facilities, where reimbursement makes or breaks you, case costs are a large issue," says Dr. Baxt. "Do you go disposable or reusable? What's the cost of the tubing and the evacuation tip?"

smoke evacuation DOWN THE TUBES Insufflation and smoke evacuation play complementary roles.

There's also an issue of will. "Not enough people have that as a routine, to hook up the unit while doing laparoscopy," says Guy Voeller, MD, FACS, a professor of surgery at the University of Tennessee in Memphis. "If the Joint Commission came in and required the evacuation of smoke, people would do it."

An automatic smoke evacuation system isn't the only solution for a polluted pneumoperitoneum. "If you don't have a system set up, the most common solution is to open the valve on a port or trocar and vent it out," says Dr. Voeller. While simple, this method presents a couple of difficulties on its own, he notes.

"When you have the valve open, you lose some of that pneumoperitoneum," he says. "By eliminating the smoke, you're losing the CO2. It's a double-edged sword," since the deflation that clears the view leaves the laparoscopic surgeon unable to see.

The other problem is that once the port has been opened, the inflated pneumoperitoneum expels the gases inside under pressure. "You're contaminating the OR environment with the toxic fumes. Then everyone gets to breathe it," says Dr. Voeller.

The solution is compromise: Don't open the port too much or too fast, advises Dr. Voeller. Partially opening the trocar to vent the smoke, while an insufflator is replacing the lost gas and an external suction hose captures the escaping smoke, can maintain a steady state. An even and continuous flow can prevent the case from screeching to a halt while the cavity is re-insufflated.

Another solution is to utilize trocars that do the job for you. One manufacturer's trocar is part access port, part smoke evacuator and part pressure regulator. The device incorporates an air curtain that not only provides a stable pneumoperitoneum, but also continuously evacuates smoke throughout the procedure.

2 Fight the fog
Anyone who's ever worn eyeglasses going indoors from winter's chill or outdoors from summer's air conditioning knows what happens when a laparoscope readied in a cool, dry OR enters the warm, humid environment of the pneumoperitoneum. The lens fogs up.

This may happen even in the short span of time it takes for a surgeon to remove, wipe and replace a scope. Condensation may obscure the view while a filtering system replaces smoke-saturated air with cooler air. And hemostatic devices such as ultrasonic scalpels create a byproduct of water vapor as well as smoke, which can mist up the lens. There are multiple causes of fogged laparoscope lenses, and multiple solutions.

Pre-warming and pre-treating the scope ahead of time simplifies the entry. "We put it in a scope warmer, like a thermos full of warm water," says Dr. Barrett, in order to lessen the temperature difference between the room-air-cooled instrument and the pneumoperitoneum. There is also commercially available anti-fog solution which, applied to the scope tip, can keep the lens clear.

If mid-procedure defogging becomes necessary, one manufacturer offers a single-use, stable-based laparoscope holder that cleans, warms and anti-fog treats the scope's tip upon insertion. Dr. Baxt says an instrument bath of warm saline on the back table can deliver similar results. "Every OR's got sterile basins and saline from the warmer," he says. "It's cheap and easy."

The way a surgery is set up can also reduce the likelihood of fog delays. An insufflator that maintains the proper temperature and humidity during a case or a smoke evacuator that pumps in warmed, humidified CO2 can help to prevent mid-procedure fogging, says Dr. Baxt. So can being mindful of the direction of the insufflator or evacuator's airflow, adds Dr. Barrett. "I typically make sure that the air coming in isn't coming through the same port as the scope is, to minimize fog," he says.

instrument exchanges PORT OF ENTRY Instrument exchanges in mid-case can smudge ports, and scope lenses.

3 Solve the smudges and smears
"The scope smears with blood, fat or slime," says Dr. Voeller. "Depending on the case, you sometimes spend more time wiping the scope than doing the procedure."

Applying a surfactant substance to the lens before a procedure can provide a preliminary defense against a buildup of debris. In mid-procedure, cleaning smudged lenses with a squirt of saline from the scope's irrigation channel or a quick wipe against organ tissue can clear the view without the need to remove the scope from the site, says Dr. Baxt. This keeps the case moving and ensures surgical safety.

"It's so important not to lose focus on what you're operating on," he says. "If you go in and out of the port, if you take your eye off the spot, you lose your critical focus on the area."

The laparoscopic market has seen the development of accessories to keep the lens clear without withdrawing it from the site. One such device, a single-use sheath that fits over the scope, channels CO2 from the insufflator to flow over the lens. The warmth prevents fogging and the airflow repels debris. Another product, a sterile, single-use laparoscopic sponge, has been designed to reach through the trocar to swab a dirty lens where it stands.