Great laparoscopic surgeons are made, not born. The key is working on the craft and having the right equipment. So says James "Butch" Rosser, MD, FACS, chief of minimally invasive surgery and director of the Advanced Medical Technology Institute at Beth Israel Medical Center in New York City. The right equipment starts, of course, with the laparoscopes themselves.

"When I look now at laparoscopes we were happy with just five years ago, I can't believe how we even used the old ones. That's how dramatic the difference is," says Blacksburg, Va., general surgeon David Stoeckle, MD.

Building a better laparoscope
Experts believe these are the key innovations in scope technology over the last few years:

• Improved optics. Excellent optics set the new generation of scopes apart. Better lighting and resolution allow the surgeon to detect the smallest abnormalities in internal structures, even under low light conditions or in patients with complicated anatomies. The "honeycomb" effect of older scopes is all but gone now as fiber optic light sources have been improved or even replaced. Dr. Rosser says that today's systems pick up different spectrums of light and allow the surgeon to visualize structures with crystal clarity and get more of a true color representation of tissue even after the camera is attached.

Dr. Rosser and other surgeons we consulted were especially enthusiastic about "chip-in-the-tip" scopes - scopes with a camera chip in the distal end, which were first developed around 1993 but perfected only recently.

New Jersey-based thorascopic surgeon Michael Curcio's only criticism of these scopes is that the business end could be a little smaller. "That's a minor trade-off, though, because the optics are so much better," he says.

• Smaller diameter. It is now possible to get a comparable quality of visualization from a 5-mm laparoscope that used to require a 10-mm scope; a 2-mm scope is comparable to older 5-mm laparoscopes. "This means I can work through smaller incision ports close to the chest wall, which reduces post-op pain," says Joseph Petelin, MD, a general surgeon in Shawnee Mission, Kan.
• Improved ergonomics. Angled laparoscopes (such as 30' scopes) were invented as an alternative to zero-degree scopes, which only let the surgeon look straight ahead. Some of them now have mobile tips, which flex and help surgeons look around corners, which is particularly useful in general surgery, says Dr. Stoeckle. The tips also make it possible to see around pockets of fat in obese patients.
• Specialized scopes for specialized procedures. Laparoscopes have been developed specifically for robotically-assisted laparoscopic surgery, minimally invasive disc surgery, lap-band surgery for obesity and microlaparoscopic lysis of gynecological lesions.
• Easier, more efficient sterilization. Many of the new systems (Olympus's Visera EndoEye, Richard Wolf's Panoview Plus and the new bariatric scopes from Stryker) are designed for autoclavability by virtue of specific modifications in their construction to make them better able to withstand the rigors of the sterilization process.

A product rundown
Here's a look at some of the features of the newest scopes:

Visera EndoEye Videoscope from Olympus
The EndoEye is an autoclavable digital videoscope system recently launched by Olympus. The company offers both rotating and non-rotating 5-mm and 10-mm versions of the scope. Drs. Stoeckle and Petelin use the rotating 5-mm, 30-degree models and rave about their optics and maneuverability.

The key to the EndoEye system is its "chip-in-tip" technology. A miniaturized camera chip resides in the scope's distal end, where the objective lens is located, rather than fiber-optic bundles at the proximal end, where the ocular lens at the eyepiece would be in a traditional scope. Dr. Rosser says that this "allows the business end of the scope get closer to the target" than with both the scope and attached camera head and eliminates the "honeycomb" appearance on the video output produced by the fiber optics.

Says Dr. Stoeckle, "With the older generation of scopes, if anything happens to the cable bundles, you don't get clear images. Now, the continuous clarity of the images is amazing. It's always in focus and it doesn't fog." Says Alan Barnett, MD, of Indianapolis, Ind., "it's like being inside instead of looking through a series of windows."

Olympus scopes feature "light enhancers" to overcome the problem of blood in the surgical field; blood absorbs light and can darken the image. "I can't figure out yet how they did it. No scope I ever used increased the light to nearly the same degree," says Dr. Stoeckle.

Dr. Petelin is impressed by the scope's color rendering. Visualizing structures in their true color is critical for assessing tissue. He notes that with other scopes, if you remove the camera and look through the scope itself, you get "beautiful color cues." However, adding a camera distorts the color, even after color correction.

Both surgeons praise the ergonomics of the rotating 5-mm scopes. According to Dr. Stoeckle, it is "a great advantage to be able to maneuver the scope and be able to see in any direction, regardless of the anatomical obstructions. You get crisp images no matter where you look."

Another big change in the EndoEye is that the system is a one-piece unit and does not require four-part assembly. With traditional scopes, the laparoscope itself has to be put together with a coupler to hold the scope and camera. Next, there's the camera to attach. Finally, there is a fiber optic light cable. There are two cables coming out - the fiber optic cable and the video cable. With the new Olympus system, there's only one cable to attach.

Says Dr. Stoeckle, "Assembly with a zero-degree scope isn't really very time-consuming, but it's a bit harder to put together a 30 degree scope. Now, there's virtually no set-up time."

The EndoEye is autoclavable. The entire unit, from end-to-end, can be flash sterilized.

10-mm Bariatric Scopes from Stryker
Stryker Endoscopy offers three different 10-mm scopes for bariatric surgery: a 0-degree scope, a 30-degree scope and a 45-degree scope. They have a longer working length (555 mm for the 0- and 30-degree scopes and 559 mm for the 45-degree scopes) than other types of laparoscopes.

These scopes solve the long-standing problem of the fiber optic bundles creating uneven lighting in the field by having the fibers aligned throughout its three-tube design. The result is evenly distributed brightness and a remarkably crisp image, says general surgeon Giselle Hamad, MD, director of minimally invasive surgery at Magee-Women's Hospital in Pittsburgh, Pa.

"The scopes have top-notch depth of focus," she says. "When you attach the camera, the image you get on the screen is very bright and the resolution is extremely high. There's a very noticeable difference in image clarity compared to older scopes."

In bariatric surgery, the surgeon must be able to maneuver the camera in the anatomy of morbidly obese patients. Dr. Hamad says the Stryker scopes excel in this regard, creating "a lot of maneuverability" for the surgical tools in the intraperitoneum.

Stryker's bariatric scopes are autoclavable. A Stryker spokesperson says that the scopes are designed with flash sterilization in mind. Each joint of the scope is laser welded. Additionally, Stryker's proprietary soldering technique lets the distal window (the side with the objective lens) be soldered to the sheath. The soldered windows and the welded joints make the scopes durable enough to withstand the rigors of steam processing.

Extended-length scopes from Karl Storz
Karl Storz's extended length scopes are available in 31-cm, 42-cm and 57-cm lengths. Some patients require a lower port placement of the scope, and a longer scope working length is necessary to compensate, according to Marc Bessler, MD, director of laparoscopic surgery at Columbia Presbyterian Medical Center. Additionally, with robotic surgery, the robotic arm requires some extra length to maneuver the scopes. The longer Storz scopes allow better visualization of the upper abdomen in bariatric surgery and are ergonomically better than the very long veterinary scopes previously used.

Extended length scopes make it easier to do laparoscopic gastric bands and nissen fundoplications on obese patients, says Dr. Bessler. Together with better anesthesia medications and techniques, these technologies are giving surgeons alternatives to open surgery for obese patients, who are especially prone to post-op pain and slower recovery.

Fujinon's EL2-TF410 and EL2-R410
The rigid EL2-R410 (top) and the flexible EL2-TF410 (bottom) are ultra-high resolution (410,000 pixel), 80-degree, 10-mm video laparoscopes. Both devices incorporate a digital color CCD (charge-coupled device) camera chip on the distal end of the scope. The image is then processed by the Fujinon EVE (Electronic Video Endoscopy) system and sent to the monitor.

The image resolution and clarity of the scopes are "nothing short of stunning," says John Taylor, MD, of Los Angeles.

These scopes also feature a lens wash mechanism on the distal tip, which allows the surgeon to clean blood and tissue off the lens without withdrawing the scope, says Dr. Taylor. This feature helps maintain continuous image clarity and shorten case times, he says.

Unlike conventional laparoscopes, a video laparoscope such as the EL2-R410 laparoscope has no eyepiece at the proximal end. The surgeon relies on the video monitor alone. Fujinon says that this facilitates the operability of the laparoscope and reduces eye fatigue over a long procedure.

The EL2-TF410 model has a flexible tip that can be bent 100 degrees up or down and 90 degrees left or right to look around as the camera moves forward. Both scopes are fully submergible for sterilization or can be steam sterilized.

YESS Spinal Endoscope from Richard Wolf
The YESS (Yeung Endoscopic Spine System) scope from Richard Wolf is the backbone of an integrated system for doing endoscopic disc surgery (best known under the trademarked name Selective Endoscopic Discectomy, or SED).

Here's what makes the spinal scope different. First, because it is used in a posteriolateral procedure, the surgeon needs to be able visualize posteriorly as the scope moves (a zero-degree scope can only "see" forwards). The Wolf scope is angled 20 degrees to provide the proper viewing angle.

Secondly, the scope has a working channel of 2.7-mm and an offset eyepiece, allowing any tool with a length of 32 cm or longer and a diameter of 2.7 mm or smaller to be introduced to the surgical site. This lets the surgeon introduce the tools used to dissect and remove the disc directly to the site, says orthopedic surgeon Paul Tsou, MD, of Santa Monica, Calif.

Lastly, there's the scope's optics. Says Dr.Tsou, "Before the spinal scope, we had to use disposable scopes to do endoscopic disc surgery. They had fiber optics that produced a low-resolution image. Other scopes aren't designed suitably for back surgery." Richard Wolf says the scope employs state-of-the-art fiber optics in the rod lens to offer superior optics, especially when paired with a 3-chip camera.

At what price technology?
Dr. Stoeckle, whose facility recently updated its scopes for the fourth time in thirteen years, says that the going price on any current generation laparoscope is at least $10,000. Many scopes also require the purchase of other equipment.

The EndoEye system, for example, requires three purchases to use the system. Dr. Stoeckle's facility spent a total of $33,680 to purchase the scope itself ($15,000), the Visera system light source ($6,690) and the Visera digital imaging processors ($11,990). The Wolf scopes for spinal surgery are part of a procedure that is extremely expensive to perform, running well over $115,000 to purchase all the related capital equipment.

Dr. Curcio advises facilities not to feel pressured to upgrade unnecessarily if you elect to stay with traditional scopes. He says that unless the other equipment has become notably outdated - such as old CRT monitor - the scope's benefits won't be noticeably diminished in terms of qualities such as color rendering.

When it comes to cost-justifying the scopes, Dr. Curcio says that your surgeons' previous volumes and outcomes are still the main indicator of the potential impact that new equipment might have. "The new laparoscopes...can help make a good surgeon better the same way a baseball stadium with a good visual backdrop makes a hitter see the ball better," he says. "But they won't miraculously turn a mediocre laparoscopic surgeon into a good one."