You're in the middle of a laparoscopic procedure. Suddenly, the picture is flickering, and the screen goes blank. Now what?

Problems such as flickering, blurring, distortion, fog and blank monitors not only delay surgery, extend anesthesia time and increase stress but also, in the worst of cases, can lead to iatrogenic injury. Almost half (48 percent) of the responders to an Outpatient Surgery survey (n=60) say they experience laparoscopy problems "occasionally" and another 11 percent say they deal with them "regularly." We asked a panel of our readers to share their best troubleshooting tips.

Preventive maintenance
The best way to deal with most common laparoscopy problems? Prevent them by thoroughly inspecting your set-up and equipment pre-operatively.

"Perform a complete check of all areas (electrical cords, suction, lights) before you use the equipment and supplies," says a nurse manager. "This eliminates or allows time to correct 99 percent of potential problems."

For example, fogging and blurring - the two most common hitches reported by our responders - can result from condensation on the surfaces of the eyepiece, coupler lens and camera lens.

Look through the scope before surgery. If you see problems, detach the camera and clean the lenses. The Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) Laparoscopy Troubleshooting Guide recommends checking to be sure a cracked lens isn't the cause of the gathered moisture.

To facilitate this pre-flighting, some panelists use simple but effective communication.

At the Upland, Calif.-based San Antonio Ambulatory Surgical Center, director of nursing Susan Dievendorf, RN, color-codes ports to respective cables. "We used to have problems like the screen blanking out or an inability to take pictures," she says. "Now we can immediately look to see if the cables are in the right ports."

Carol M. Gerisch, RN, BSN, MBA, director of surgical services with St. Luke Community Hospital in Saint Ignatius, Mont., posts instructions for slaving the monitors to each other and says this simple step has made set-up easier and reduced operator error.

Getting the fog out
Even the best preparation won't eliminate all problems. According to our survey, fog, blurring/distortion and flickering are the three most common.

Nearly two-thirds (64 percent) of responders deal with lens fogging at least occasionally. Fog usually forms when the surgeon removes the laparoscope from the body, the scope cools down and humidity inside the body condenses on the lens upon reinsertion. Subsequent injection of cold CO2 causes more temperature instability and worsens the problem. Here are four fixes.

• Touch the organ surfaces. Gently wiping the lens on viscera can remove condensation and obviate the need to withdraw the scope to wipe the outer lens.
• Reduce insufflation flow. "High flow fills the abdomen quicker and may give the CO2 less time to warm," says Annie Knotts, RN, with Sewickley Valley Hospital in Sewickley, Pa. "Connecting the insufflator tubing to a port other than the scope port, like an ancillary 5mm port, helps somewhat but requires the physician to be patient."
• Minimize CO2 leakage. This can reduce the need to continue insufflating with cold gas, helping to maintain a more consistent temperature in the pneumoperitoneum. Some recommend stitching overly large trocar sites, and one responder routinely uses Vaseline gauze around trocar sites "Check trocars for open valves or too large an incision around the primary port," adds Karen Geiger, RN, with Gundersen Lutheran Hospital in La Crosse, Wis. Importantly, say many, these measures also help maintain the pneumoperitoneum.
• Considere smoke as the source. Cautery or other heat-induced smoke can look like fog through the scope. "Insufficient venting of the plume will cause the picture to fog up, too," says Ms. Geiger. "We use a smoke evacuator attached to a 5mm side port on laser laparoscopy cases to evacuate the plume. A low setting on our machine doesn't interfere with the pneumoperitoneum."

Many panelists also use anti-fog solutions and scope warmers. Although most are disappointed in their results, those who say they rarely or never experience fogging (n=11) report using anti-fog solutions liberally - before every case and throughout surgery as needed. In addition, the way you use the solutions may influence their efficacy. The SAGES manual recommends cleaning the eyepiece with irrigation on the inside and wiping it with cotton soaked in warm, non-saline water externally, then wiping with dry gauze before applying anti-fog solution. Adds one panelist: "Clean laparoscope lenses with alcohol after decontamination to prevent anti-fog buildup."

Clearing up the picture
Thirty-two percent of responders experience blurring or distortion at least occasionally. While experts say motion of tissue and instruments as well as patient movements like pulsation, respiration and intestinal peristalsis influence image quality, blurring and distortion can also be fog- or equipment-related. Once you've ruled out fog, consider these equipment-troubleshooting measures:

• Check focus. Susan Hatheway, OR supervisor with the Reproductive Science Center of the San Francisco Bay Area in San Ramon, Calif., recommends focusing the camera before the procedure. Intraoperatively, check manual focus and check to see of the auto-focus button is pressed.
• Adjust settings. The SAGES manual recommends adjusting the enhancement and/or grain settings if your unit has these capabilities.
• Clean the lens. Blood or fat on the lens can compromise image quality.
• Ensure an adequate pneumoperitoneum. Double-check to ensure an adequate pneumoperitoneum and adjust the insufflator pressure if needed, says Ms. Geiger.
• Change out equipment. If you're still experiencing problems, it's time to change out the lens and perhaps the camera head. "For us, blurring and distortion generally mean the integrity of the scope's working components are damaged, and we send the scope out for evaluation and repair," reports one manager of surgical services. Says another: "Blurring and distortion are due to scope damage for us, and we spend way too much on scope repair."

Stopping the flicker
"Flickering can result in momentary loss of landmarks, unplanned dissection of tissue, or worse," says Jennifer Misajet, director of surgical services with North Colorado Medical Center in Greeley, Colo. More than one-fourth (27 percent) of our panelists experience flickering at least occasionally. This problem typically results from inadequate electrical connections, and responders suggest first checking to ensure that they are secure.

"Check the camera head wire, check the video cable connection at each monitor and check the adapter that plugs into the CCU to see if it is dry," recommends one California-based equipment administrator. Indeed, the SAGES guide says flickering can result from moisture in the camera-cable connecting plug and recommends using suction or compressed air (but not cotton-tip applicators) to dry it. Pam Kendrick with the Cumberland Medical Center in Crossville, Tenn., says that flickering can result from radiofrequency interference from the cautery unit and, as such, is difficult to completely eliminate.

Other less-common but potentially significant trouble spots include lighting problems, inadequate insufflation/loss of pneumoperitoneum and suddenly blank monitors.

• Too much light/too bright. Readers recommend these approaches: reduce light intensity on the camera head or light box, readjust monitor brightness, adjust the shutter between the light source and camera box, and decrease gain. The SAGES guide also recommends switching to "automatic" if the light is turned to "manual-maximum" and deactivating the light boost if it's on.
• Partial or complete loss of light. First check for loose connections at the source or scope and replace burned-out bulbs. Then, adjust shutter position. Sometimes, an automatic iris closes in response to a bright reflection from an instrument; in this case, switch to manual or reposition the instruments. If you're already on manual, according to SAGES, switch to the "automatic" light setting. SAGES also recommends reducing monitor brightness and dimming room lights. Finally, if you're still having trouble, replace the light cable because the fiber optics may be damaged.
• Inadequate insufflation/ loss of pneumoperitoneum. The most common reason for this problem, say our responders, is trocar leakage. Responders had different ideas for reducing leaks around trocars, including stitching overly large incisions, wrapping Vaseline gauze around the trocar, and ensuring proper trocar sizing. One reader recommends you check that the patient is sufficiently relaxed. The SAGES guide also recommends checking for an empty CO2 tank, inspecting all accessory ports and opening/closing stopcocks as needed, repairing any leaks in the sealing cap or stopcock, temporarily halting excessive suctioning, tightening or reconnecting any loosening or disconnection of the insufflator tubing at the source or the port, checking for and securing any loose Hasson stay sutures and increasing flow rates.
• Suddenly blank monitor. This can signify a lack of power, and SAGES suggests first making sure all power sources are plugged in and turned on. The group also recommends evaluating cable connections to be sure they're plugged in to the right places; that is, cables should run from "video out" on the CCU to "video in" on the primary monitor. The cable should also run from "video out" on the primary monitor to "video in" on the secondary. In addition, recommend several of our survey responders, be sure the input-select button on your monitor is properly set.

"With a blank monitor, trying to troubleshoot video equipment in the middle of a case is very frustrating. You also have an upset surgeon who has no visual field at all now," says Denise Lamberton, director of the Welborn Clinic Surgery Center in Evansville, Ind. "This could be dangerous for the patient, especially if any bleeding was evident before loss of the picture."

• Paper and cartridge problems. Finally, for a minority of our responders (11 percent), printer problems such as jamming or loss of pictures are their bane. "We run out of paper in the middle of a case or we need a cartridge change in the middle of a case," says Ms. Gerisch of St. Luke Community Hospital, where surgeons take hard-copy pictures during laparoscopy. Her advice: "We always stock a new cartridge and paper pack on the tower."

Too many cooks
Laparoscopic equipment is complex and sensitive - and prone to operator error, especially when there are too many cooks in a rushed kitchen. The experience of Lisa Didier, clinical director with Davis Surgical Center in Layton, Utah, is typical of many responders. "We have a problem with too many experts. Everyone has an opinion about how the system works best," she says. "The reps come and adjust the systems so everything is working well, then one little thing happens and the fingers start flying to adjust the camera box, move the lines, etcetera."

Ultimately, agree many of our panelists, the most important troubleshooting rule of thumb is to stay calm and approach problems very deliberately. One nurse manager in California restricts troubleshooting responsibilities to one helper and the primary circulator. "A calm circulator who can block out an irritated physician and focus on troubleshooting is wonderful," she says.