Impact of Laparoscopic Lens Contamination in Operating Theaters: A Study on the Frequency and Duration of Lens Contamination and Commonly Utilized Techniques to Maintain Clear Vision

Routine Automated Assessment Using Surgical Intelligence Reveals Substantial Time Spent Outside the Patient's body in Minimally Invasive Gynecological Surgeries

OBJECTIVE

To demonstrate the use of surgical intelligence to routinely and automatically assess the proportion of time spent outside of the patient's body (out-of-body-OOB) in laparoscopic gynecological procedures, as a potential basis for clinical and efficiency-related insights.

DESIGN

A retrospective analysis of videos of laparoscopic gynecological procedures.

SETTING

Two operating rooms at the Gynecology Department of a tertiary medical center.

PARTICIPANTS

All patients who underwent laparoscopic gynecological procedures between January 1, 2021 and December 31, 2022 in those two rooms.

INTERVENTIONS

A surgical intelligence platform installed in the two rooms routinely captured and analyzed surgical video, using AI to identify and document procedure duration and the amount and percentage of time that the laparoscope was withdrawn from the patient's body per procedure.

RESULTS

A total of 634 surgical videos were included in the final dataset. The cumulative time for all procedures was 639 hours, of which 48 hours (7.5%) were OOB segments. Average OOB percentage was 8.7% (SD = 8.7%) for all the procedures and differed significantly between procedure types (p < .001), with unilateral and bilateral salpingo-oophorectomies showing the highest percentages at 15.6% (SD = 13.3%) and 13.3% (SD = 11.3%), respectively. Hysterectomy and myomectomy, which do not require the endoscope to be removed for specimen extraction, showed a lower percentage (mean = 4.2%, SD = 5.2%) than the other procedures (mean = 11.1%, SD = 9.3%; p < .001). Percentages were lower when the operating team included a senior surgeon (mean = 8.4%, standard deviation = 9.2%) than when it did not (mean = 10.1%, standard deviation = 6.9%; p < .001).

CONCLUSION

Surgical intelligence revealed a substantial percentage of OOB segments in laparoscopic gynecological procedures, alongside associations with surgeon seniority and procedure type. Further research is needed to evaluate how laparoscope removal affects postoperative outcomes and operational efficiency in surgery.

Quantitative assessment of the troCarWash™ system for automated laparoscopic camera cleaning

BACKGROUND

Soilage of the surgical endoscope occurs frequently during minimally invasive surgery. The resultant impairment of visualization of the surgical field compromises patient safety, prolongs operative times, and frustrates surgeons. The standard practice for cleaning the surgical camera involves a disruption in the conduct of surgery by completely removing the endoscope from the field, manually cleaning its lens, treating it with a surfactant, and reinserting it into the patient; after which the surgeon resumes the procedure.

METHODS

We developed an automated solution for in vivo endoscope cleaning in minimally invasive surgery- a port that detects the position of the endoscope in its distal lumen, and precisely and automatically delivers a pressurized mist of cleaning solution to the lens of the camera. No additions to the scope and minimal user interaction with the port are required. We tested the efficacy of this troCarWash™ device in a porcine model of laparoscopy. Four board-certified general surgeons were instructed to soil and then clean the laparoscope using the device. Representative pre- and post-clean images were exported from the surgical video and clarity was graded (1) digitally by a canny edge detection algorithm, and (2) subjectively by 3 blinded, unbiased observers using a semi-quantitative scale.

RESULTS

We observed statistically significant improvements in clarity by each method and for each surgeon, and we noted significant correlation between digital and subjective scores.

CONCLUSION

Based on these data, we conclude that the troCarWash™ effectively restored impaired visualization in a large animal model of laparoscopy.

Impaired robotic surgical visualization: archaic issues in a modern operating room

While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow.

COMPASS: a formal framework and aggregate dataset for generalized surgical procedure modeling

PURPOSE

We propose a formal framework for the modeling and segmentation of minimally invasive surgical tasks using a unified set of motion primitives (MPs) to enable more objective labeling and the aggregation of different datasets.

METHODS

We model dry-lab surgical tasks as finite state machines, representing how the execution of MPs as the basic surgical actions results in the change of surgical context, which characterizes the physical interactions among tools and objects in the surgical environment. We develop methods for labeling surgical context based on video data and for automatic translation of context to MP labels. We then use our framework to create the COntext and Motion Primitive Aggregate Surgical Set (COMPASS), including six dry-lab surgical tasks from three publicly available datasets (JIGSAWS, DESK, and ROSMA), with kinematic and video data and context and MP labels.

RESULTS

Our context labeling method achieves near-perfect agreement between consensus labels from crowd-sourcing and expert surgeons. Segmentation of tasks to MPs results in the creation of the COMPASS dataset that nearly triples the amount of data for modeling and analysis and enables the generation of separate transcripts for the left and right tools.

CONCLUSION

The proposed framework results in high quality labeling of surgical data based on context and fine-grained MPs. Modeling surgical tasks with MPs enables the aggregation of different datasets and the separate analysis of left and right hands for bimanual coordination assessment. Our formal framework and aggregate dataset can support the development of explainable and multi-granularity models for improved surgical process analysis, skill assessment, error detection, and autonomy.

Randomized controlled trial evaluating the effect of the use of a laparoscopic lens-cleaning device during laparoscopic colorectal surgery on the multidimensional workload (YCOG1903)

BACKGROUND

OpClear® is a newly developed laparoscopic lens-cleaning device that can be attached to a laparoscope. The present study determined whether or not the use of a OpClear® reduces the multidimensional surgery-specific workload of the operator during laparoscopic colorectal surgery for colorectal cancer compared with the reference technique (warm saline) by a randomized controlled trial.

METHODS

Patients diagnosed with colorectal cancer and scheduled for laparoscopic colorectal surgery were randomly allocated to the warm saline arm or Opclear® arm. The primary endpoint was the multidimensional workload of the first operator (value of SURG-TLX). The secondary endpoints were the operative time and total number of lens washes outside the abdominal cavity.

RESULTS

Between March 2020 and January 2021, a total of 120 patients were enrolled in this study. A total of 4 patients were excluded from the full analysis set. A total of 116 patients (warm saline arm: 59 patients, Opclear® arm: 57 patients) were therefore analyzed. The baseline factors were well-balanced between the two arms. Regarding SURG-TLX, there was no significant difference in the overall workload between the two arms. Operators in the Opclear® arm required significantly less physical demand than in the warm saline arm (Opclear® arm: 6, warm saline arm: 7; p = 0.046). The operative time was similar between the two arms. The total number of lens washes outside the abdominal cavity in the Opclear® arm was significantly lower than that in the warm saline arm (Opclear® arm: 2, warm saline arm: 10; p < 0.001).

CONCLUSIONS

There was no significant difference in the overall workload, but the physical demand and total number of lens washes outside the abdominal cavity were significantly lower in the Opclear® arm than in the warm saline arm. The use of this device may thus help reduce operator stress in terms of physical demand. The study was registered with the Japanese Clinical Trials Registry as UMIN0000038677.

Stop the Smudge: A Novel Solution to Loss of Vision During Laparoscopic Colorectal Surgery

BACKGROUND

An obscured vision of surgical field during laparoscopic surgery is inconvenient. Several temporary methods were described as solutions to loss of vision, and common practice is scope removal, cleaning, and heating. A lately developed and introduced device claims continuous clear vision during laparoscopic surgery. This study aims to present our initial experience with the device during laparoscopic colorectal surgery.

MATERIALS AND METHODS

We have included medical records of all patients scheduled for laparoscopic colorectal surgery with the device between March and August 2021 at Cleveland Clinic. Patient demographics, surgery type and time, the number of loss of vision events were recorded.

RESULTS

Fifteen patients underwent laparoscopic colorectal surgery during the study period. The median age was 42 (range: 25 to 86) years, and 10 (66%) were female. The median surgery time was 127 (range: 67 to 240) minutes, and the median loss of vision event number was 3 (1 to 6) per surgery. There was no need for laparoscope removal during any of the surgeries. All surgeries were completed without any intraoperative complications.

CONCLUSION

The novel system, provides clear vision during laparoscopic colorectal surgery with no need of scope removal for loss of vision events. The system provides removal of particulate gathering on the tip of the scope.

Effectiveness of oolong tea and simethicone solution for lens cleansing during colonoscopy: A double-blinded randomized study

BACKGROUND AND AIMS

water is an imperfect agent for lens cleansing during endoscopy due to its incompetence to clean hydrophobic dirt, whereas amphiphilic surfactants have the potential to overcome the limitation of water. The trial was aimed to evaluate the cleansing effectiveness of 2 typical surfactants (simethicone solution and oolong tea) for colonoscopic lens.

METHODS

Oolong tea (O-), low concentration simethicone solution (S1-), high concentration simethicone solution (S2-) and distilled water (D-) were used as washing solutions for colonoscopic lens. Study I: The tip of the colonoscope was immersed in lard oil in order to simulate the blur, and photographs were taken toward a standard colonoscopy image in-vitro pre- and post- each cleansing procedure. The blurred areas of each image were quantified and compared. Study II: 395 consecutive patients who were due to colonoscopy examination were enrolled and randomized into O-, S2-, D-group. The volume of washing solution used and cleansing level during the examination procedure, adenoma and polyp detected per colonoscopy, insertion time and withdraw time were analyzed.

RESULTS

Study I: There were no differences in 4 groups for the blurred areas on images before lens cleansing. The blurred areas after lens cleansing were significantly smaller in 3 groups (O- 8.47 ± 20.91 vs S1- 13.06 ± 10.71 vs S2- 6.76 ± 8.49 vs D- 38.24 ± 29.69, P < .05) than water. The decline range of blurred areas after lens cleansing in oolong tea, low concentration simethicone solution, high concentration simethicone solution groups were significantly higher than that in distilled water group (O- 87.35 ± 20.81 vs S1- 78.12 ± 19.24 vs S2- 89.57 ± 8.50 vs D- 53.39 ± 28.45, P < .05). Study II: The volume of washing solution used in S2-group was significantly smaller than that in O-group and D-group. The cleansing level of the colonoscopic lens of O-group was significantly superior than that of S2-group and D-group.

CONCLUSIONS

The in-vitro test showed oolong tea and simethicone solution can effectively cleans the colonoscopic lens. The clinical trial demonstrated that oolong tea instead of water is effective to provide better visualization during colonoscopy.Registration: Chictr.org.cn No: ChiCTR1900025606.

Design and Performance Testing of a Novel In Vivo Laparoscope Lens Cleaning Device

A common tool for diagnosis and treatment of gastrointestinal, gynecologic, and other anatomical pathologies is a form of minimally invasive surgery known as laparoscopy. Roughly 4 × 106 laparoscopic surgeries are performed in the U.S. every year, with an estimated 15 × 106 globally. During surgeries, lens clarity often becomes impaired via (1) condensation or (2) smearing of bodily fluids and tissues. The current gold standard solution requires scope removal from the body for cleaning, offering opportunity for decreased surgical safety and efficiency, while simultaneously generating mounting frustration for the operating room team. A novel lens cleaning device was designed and developed to clean a laparoscope lens in vivo during surgery. Benchtop experiments in a warm body simulated environment allowed quantification of lens cleaning efficacy for several lens contaminants. Image analysis techniques detected the differences between original (clean), postdebris, and postcleaning images. Mechanical testing was also executed to determine safety levels regarding potential misuse scenarios. Compared to gold standard device technologies, the novel lens cleaning device prototype showed strong performance and ability to clear a laparoscope lens of debris while mitigating the need for scope removal from the simulated surgical cavity. Mechanical testing results also suggest the design also holds inherently strong safety performance. Both objective metrics and subjective observation suggests the novel design holds promise to improve safety and efficiency during laparoscopic surgery.

Stop the leak!: Mitigating potential exposure of aerosolized COVID-19 during laparoscopic surgery

BACKGROUND

Viral particles have been shown to aerosolize into insufflated gas during laparoscopic surgery. In the operating room, this potentially exposes personnel to aerosolized viruses as well as carcinogens. In light of circumstances surrounding COVID-19 and a concern for the safety of healthcare professionals, our study seeks to quantify the volumes of gas leaked from dynamic interactions between laparoscopic instruments and the trocar port to better understand potential exposure to surgically aerosolized particles.

METHODS

A custom setup was constructed to simulate an insufflated laparoscopic surgical cavity. Two surgical instrument use scenarios were examined to observe and quantify opportunities for insufflation gas leakage. Both scenarios considered multiple configurations of instrument and trocar port sizes/dimensions: (1) the full insertion and full removal of a laparoscopic instrument from the port and (2) the movement of the scope within the port, recognized as "dynamic interaction", which occurs nearly 100% of the time over the course of any procedure.

RESULTS

For a 5 mm instrument in a 5 mm trocar, the average volume of gas leaked during dynamic interaction and full insertion/removal scenarios were 43.67 and 25.97 mL of gas, respectively. Volume of gas leaked for a 5 mm instrument in a 12 mm port averaged 41.32 mL and 29.47 for dynamic interaction vs. instrument insertion and removal. Similar patterns were shown with a 10 mm instrument in 12 mm port, with 55.68 mL for the dynamic interaction and 58.59 for the instrument insertion/removal.

CONCLUSIONS

Dynamic interactions and insertion/removal events between laparoscopic instruments and ports appear to contribute to consistent leakage of insufflated gas into the OR. Any measures possible taken to reduce OR gas leakage should be considered in light of the current COVID-19 pandemic. Minimizing laparoscope and instrument removal and replacement would be one strategy to mitigate gas leakage during laparoscopic surgery.

A novel one-step lens cleaning device using air and water flow for endoscopic surgery

In a surgical operation requiring endoscopy, it is essential to obtain a clear endoscopic view. However, it is often disturbed by the contamination on the lens during the surgery. No device can clean the lens surface simply and completely. Many surgeons are hampered by the impaired view and the distraction by the repeated cleaning of the lens. Therefore, we developed a novel endoscope cleaning device to address this problem. The device was made of 3D-printed rubber-like plastic. It contains a syringe filled with saline and an aspiration system. It would be used intraoperatively to wash the lens surface in a few seconds with rapid flow of water and air. The cleaning ability of the device was evaluated using mayonnaise with adenosine triphosphate (ATP) as a model contaminant. The gauze-wiping maneuver was selected as control. After each maneuver, the clarity of the endoscopic view was evaluated, and residual contaminants were assessed quantitatively with ATP assay. The cleaning device obtained a crisp and clear view and eliminated the contaminant on the lens every time after a single cleaning maneuver. The gauze-wiping maneuver required for the lens to be wiped at least three times to obtain a clear view, and even then, some contaminants remained. Repeated contamination and cleaning using gauze led to accumulation of contaminants on the lens, which resulted in difficulty in cleaning the lens as the operation proceeded. The cleaning device did not show such accumulation. Our novel cleaning device with air and water flow has been shown to wash out the lens contaminants completely and immediately in a simple manner. It is expected to improve the safety and cost-effectiveness of endoscopic surgery.

Effectiveness of Heated Sterile Water vs ResoClear® for Prevention of Laparoscopic Lens Fogging in a Randomized Comparative Trial

BACKGROUND

Laparoscopic surgery may be complicated by visual disturbances, including lens fogging. Several techniques have been developed to prevent laparoscopic lens fogging (LLF). We aim to compare the effectiveness of two commonly available techniques in prevention of LLF: heated sterile water in a thermos flask and ResoClear^® impregnation wipes.

MATERIALS AND METHODS

In this single-center prospective randomized study, 50 patients underwent an elective laparoscopic donor nephrectomy and were allocated to either heated sterile water or ResoClear^® impregnation wipes as the antifogging method. The primary outcome was the number of fogging events during the first 30 minutes of the operation, whereas secondary outcomes were operating time, number of cleaning events because of other causes, cost differences, and assessment of predicting factors for fogging events.

RESULTS

In 50 patients, the outcomes were analyzed. The number of fogging events was significantly lower when using heated sterile water (median = 0, interquartile range [IQR]: 0-0) compared to ResoClear^® (median 1.0, IQR: 0.5-3.0), p < 0.001. There were no significant differences in operating time, number of cleaning events because of other causes, and costs. No predictors of fogging events were found.

CONCLUSION

The use of heated sterile water leads to significantly less fogging events than the use of ResoClear^® impregnation wipes, resulting in an improved continuity of the surgery without differences in operating time and costs.

First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device

BACKGROUND

Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology.

METHODS

A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction.

RESULTS

Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system.

CONCLUSION

Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Prospective, randomized comparison of the use of FloShield Air System® versus the reference technique (water + povidone-iodine solution) during gynecologic endoscopic surgery to evaluate the operative lens vision quality

BACKGROUND

The FloShield Air System^® is a new device for laparoscopic surgery that utilizes a continuous dry CO₂ gas flow over the scope to defog the lens and protect it from condensation, debris and smoke. We set out to compare the performance and efficiency of the device in terms of operative lens vision quality (OLVQ) with the reference technique (water + povidone-iodine (PVI) solution) during gynecologic laparoscopic surgery.

MATERIALS AND METHODS

We conducted a single-center randomized prospective study between March and June 2016 (Trials Database Registration NCT02702531) including 53 patients undergoing gynecologic laparoscopic surgery with water + PVI solution and 51 patients who underwent surgical procedures with the FloShield Air System. The primary outcome measure was the number of laparoscope removals during surgery. Secondary outcome measures were the time to clean, assessment of the quality of vision, the correlation between the laparoscopic surgical complexity and outcomes, and cost effectiveness.

RESULTS

Overall, the mean patient age was 43.2 years (range 22-86) and body mass index 24.8 (range 16.8-42.7). The mean number of endoscope removals during surgery was 7.0 (range 0-37) in the water + PVI solution arm and 2.8 (range 0-12) in the FloShield Air System^® arm. The number of removals was significantly lower in the FloShield arm (p < 0.001). No difference in time to clean, quality of vision, level of laparoscopic procedure complexity, or cost was observed between the groups.

CONSLUSIONS

The FloShield Air System^® resulted in fewer laparoscopic lens removals than the water + PVI solution solution, but that there was no difference in quality of vision, cleaning time or cost, especially for the more complex surgery.