Minimally invasive surgery is tough on surgeons, who constantly struggle to manage the technique's inherent challenges: access to the abdominal cavity, and clear views of tissue and anatomy. Luckily, newer laparoscopes offer promising solutions. Here are some of the latest improvements and the impact they can have on surgical visualization:

• High-definition video. One of the first big improvements was the development of the 5mm deflectable HD laparoscope with a charge-coupled device (CCD) at the tip, says Sharona Ross, MD, director of minimally invasive surgery and surgical endoscopy at Florida Hospital's Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery in Tampa. "Having the CCD image sensor at the tip delivers a brighter, larger depth-of-field picture, and it has a focus-free operation," she says. "It was also very advantageous cost-wise, because it removed the rod lens system, which reduces repair costs. The fact that it's autoclavable also reduces costs."
• Improved ergonomics. The all-in-one design of the deflectable tip laparoscope, with its integrated light cable and camera system, also represents an ergonomic improvement. "Eliminating the (external) light source coming in at 90 degrees from the actual shaft of the camera was very useful, especially for single-incision laparoscopy," says Dr. Ross, "because you can lean it down and parallel to the patient's body. It lets you have more range of motion for the other instruments."
• Bariatric length. Another step forward, says Dr. Ross, was one company's decision to provide high-definition articulating laparoscopes in 45cm lengths. "The technology is similar," she says, "but the advantage is the bariatric length. When we use the single-incision laparoscopic approach, all the instruments are bariatric length because you're working from a single port. It lets you stagger instruments and the scope nicely."
• 180-degree articulation. Unquestionably one of the most dramatic improvements, articulation "adds another level of safety," says Dr. Ross. "It lets you visualize the surgical field from different angles, so there's no question in your mind as to what it really is. You can direct the scope behind the tissue you're about to cut and make sure it's what you think it is."

• 3D imaging and recording. This is truly state of the art, and it lives up to the hype. "It's absolutely amazing. Three-dimensional perspective is an immediate game-changer with regard to patient safety," says Dr. Ross. "It provides you with more information and lets you be very careful with your dissection. You can visualize the blood vessels and see the tissue planes clearly, which lets you avoid injuries."

The HD 3D laparoscope provides more information with better precision and resolution, adds Dr. Ross. "All the advantages that you have while sitting at a robot console and visualizing tissues in 3 dimensions, you're now able to have with the laparoscopic approach," she says. "It's ideal for tasks such as suturing. It's truly beautiful."

Another plus: At least one company allows you to add the upgraded 3D scope to its existing imaging system. "Some companies force you to purchase an entire tower when you buy a new, upgraded scope," says Dr. Ross. "Being able to use the same tower system decreases the capital investment and simplifies training."

The only disadvantage is that the 3D technology currently requires 10mm scopes, which means you need a slightly larger incision than might be ideal under some circumstances — at least, that is, until the next improvement comes along.

Oh, and you also need to wear 3D glasses. Not a problem, says Dr. Ross, who was given an early prototype. "They showed me these ugly, ugly glasses and I said, 'Listen, if I need to wear this in the operating room, there's no way I'm wearing these. I've got to have something designer-like,'" she laughs. "And wouldn't you know, they came up with glasses now that are really like designer glasses. They're really very nice."

What's next?

So, has the technology gone about as far as it can go? "I think if you asked an older surgeon, he'd say it's probably pretty close to where it's going to be," says Alexander Rosemurgy, MD, director of the Surgical Digestive Disorders and GERD Center at Florida Hospital. "But if you ask a young surgeon what kind of improvement there will be over the next 25 years well, if you go back to 1989, they were just beginning to do laparoscopic cholecystectomies in a couple of places then. I don't think we foresaw 25 years ago what's going on today."

Drs. Ross and Rosemurgy are also working with various companies to implement other improvements that may become more widely available. One of the devices they've developed reorients the laparoscopic view so that it's able to be broadcast onto the patient's abdominal wall, says Dr. Rosemurgy. "It's reformatted so people can see where their instruments are," he explains. "One of the problems with novice surgeons is that they don't know where their instruments are until they're in the view of the camera. If they've got to pull the camera back, find out where they are and then advance the camera with the instrument sets, it takes some time. If you have an operation where you have to do that 30 times, and each time takes a minute, you've just made the operation 30 minutes longer."

They're also working to develop what they call laparoscopic "no-fly zones." It's possible with the new camera they've developed to designate areas as off limits, and if a surgeon ventures into the zone, an alarm will sound.

"I think the answer to the question of what the future holds lies in some of these things," says Dr. Rosemurgy. "The trocars will be smaller, the cameras will be brighter, but more importantly, we're going to come up with new paradigms for patient safety, and develop new techniques for education and training."