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In laparoscopic surgery diathermy-generated fume annoyes not only me but a lot of surgeons. It affects the visibility in surgery, requires to clean the scope repeatedly. Smoke management really slows the operation down, increases blood loss and therefore prolongs hospital stay and has an impact on recovery from surgery for women. Its simply a nuisance we all put up with. There is no value for patients or surgeons of fume.

I use the Ligasure device for vessel sealing and in regards to monopolar I mostly use the “coagulation” function of the monopolar scissors. While both surgical devices are divine to work with, the smoke generated through those is significant.  Smoke generated through monopolar “cut” is even more of an issue. The cut function cuts through tissue really well and injuries to adjacent structures such as bowel and ureters have been reported.

The typical “smoke evacuator”, simply a piece of hose with a filter at its end that ends blindly, is a fake surgical device. It actually does not work and it puzzles me how many of these fake devices can be sold over so many years without proof of efficacy. The original intention was that contaminated gas passively drains out of the belly and gets filtered before doctors, nurses and everyone else in the operating room inhales it.

As we all know those “smoke evacuators” clog up after a few minutes. After every 15 minutes we need a new “smoke evacuator” and you go through a number of these “cheap” surgical devices, racking up costs for a piece of surgical equipment that performs very poorly. I decline using these fake surgical smoke evacuators. It slows the operation down and annoys everyone involved quite a bit.

Stryker provides the insufflators for two hospitals I operate at. I spoke to Stryker management about this issue on several occasions. I enquired about a system that pumps CO2 in but also evacuates contaminated CO2 into the same insufflator. As always Stryker’s customer service staff were very friendly and helpful. Their insufflator is produced in Germany and Stryker very kindly even arranged for me to meet one of their German engineers. I had a lengthy chat about this most annoying issue with them. No outcome. I assume Stryker makes its revenue mostly with orthopaedic surgery; there they don’t need insufflators, don't create fumes. Laparoscopy is simply not high enough on the agenda for Stryker to generate change. 

I was operating at the Townsville Base Hospital in North Queensland this week and was approached by an I.C. Medical rep who showed me a completely novel approach to this issue, which I would like to share with you because its so great and easy.

First, their system works in addition to what I already use. Hence, I do not need to change anything I do. I still use whatever insufflator is available. I use my diathermy instruments as usual. 

In brief, we connected a soft suction tube from one of the laparoscopy ports to a “vacuum cleaner”. When you turn your diathermy on, the vacuum cleaner will turn itself on also and evacuate gas at a flow range between 1 and 20 litres per minute. I have the dial at set 4 L/min evacuation, which was working perfectly fine – provided you insufflate gas at a rate higher than 4 L/min. The contaminated gas gets evacuated, filtered and does not get pumped back into the abdomen. The only gas that gets pumped into you abdomen is clean and comes from the insufflator.

Most surprisingly, the vacuum cleaner did not generate any noise. At one point I asked if it actually does anything. The rep turned the vacuum cleaner off and the belly was full of smoke again – like usual. What a difference that was.

You activate your diathermy, a brief episode of fume appears, and then you can see that the fume gets sucked out of the body. I love it.

The smoke evacuation does not continue all the time. It turns itself on when you activate the diathermy and turns itself off after a few seconds. The system requires you wrap the diathermy lead (monopolar and bipolar) around a small black magnet. If the diathermy is turned on, the magnet will pick up an electromagnetic signal and turn the smoke evacuation on.

I was glad, I could trial this new device. Blood loss was negligible, operating time was even shorter and the three patients I used it for did even better than usual after surgery. I like it – a lot!

The system is called Crystal Vision and distributed by IC Medical in Australia. Cheap as chips - Funny enough, I saw it on ebay for $93. 

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