Visual occlusion during minimally invasive surgery: a contemporary review of methods to reduce laparoscopic and robotic lens fogging and other sources of optical loss

Abstract

Background: Maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. Hampered vision is commonly caused by laparoscopic lens fogging (LLF) which has prompted the development of various anti-fogging fluids and warming devices. However, limited comparative evidence exists in contemporary literature. Despite technological advancements there remains no consensus as to superior methods to prevent LLF or restore visual acuity once LLF has occurred. We performed a review of literature to present the current body of evidence supporting the use of numerous techniques. Methods: A standardized Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) review was performed and PubMed, Embase, Web of Science and Google Scholar were searched. Articles pertaining to mechanisms and prevention of LLF were reviewed. We applied no limit to year of publication or publication type and all articles encountered were included in final review. Limited original research and heterogenous outcome measures precluded meta-analytical assessment. Results Vision loss has a multitude of causes and although scientific theory can be applied to in vivo environments, no authors have completely characterized this complex problem. No method to prevent or correct LLF was identified as superior to others and comparative evidence is minimal. Robotic LLF was poorly investigated and aside from a single analysis has not been directly compared to standard laparoscopic fogging in any capacity. Conclusions Obscured vision during surgery is hazardous and typically caused by LLF. The etiology of LLF despite application of scientific theory has yet to be definitively proven in the in vivo environment. Common methods of prevention of LLF or restoration of vision due to LLF have little evidence-based data to support their use. A multi-arm comparative in-vivo analysis is required to formally assess these commonly used techniques in both standard and robotic laparoscopes.