EinsteinVision 3.0 - Aesculap 3D

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EinsteinVision® 3D Camera System

SCOPE FOGGING AND IMPAIRED VISION IMPLICATIONS FOR MINIMALLY INVASIVE SURGERY

COMPROMISED VISUALISATION IN ENDOSCOPIC SURGERY THE ISSUE OF IMPAIRED VISION Impaired vision is one of the longest standing challenges associated with Minimally Invasive Surgery, and is experienced across all surgical specialties.1, 3, 5, 6, 8, 9, 12 The issue has been likened to driving with a dirty windscreen and having to step out of the car to clean it before continuing the journey.6 Lens fogging and impaired vision are major impediments to a clear visual field during endoscopic surgery and are mainly caused by condensation of the distal part of the endoscope, but the causes can be multi-factorial.1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12 The aetiology of lens fogging is related to condensation occurring when the temperature of the endoscope is at or below the dew point temperature of the anatomical cavity, much like when wearers of spectacles enter a warm room directly from a very cold environment.1, 4, 5, 8, 9. 10, 12 Water vapour and electrosurgical smoke are additional causes of impaired vision, as in a stable pneumoperitoneum (laparoscopy) there is little or no movement of CO2. The white smoke rapidly becomes impenetrable to the human eye, especially in confined spaces.1, 2, 5, 8, 9 Moisture can also build up between detachable camera heads and endoscopes, necessitating disconnection and cleaning, potentially compromising the sterile field.8 The average time lost to dealing with lens fogging is estimated to be 6 minutes for procedures of up to 45 minutes duration.

One study found that in some laparoscopic procedures, 37% of the time was spent with impaired vision. The same study analysed different aspects of the issue and found that whilst lens cleaning was necessary throughout the procedures, 34% of all cleaning procedures occurred during the 1st quarter of the surgery, impeding its progress. There was an average of 15.3 lens contamination events during laparoscopic procedures in the study, but on occasions there were as many as 35 episodes of lens cleaning.6 Data has identified that lead surgeons were involved in scope cleaning 56% of the time, 1st assistants 48% of the time, and scrub nurses 20% of the time.6

THE IMPACT OF IMPAIRED VISION Impaired vision during endoscopic procedures can be dangerous as there is no tactile / haptic feedback. Visual input is the only sensory modality available to the endoscopic surgeon.1, 4, 8, 9, 10 Numerous studies have shown that impaired vision during endoscopic surgery leads to increased operative time and suboptimal views. Repeated removal and cleaning of the endoscope compromises the fluidity of movement and slows surgical progress.2, 3, 4, 5, 6, 8, 9, 10 Often, and paradoxically, vision is most likely to be impaired just where the best vision is required, in tight spaces and close to critical structures.6, 8, 9 A World Health Organisation report identified that problems associated with laparoscope lenses may contribute to surgical errors such as incorrect use of devices or placing instruments on structures other than those intended.8, 14 Patient safety is ultimately compromised by sub-optimal visualisation, and can affect surgeon performance, with increased risk of surgical complications and increased financial costs.1, 2, 3, 4, 6, 8, 9, 10 Continual and repeated episodes of lens fogging leads to irritation and frustration for the surgeon, and scrub nurses experience stress trying to resolve issues around lens fogging. Their concentration is also disrupted by these episodes, and this may result in lack of continuity due to disrupted activity and increased stress levels.1, 3, 4, 6, 8, 9, 10, 11, 13 Compromised visualisation during endoscopic procedures, increases operating time and has potential morbidity.1, 3, 5, 6, 7, 8, 9, 10

SKI

S LL

CO

ST

NEED FOR CHANGE Current methods of dealing with scope fogging are not entirely effective as they do not address the core issue of the temperature differential between the front of the endoscope lens and the anatomical cavity.1, 2, 3, 6, 8, 9, 11, 12

CU

LT U R E

Studies have shown that endoscopes with integrated heating can eliminate the need for extracorporeal cleaning cycles and can deliver unimpeded vision.1,3, 8, 9, 10, 12

Furthermore the issue of electrosurgical or ultrasonic water vapour, and of electrosurgical smoke can be addressed by active exsufflation and smoke evacuation.8, 9 Indeed these characteristics are recommended as key determinants for optimal, clear vision.1, 8, 9

THE SOLUTION B. Braun offer a solution in the form of the Aesculap EinsteinVision® 3D camera system.

The system incorporates an integrated camera head and endoscope, eliminating the interface where there is potential for moisture to collect and so eliminating one of the potential causes of impaired vision.

Furthermore, the laparoscopes have an integrated heater at the distal tip of the endoscope, to heat the distal part of the lens. This eliminates the biggest cause of impaired visualisation, condensation of the distal lens with resultant lens fogging.

As part of the visual tower system, the 50 litre insufflator offers active smoke evacuation by providing exsufflation to remove troublesome water vapour and smoke produced from electrosurgery and advanced energy devices. The insufflator dynamically compensates for exsufflation in order to preserve the intra-abdominal pressure and protect the pneumoperitoneum.

The stereoscopic endoscopes also deliver a narrower field of view which offers increased magnification. This results in the scope(s) being further away from the target tissues with a significant reduction of the incidence of endoscope contamination and decreased requirement for scope cleaning due to soiling.

These features have the potential to significantly reduce surgical procedure times, help maximise patient safety and help improve theatre efficiency.

SUMMARY Adopting the B. Braun Aesculap EinsteinVision® 3D camera system offers potential to improve theatre efficiency, reduce procedural costs and allow for increased activity and increased revenue.

Utilising this technology could assist with meeting a key NHS objective of improving operating theatre efficiency by enabling more surgical procedures to be performed.

Based on eliminating 6 minutes of wasted time per procedure, and assuming 4 endoscopic procedures per day, a saving of 24 minutes could be realised per day.

Assuming 300 operating days throughout the year, this represents 7,200 minutes, or 120 hours of additional operating time. With the hourly cost of running an operating theatre at £1,200, this represents an annual saving of £144,000.

Utilising this additional theatre time could allow for an additional 240 Minor Laparoscopic or Endoscopic, Upper Genital Tract Procedures (MA10Z), generating an additional £1,022 per procedure, and £245,280 per annum.

The EinsteinVision® technology also incorporates a unique sterile sheath concept, negating the need for reprocessing endoscopes, offering potential for additional savings from reprocessing costs and repair costs associated with endoscope repairs.

Accounting for the investment and running costs of the EinsteinVision® 3D camera system, £1,100,400 could be generated over 5 years, through additional revenue and efficiency savings, based on performing 1,200 endoscopic procedures per annum.

References 1.

Manning TG, Perera M, Christidis D, Kinnear N, McGrath S, O’Beirne R, Zotov P, Bolton D, Lawrentschuk N. Visual Occlusion During Minimally Invasive Surgery: A Contemporary Review of Methods to Reduce Laparoscopic and Robotic Lens Fogging and Other Sources of Optical Loss. DOI: 10.1089/ end.2016.0839

2.

Abbitt D, Khallouq BB, Redan J. Quantifying Intraoperative Laparoscopic Visual Field Opacity. DOI: 10.4293/JSLS.2017.00004

3.

Gu L, Liu PL, Zhou H, Xu Q. A Pilot Study for a Better Visibility in the 3D Laparoscopic Right Colectomy Surgery. World J Surg. 2017 Dec 29. DOI: 10.1007/ s00268-017-4402-z

4.

Merkx R, Muselaers C, d’Ancona F, Warlé M, van der Jagt M, Kusters A, Poyck P, Schulte R, Langenhuijsen J. Effectiveness of Heated Sterile Water vs ResoClear® for Prevention of Laparoscopic Lens Fogging in a Randomized Comparative Trial. J Endourol. 2018 Jan 3 DOI: 10.1089/end.2017.0683

5.

John Teague Calhoun, corresponding author and Jay A. Redan, MD. Elimination of Laparoscopic Lens Fogging Using Directional Flow of CO2. JSLS. 2014 Jan-Mar; 18(1): 55-61. DOI: 10.4293/108680813X13693422520431

6.

Yong N, Grange P, Eldred-Evans D. 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. Surg Laparosc Endosc Percutan Tech. 2016 Aug;26(4):286-9. DOI: 10.1097/ SLE.0000000000000289

7.

Nicholas Campbell, Graham Eames, Nathan Lawrentschuk. Laparoscopic Camera Fogging in Urological and General Surgery - Why This Occurs and Methods to Reduce It. The Journal of Urology Vol. 181, No. 4, Supplement, Page 465 Tuesday, April 28, 2009. DOI: http://dx.doi.org/10.1016/S0022-5347(09)61319-7

8.

Lawrentschuk N, Fleshner NE, Bolton DM. Laparoscopic lens fogging: a review of aetiology and methods to maintain a clear visual field. J Endourol. 2010 Jun;24(6):905-13. DOI: 10.1089/end.2009.0594

9.

Bessell JR, Flemming E, Kunert W, Buess G. Maintenance of clear vision during laparoscopic surgery. Minimally Invasive Therapy & Allied Technologies, 5:5, 450-455 DOI: org/10.3109/13645709609153708

10.

Manning TG, Papa N, Perera M, McGrath S, Christidis D, Khan M3, O’Beirne R, Campbell N, Bolton D, Lawrentschuk N. Laparoscopic lens fogging: solving a common surgical problem in standard and robotic laparoscopes via a scientific model. Surg Endosc. 2017 Aug 8. DOI: 10.1007/s00464-017-5772-x

11.

Van Deurzen DF, Mannaerts GH, Jakimowicz JJ, Cuschieri A. Prevention of lens condensation in laparoscopic surgery by lens heating with a thermos flask.

Surg Endosc. 2005 Feb;19(2):299-300. Epub 2004 Dec 9. DOI: 10.1007/s00464-004-8231-4

12.

Flemming E, Bessell JR, Kunert W, Eibl H, Buess G. Principles determining optical clarity in endoscopic surgery. Minimally Invasive Therapy & Allied Technologies, 5:5 440-444. DOI: org/10.3109/13645709609153706

13.

Alfonso Barnard Barragan, MD; Eldo Ermenegildo Frezza, MD. Impact of a Warm Gas Insufflation on Operating Room Ergonometrics during Laparoscopic Gastric Bypass: A Pilot Study. Obesity Surgery, 15, 70-72. DOI: 10.1381/0960892052993611

14.

World Health Organization. Female sterilization: A guide to provision of services. Geneva: WHO,2002. Available at http://whqlibdoc.who.int/ publications/1992/9241544341_(part2).pdf

B. Braun Medical Ltd | Aesculap | Thorncliffe Park | Sheffield | S35 2PW Tel 0114 225 9000 | Fax 0114 255 9111 | www.bbraun.co.uk XX-ASF-05-18

PROVEN VALUE

OF AESCULAP® 3D EinsteinVision® 3.0 PRODUCT

BEYOND THE PRODUCT

Antifog effect

100% Image brightness

100%

Image resolution

97% 97%

Depth perception

Draping concept

100%

Permanent availability

97%

Lower investment

94%

Improved team efficiency

79%

97% appreciate the ease of use and overall performance of EinsteinVision 3.0. ®

D-ST18030

Results of an EinsteinVision 3.0 questionnaire answered by 34 European surgeons. The mentioned percentage combines the top two ratings “excellent” and “very good” on a scale of 5 possible answers.

3.0 NEXT GENERATION

LAPAROSCOPIC SURGERY

SEE BETTER

AESCULAP® 3D EinsteinVision®

The current developments in health care pose a variety of challenges for hospitals, such as Increasing cost pressure Cost and treatment transparency Necessity for process optimization Increasing hygiene requirements Reduction of interfaces and errors Balance between employee satisfaction and time pressure Competition for patients

The question is posed as to how new products can contribute to bringing about improvements in these areas?

SAFETY

TIME SAVINGS

ERROR REDUCTION

EMPLOYEE SATISFACTION

2

Next Generation: AESCULAP ® 3D EinsteinVision®

3.0-SEE BETTER

Premium 3D

Anti-fogging function

EinsteinVision® 3.0 offers exceptional 3D image quality with native Full HD resolution. In addition, the system convinces with an impressive depth of field and high image contrast.

Fogged optics are bothersome, impair the view, disrupt work and can affect patient safety.

Pure viewing pleasure

Integrated heating elements in the endoscope tip of the camera effectively and permanently prevent fogging of the optics within seconds.

Complete perspective

Smoke reduction

Red enhancement

Electrosurgical current regularly generates disruptive smoke. Limited visibility conditions can have an influence on patient safety.

A clearer representation of vessels and greater differentiation of red tones are also desirable.

With the push of a button, a special algorithm reduces the impairment visibly.

Clarity

The integrated algorithm provides precisely that at the push of a button.

Differentiated seeing

3

Sterile provision of 2D components (endoscope, light cable)

TRANSPORTATION

2D OR

TRANSPORTATION

Endoscope, Light cable (camera head)

Interim storage

TRANSPORTATION

Placing in storage Removal from storage

Cleaning, preparation for sterilization

Administration / Purchasing Repair, replacement, complaint

Problem Optical components are thermally sterilized and are thereby subject to constant wear (image quality loss for users) Process demonstrates numerous interfaces (sources of error) Regular repair and/or replacement (administrative effort) Stocking for OR operation and "emergencies" (investments and running costs)

4

Central sterilization

The 3D EinsteinVisionÂŽ sterile delivery concept

Administration / Purchasing Repair

3D OR Camera head with endoscope: Wipe disinfection plus sterile cover

Sterile cover in one piece with shaft for endoscope and drapefoil for camera head and cable

Solution Sterile cover: sterile barrier between patient and camera Process optimization (product remains in the OR) Fewer interfaces (saves time and reduces sources of error) Consistent image quality (no thermal sterile preparation) Cost transparency (minimal repairs) Simple handling Reduces the risk of cross-contamination

SEE BETTER 5

AESCULAP® 3D EinsteinVision® 3.0

SEE BETTER

Platform technology In combination with EinsteinVision® 3.0, 3D and 2D camera heads are used.

Can be used universally

Cable management Integration of camera and light cable in a "mono-cable".

Less is more

Autofocus effect View the OR situs in sharp depth of focus without manual re-focusing.

Always in focus

6

TO PROTECT AND IMPROVE THE HEALTH OF PEOPLE AROUND THE WORLD

Image rotation When your image is "standing on its head" you can rotate it with the push of a button (180° image rotation).

Adaptable

ZOOM

Light

Enlargement of image details with the push of a button

LED offers a long service life with a high quantity of light and less maintenance.

Flexible

Always available

Handling Box-shaped camera head design enables a proper orientation for the viewing position.

Simply good

7

AESCULAP ® – a B. Braun brand Aesculap AG | Am Aesculap-Platz | 78532 Tuttlingen | Germany Phone +49 7461 95-0 | Fax +49 7461 95-2600 | www.aesculap.com

The main product trademark “Aesculap” is a registered trademark of Aesculap AG, the product trademark “EinsteinVision” is a registered trademark of “The Hebrew University of Jerusalem” Subject to technical changes. All rights reserved. This brochure may only be used for the exclusive purpose of obtaining information about our products. Reproduction in any form partial or otherwise is not permitted.

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