title: 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 antifogging fluids and warming devices. However, limited comparative evidence exists in contemporary literature. Despite technologic 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 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 is 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 multiarm comparative in vivo analysis is required to formally assess these commonly used techniques in both standard and robotic laparoscopes.
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .|2 Young Urology Researchers Organisation (YURO) , Melbourne, Australia .
authors.forename: Todd G
authors.initials: TG
authors.lastname: Manning
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .|2 Young Urology Researchers Organisation (YURO) , Melbourne, Australia .
authors.forename: Marlon
authors.initials: M
authors.lastname: Perera
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .|2 Young Urology Researchers Organisation (YURO) , Melbourne, Australia .
authors.forename: Daniel
authors.initials: D
authors.lastname: Christidis
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .
authors.forename: Ned
authors.initials: N
authors.lastname: Kinnear
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .|2 Young Urology Researchers Organisation (YURO) , Melbourne, Australia .
authors.forename: Shannon
authors.initials: S
authors.lastname: McGrath
authors.affiliation: 3 Department of Engineering (Chemical), University of Melbourne , Melbourne, Australia .
authors.forename: Richard
authors.initials: R
authors.lastname: O'Beirne
authors.affiliation: 2 Young Urology Researchers Organisation (YURO) , Melbourne, Australia .
authors.forename: Paul
authors.initials: P
authors.lastname: Zotov
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .
authors.forename: Damien
authors.initials: D
authors.lastname: Bolton
authors.affiliation: 1 Department of Surgery, Austin Health, University of Melbourne , Melbourne, Australia .|4 Department of Surgical Oncology, Peter MacCallum Cancer Centre , Melbourne, Australia .|5 Olivia Newton-John Cancer Research Institute , Melbourne, Australia .
authors.forename: Nathan
authors.initials: N
authors.lastname: Lawrentschuk
mesh_terms: D006801:Humans; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D007909:Lenses; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D065287:Robotic Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D013227:Steam; D013696:Temperature; D014785:Vision, Ocular
chemical_list: D013227:Steam
keywords: fogging; laparoscopic equipment; laparoscopic lens fogging; laparoscopic surgery; robotic surgery; surgery