Assessing visualization in robotic-assisted surgery: demystifying a misty lens

Despite major technological advancements in robotic-assisted laparoscopic surgery (RAS), there remain shortcomings yet to be addressed. This study assesses the prevalence of suboptimal vision in minimally invasive RAS and corresponding factors regarding related surgical conditions. 45 minimally invasive robotic surgeries, performed using Da Vinci XI, were observed across three surgical subspecialties: general, urology, and OB/GYN. Lens occlusion events were monitored and defined as the presence of a visual distortion caused by debris deposition on the scope lens. Lens occlusions and cleanings, and "active instrumentation" were recorded. Descriptive statistics summarized duration-based variables, and one-factor ANOVA compared the presence of active instrumentation. Cases averaged 127 ± 76 min. Active instrumentation ANOVA during lens occlusions demonstrated significant variation between categories (F_{7, 256} = 11.63, p = 2.558e-13). Post hoc Tukey HSD found electrocautery devices were active significantly more during occlusion events (37.9%) than other instruments. On average, lens cleaning occurred every 36.5 ± 39.8 min despite lens occlusion occurring every 24.5 ± 15.7 min. Of the operative time observed, 41.4% ± 28.1% was conducted with visual distortion. 1.16% ± 0.97% of time observed was spent cleaning. Although only 1.16% of operative time was spent cleaning, surgeons experienced suboptimal conditions for nearly 35× the time it would take the clear lens, potentially indicating a tendency to avoid cleaning the lens to disrupt surgery. Future research may examine the impact of occluded visualization and lens cleaning on other aspects of surgery.