Clear Vision, Clear Savings: Enhancing Efficiency in Minimally Invasive Surgery

Abstract

Background and Objectives:

Minimally invasive surgery (MIS) offers faster recovery and smaller incisions but is limited by persistent visualization issues such as lens fogging, debris, and camera instability. These challenges compromise surgical performance, increase complications, and elevate healthcare costs. This review evaluates the clinical and economic impact of suboptimal visualization in MIS and explores potential solutions.

Methods:

A systematic review was conducted using peer-reviewed literature from January 1990 to August 2024. Studies included those examining visualization challenges in laparoscopic and robotic MIS, clinical outcomes, surgeon-reported frustrations, and cost analyses. Exclusion criteria included studies with significant conflicts of interest, especially those funded by medical device companies.

Results:

Surgeons spend an estimated 40% of MIS operating time under suboptimal visual conditions, contributing to nearly 20% of surgical complications. Lens cleaning adds $132–$493 per procedure, averaging $312.53 based on 9.7 cleaning events per case. Visualization-related complications contribute an additional $251 per case. Combined, these issues result in over $2.2 billion in annual costs in the U.S. Poor visualization also disrupts workflow, increases surgeon fatigue, and hinders integration of emerging technologies such as artificial intelligence (AI).

Conclusions:

Suboptimal visualization in MIS stands to significantly affect patient safety and healthcare costs. Addressing these challenges through standardized cleaning protocols, improved surgeon training, and adoption of advanced technologies—including AI-driven imaging—is essential. Enhancing visualization is not just a technical upgrade but a critical step toward safer, more efficient, and cost-effective surgical care.

INTRODUCTION

Every year, millions of patients undergo minimally invasive surgery (MIS), drawn to the promise of faster recovery, smaller incisions, and reduced pain from laparoscopic and robotic surgery.¹ Both laparoscopic and robotic surgery have seen significant advancements in recent years, with the development of automated insufflation machines, endoscopic camera systems, and multifire clip application devices.² Even more recently, robotic-assisted surgery has seen a rise in popularity and usage, demonstrating a clinical appreciation for the advanced platforms, offering new technological features such as advanced real-time navigation feedback, haptic feedback, and articulating instruments that lead to potential benefits in faster recovery times and reduced complications.^3,4 Implementation of state-of-the-art medical technologies bring novel medical opportunities to the operating room (OR) to positively impact surgical performance.⁵ These advancements have and will continue to propel the field forward. The future of these procedures lies in the continued development of innovative techniques and technologies, particularly in the area of visualization. Further still, focused efforts to improve surgical visualization lie at the frontiers of innovation for the field. New advancements such as 3D video imaging, augmented reality, fluorescence imaging, and remote telementoring systems, stand to change the game as they aim to make surgeries faster and safer for patients, as well as more seamless and sustainable for clinicians.^6,7 The more recent emergence of artificial intelligence (AI) creates even more opportunity to level up all technologies, but perhaps most especially it might enhance and accelerate initiatives for improving visualization.^8,9

Still, challenges in surgical visualization can impede the standard of care.¹⁰ Significant challenges in laparoscopic visualization, such as lens debris and camera instability, showcase outstanding needs in the OR and research reveals a strong demand for AI-based solutions that improve the surgical field of view, training, and patient safety.⁸ Robotic and other digitally-enhanced platforms such as Intuitive Surgical, Moon Surgical, and Distal Motion are helping to address camera instability with mechatronic “arms,” while a number of companies and techniques have been, and continue to be, developed for lens cleaning—both ex vivo and in vivo. Despite technology advancements and established shortcomings surrounding visualization, the current standard of care in MIS remains subpar, particularly regarding the quality and reliability of intraoperative visualization. The status quo has been accepted as the normal, despite falling short of clinically expected standards.² This review proposes a definition for the current standard of care for intraoperative visualization in MIS to typically involve endoscope visualization, with key elements that include: (1) a pneumoperitoneum, or insufflation, of the abdominal cavity, (2) a camera-equipped endoscope with an external video monitor for image display, (3) manual manipulation of the endoscope that is ultimately controlled/managed by a clinician, and (4) recurring intraoperative episodes of lens obstruction. While practices for instrument selection, camera control, and lens cleaning vary between robotic and straight-stick laparoscopy, these features constitute the foundations of the current standard of care. An assessment of scientific and medical literature may highlight key areas of the field to assess and understand gaps and opportunities that may enable future advancement of the standard.

One of the primary challenges faced by surgeons is the issue of lens obscuration, which can hinder the ability to clearly view the operating field. This issue not only complicates surgical maneuvers, but also increases the risk of errors and adverse outcomes for the patient, surgeon, and staff.² In fact, a recent clinician survey study showcased that lens contamination and lens fogging were the most uncomfortable aspects about laparoscopic surgery, right behind inappropriate camera moving, highlighting the clinician-perceived criticality of lens cleaning.¹¹ Despite the importance of lens clarity and the complex and pressing issues associated with an obstructed lens, the problem has not yet been wholly characterized in scientific literature. There is an undeniable need for further research to understand the true magnitude and impact of suboptimal visualization in surgical procedures.

To address this gap in understanding, this paper undertakes a thorough review of academic literature to outline and understand the complexities of visualization challenges in laparoscopic and robotic surgeries. Additionally, the aim is to provide insights into the underlying causes, potential errors, and overall impact on patient care, and underscore the urgency for further research and innovation to enhance the standards of surgical visualization and improve patient outcomes.

MATERIALS AND METHODS

A systematic review of the literature was conducted to assess limitations of current standard of care principles revolving around visualization within robotic and laparoscopic surgeries. It also assessed the impact of visualization in MIS according to the PRISMA guidelines. The selection criteria focused on peer-reviewed literature published from January 1990 to August 2024 to ensure the inclusion of relevant and contemporary studies. The primary databases included PubMed and Google Scholar, with additional sources utilized to ensure comprehensive coverage. The search employed specific keywords such as “surgical errors,” “laparoscopy,” “minimally invasive surgery,” and “laparoscope camera obscured” to identify pertinent articles.

Inclusion criteria required studies to (1) assess visualization issues during laparoscopic or robotic MIS, (2) be peer-reviewed, (3) report clinical or economic outcomes, and (4) not be funded or significantly influenced by medical device manufacturers. Exclusion criteria included studies focused solely on open surgery, animal models, editorials, or lacking discussion of intraoperative visualization. Two independent reviewers screened titles and abstracts, followed by full-text review. Disagreements were resolved by consensus. Data was extracted using a standardized form, capturing study type, sample size, surgical setting, visualization challenges, interventions, complication rates, and economic impact. While no formal meta-analysis was performed due to heterogeneity across studies, qualitative synthesis was conducted to identify common trends and reported outcomes. Special attention was given to surgeon-reported interruptions, device performance, and intraoperative adjustments due to poor visualization. Lastly, research into the current technologies was considered. This comprehensive approach aimed to gather a wide range of studies that explore various aspects of MIS visualization challenges and associated consequences in clinical practice.

The primary research question addressed was: “How does the current standard of care in MIS intraoperative visualization affect patient outcomes and surgical performance?” By systematically analyzing the gathered literature, the review aimed to identify correlations between visualization and associated outcomes. This involved evaluating incidence of surgical errors, complications, and overall operative efficiency in scenarios where visualization was compromised. The findings from this review highlight the critical importance of an uncompromised field of view in laparoscopic and robotic surgery and underscore the potential risks associated with visual impairments such as blurred lenses and inadequate imaging quality. On a broader scale, various aspects of surgical care influenced by shortcomings of robotic and laparoscopic medical devices regarding visualization were demonstrated, not limited to induced stress, irritation, and compromised patient safety. This comprehensive review provides a foundation for understanding the impact of visualization issues and informs future technological and procedural improvements in the field.

RESULTS

Clinical Impact

The High Stakes of Visualization: A Foundation for Patient Safety and Surgical Success

MIS is critically dependent on camera/scope visualization inside the body—without it, the benefits of laparoscopic interventions such as reduced recovery time, risk of wound infections, and lower costs would go unrealized.¹² However, there is still a need for advanced visualization techniques to enhance the surgeon’s view and improve safety for these game-changing procedures.^13,14 Advanced visualization techniques and technologies help propel surgeons and OR teams forward with stellar vision for precise operation.^8,15–17 These surgeries require an ideal environment to enable a safe and sufficiently sized field of vision to be kept in place—this is accomplished by insufflating the abdomen with CO₂, and is referred to as the pneumoperitoneum. Failure to maintain the pneumoperitoneum serves as one root cause of inadequate vision capable of leading to detrimental outcomes.¹¹ In fact, in a study out of Germany by Lünse et al, surgeons claimed the most uncomfortable aspects of conventional laparoscopy were inappropriate camera movement at 73.8% and lens condensation at 73.3%, with an additional 53.5% reporting camera lens contamination as a primary issue.⁸

This desire for technological intervention extends beyond simple lens cleaning. That same study showed 77.2% of surgeon respondents expressed a need for a self-cleaning camera system, while 80.7% desired automatic defogging features. Clearly, there's a recognized need to reduce disruptions caused by dirty or foggy lenses. Surgeons are increasingly looking towards AI-powered solutions to enhance visualization and improve surgical performance. The same survey found that the most desired AI-based features included automatic camera positioning (71.3%), image stabilization (66.8%), and anatomical landmark visualization (67.3%).⁸ These advanced capabilities aim to provide a clearer, more stable, and information-rich view of the surgical field, ultimately reducing errors and supporting better decision-making. High stakes become even more apparent, as inadequate vision has been shown to directly result in patient vessel injury, intraoperative bleeding/blood loss, and other such complications, with 1 study demonstrating that nearly 1 in 5 surgical complications are linked to poor visualization.^18–20

Laparoscopic-to-open surgery conversions can also be caused by poor visualization. Many surgeries that begin laparoscopically and experience complications are converted to open surgeries with current conversion rates spanning 5–37%, and being linked to detrimental patient outcomes including mortality, morbidity, extended recovery time (+∼3 days), comfort, and postoperative quality of life.^21–25 Furthermore, Koto et. al demonstrated poor visualization as a direct reason for conversion, with as many as 50% of conversions caused by intraoperative bleeding due directly to poor visualization.²⁵ As increased time of surgery and anesthesia correlates to higher incidence rates for surgical complications and postsurgical infections, both of which can result in increased hospital readmissions, scope removals for lens cleaning events truly generate negative downstream for many stakeholders.²⁶

Furthermore, as poor visualization caused by lens obscuration is concretely associated with scope removals from the surgical cavity for lens cleaning, consideration must be given to instrument dynamics linked to concerns regarding OR staff exposure to aerosolized contaminants such as surgical smoke carcinogens, HPV,^27–32 and potentially COVID-19. Such health concerns were rekindled during the COVID-19 pandemic,³³ and trends were discovered regarding potential OR staff exposure to aerosolized viruses through CO₂ gas leakage via trocar ports, with noted leakage spikes during instrument removal (e.g., ex vivo lens cleaning).^34–36 In fact, the foremost surgical organizations in the world recommend all measures possible to mitigate OR staff exposure to insufflation gasses.^{27–32,35,37–41}

Challenges to Maintaining Optimal Visualization

Most of the strategies currently employed to remove debris and fog in the OR do not utilize advanced technology. These include legacy techniques, such as touching the laparoscope to a solid organ or viscus to remove debris from the lens—a method documented as early as 1977 and still informally practiced today.^42,43 While this may occasionally improve visibility for lens fogging, results are inconsistent most especially when trying to clear blood and tissue fouling, with the possibility to further reduce visibility. As well, this action may cause tissue damage due to heat generated at the lens tip, and wiping the lens on tissue can increase the risk of infection through bacterial transfer.^19,44,45 Still, this is a common occurrence in surgeries simply because surgeons would prefer to not remove the scope from the abdomen for lens cleaning.^42,46 Perhaps most concerning is that more than 40% of laparoscopic and robotic-assisted surgery time is spent with impaired visualization because surgeons are often reluctant to clean lenses ex vivo as it interrupts their workflow,^45,47,48 which is arguably a justifiable approach since surgical interruptions related to instrument issues represent the highest risk of significant impact on surgical procedures and are shown to decrease OR quality and safety.^49–51 Increasing interruption levels also correlate with high levels of surgical team stress, increased workload, and higher error rates.^49,51–54 However, the problem is a double-edged sword, as the resulting impaired vision further compromises patient safety.^19,45

Currently, the gold standard for lens cleaning requires ex vivo cleaning (outside the body). Surfactants such as FRED, as well as heated sterile water have attempted to focus on addressing the issue of lens fogging. There are also widely used “cleaning stations,” namely Medtronic’s Clearify Visualization System⁵⁵ and CONMED’s LaproVue Visibility System,⁵⁶ both of which might be described a heated surfactant bath for the scope lens, plus a cloth/sponge for wiping the lens tip. Both systems also come with a trocar cannula swab, as debris often gets stuck in these cannulas throughout surgery and these can lead to more obtrusive and frustrating lens cleaning⁵⁷ interruptions upon reinsertion. As these ex vivo cleaning lens techniques are the gold standard, they are associated with the current standard of care for MIS visualization, which is well-explored throughout this article.

Disrupting the Flow: Visualization’s Impact on Surgical Teams

Another issue from obstructed visualization of surgical lenses is the disruption of surgical flow, leading to stress on surgeons and staff. As laparoscopic surgeries, on average, require multiple cleaning events per case,^42,45 sometimes up to 30 times or more per surgery (depending on the case complexity), they are constantly and consistently interrupting surgical flow.⁵⁸ Surgical flow is a state of complete absorption and instinctive action, akin to being “in the zone.”⁵⁹ This state is often achieved by surgeons to transcend physical discomfort, and is said to have 9 definitive characteristics: challenge-skill-balance, merging of action and awareness, clear goals, unambiguous feedback, concentration on the task, sense of control, loss of self-consciousness, time transformation, and autotelic experience. Furthermore, as Sutton found, improvements to reduce gaze disruptions and potentially surgical errors should focus on realigning the axis between the surgeon's eye and the visual display, as well as improving instrument design and workflow.⁶⁰ Disruptions in the surgical flow have been seen to significantly increase the occurrence of errors in surgery.⁶¹ These disruptions include technology and equipment problems, training-related distractions, communication failures, outside interruptions, and problems with surgical resources.⁵¹ Furthermore, fatigue hinders performance and threatens the desired flow experiences, and can lead to burnout.⁶² A study by Petrut et al found that as the number of tasks increases and surgeons progress through the workday, they become more fatigued, leading to increased reaction time and altered attention and memory.⁶³

Among many research studies intended to quantify interruptions experienced by working surgeons and medical staff in ORs, a prospective observation study conducted in Sweden provides perspective. Among all the interruptions experienced during medical procedures in the OR, interruptions related to equipment represented the largest proportion, at 26.7% of all distractions observed. These insights allow further investigation into the various ways that technological advancements play a role in hindering smooth medical practices.⁶⁴ Additional observational studies conducted with general and orthopedic/trauma surgeons in the United States highlight similar findings. Equipment and OR-environmental related interruptions were associated with the highest interference with team functioning, specifically in laparoscopic procedures 53. Equipment-related distractions correlate with higher levels of stress, perceived workload, and error rates. In addition, these distractions correlate with a decrease in quality teamwork skills, compromising both staff and patient safety.⁵⁴

While initial consideration for poor visualization would seem like a minor nuisance, it becomes clear with more extensive review that the clinical impact to patient and OR staff is quite significant.

Economic Impact

The Hidden Costs of Blurred Vision

The pursuit of improved visualization in MIS is not just a clinical imperative; it's an economic necessity. Suboptimal visualization carries hidden costs that impact healthcare systems, hospitals, and patients alike. Economic assessments are crucial in medicine as they assess the resource costs and healthcare outcomes of medical interventions.⁶⁵ The economic impact of cleaning the lens during operations remains to be demonstrated.⁴⁵ When MIS is not performed optimally, more errors occur, leading to more complications for patients.⁶⁶ These surgical complications have significant economic implications.^67,68 However, little has been done to quantitatively measure the techniques and devices used in MIS, making it challenging to accurately quantify the cost of a blurry laparoscopic lens with any granularity.¹⁹

As described earlier, lens visualization can directly lead to complications such as conversion to open surgery, which can have major economic implications. A 2019 study on emergent cholecystectomies revealed that the overall risk-adjusted cost per index hospitalization for laparoscopic procedures was $10,026, while it was $36,029 for conversion to open cases (a 259% higher risk-adjusted cost for conversions compared to nonconversions),⁶⁹ highlighting that higher postoperative care needs contribute to the elevated financial implications of these conversions. Aligned with this finding, Lengyel examined financial differences between laparoscopic cholecystectomy conversions and prolonged laparoscopic cholecystectomy cases.⁷⁰ The extended postoperative stay for conversion surgeries led to a disparity in total hospital charges, with conversion cases at $32,446 compared to $23,946 for prolonged cases (a 26% increase in total hospital charges for conversion cases and, on average, a 3-day longer stay for conversion cases).

Multiple comprehensive studies have shown that nearly 7–8% of total operating time is spent cleaning the laparoscope, with lens contamination events ranging from 4 to 16 events per case, on average.^42,45 Each study also found that more than one-third of laparoscopic procedure time is consistently performed without a clear display. The combined data from Rahman et al and Yong et al demonstrate that a substantial portion of operating time and costs are attributed to lens cleaning events, underscoring the need for effective solutions to minimize these disruptions and their financial implications. The broader economic impact of visual impairment during laparoscopic surgery is not readily available in the literature, highlighting the need for further investigation into this issue. A true cost-benefit analysis of poor visualization, including lens cleaning, should be thoroughly understood to adequately scope the impact of the problem.

Lens Cleaning—Time Is Money

To understand the cost-benefit analysis, one must consider the current standard of care for cleaning the scope in MIS, which involves removing the lens from the cavity to clean it. The indicators to compare will be the price per removal of the lens and the price per hour. These indicators are calculated by quantifying the price with time spent in surgery.⁷¹ Each minute in the OR was shown to cost an average of $66,⁷² however considering inflation since the time of the study, this is further extrapolated to $107.40/minute according to the Bureau of Labor Statistics. In laparoscopic surgeries studies have found that various procedures may vary on average between 4.11 and 15.3 cleaning events per case, with an average of those 2 counts at 9.7 cleaning events per case.^42,45 Each cleaning event in a laparoscopic procedure, involving removing and reinserting the laparoscope, averages 17.88 seconds (∼0.3 minutes) with a standard deviation of 18.81 seconds.¹⁹ Dollars per cleaning event were calculated by multiplying the number of cleaning events per case times the cost per minute of OR time and the time spent cleaning the scope. Additionally, the total cost per case spent on lens cleaning multiplied the dollars per cleaning event by the number of cleaning events per case. These are a calculated average from the studies.

These calculations can be seen in Table 1, and show that the price per cleaning event in laparoscopic surgery is approximately $32, and the cost of cleaning events on average appear to range from ∼$132–$493 per case, depending on literature references and associated cleaning events per case used, for a median cost of more than $1 billion across all 4.8 million cases in the United States. Regardless, the numbers are quite staggering when considering the commonly perceived “simplicity” of the task. In this situation, it is clear that “simple” translates to “costly.”

Table 1.

Economic Impact Per Cleaning Event

Scenario	# Cleaning Events Per Case	OR $ Per Minute	Minutes Per Cleaning Event	$ Per Cleaning Event	$ Per Case
Minimum	4.11	$107.40	0.3	$32.22	$132.42
Average	9.7				$312.53
Maximum	15.3				$492.97

Complications from Poor Visualization

The concern of surgical interruption and increased time (and associated negative clinical and economic implications) due to lens cleaning events may actually incentivize limiting the number of cleaning events—a notion supported by the fact that more than 40% of surgery is performed under suboptimal visualization.^45,47,48 While thresholds vary per type of surgical complication, they unequivocally correlate with higher costs. While peer-reviewed literature resources on complications linked to a poor surgical field of view are extremely limited, 1 study found that 18.2% of in situ surgical complications in a patient cohort were attributed directly to poor visualization, creating a feasible pathway to extrapolate the estimated costs of associated complications.⁷³ Table 2 looks at the economic impact of complications associated with poor visualization of a subset of 4 major procedure types to observe the projected total economic burden of associated complications. Total United States procedure volume was multiplied by the average intraoperative complication rate for each procedure type. This was then multiplied by the added average cost of associated complications for said procedure type. Finally, this value was multiplied by 18.2%—the rate of intraoperative surgical complications due to poor visualization as found by Bonrath, Gordon, and Grantcharov.⁷³ It is important to note that Bonrath, Gordon, and Grantcharov specifically correlate 18.2% of surgical injuries, and not strictly complications, to poor visualization. As such, the inference of cost is instead proposed as a rough estimate, rather than an outright calculation, since such relevant cost data on only surgical injuries was not able to be found. Still, given that many complications often include surgical injuries, the rough estimate still provides an insightful look at the notion that poor visualization is a costly burden to stakeholders beyond the clinical impact.

Table 2.

Economic Impact of Blurry Lens on Large Quantity MIS Procedures in the United States^{73–79,100–102}

Procedure	Cases/Year	Average Complication Rate	Added Cost Due to Complication	Average Complication Rate Due to Poor Visualization	Estimated Economic Burden
Cholecystectomy	885,00074	5.85%75	$15,480.0076	18.20%73	$145,861,770.60
Colectomy	116,26171	19.80%77	$17,850.0076		$74,784,027.92
Bariatric	279,967100	10.10%101	$7,457.83101		$38,380,645.89
Appendectomy	277,50078	9.51%79	$16,000102		$76,848,408.00

The calculations in Table 2 demonstrate an approximate economic impact of poor visualization—40% of surgical time—is substantial. In fact, for over 4.8 million surgeries in the United States each year,⁸⁰ this subset and its impact represents only approximately one-third of all surgeries. If assumed complication rates from the subset above were averaged over the entire 4.8 million surgeries each year, with an estimated average surgical complication cost of $12,228 as seen in the table above, this would yield a staggering $1.2 billion in global economic burden due to complications caused by poor visualization ($251.82/case).

The costs associated with lens cleaning, along with the increased risk and concurrent cost of complications, lead to significant healthcare cost burdens. As such, improving lens visualization during surgery stands to drastically improve surgical outcomes and reduce economic burdens on healthcare systems. Continuing to conduct economic assessments can provide insights into further improving MIS and lowering associated healthcare costs.

Optimal Visualization: Essential for AI in MIS

The integration of AI into MIS holds tremendous promise, but realizing this potential depends critically on consistently clear visualization as AI-powered^81–83 surgical tools rely heavily on high-quality images for their training and functional deployment in the clinical setting. Many AI systems used in surgery are trained on extensive datasets of high-quality videos/images that are specifically curated for the relevant tool being created.⁸³ This training process shapes the AI’s ability to interpret surgical scenes. When deployed in real-world scenarios where suboptimal visualization is present in nearly 40% of intraoperative time (e.g., due to lens fogging, debris, etc.), AI will struggle to interpret what it “sees” due to the video image feed being something models are not familiar with. This gap will lead to errors or diminished functionality of this robust and game-changing technologies. Many of these tools use images to identify anatomical structures, guide robotic movements, and assist surgeons in real-time decision-making.^82–87 The reliance on clear visualization extends beyond robotic surgery and time estimation. AI systems are being developed to assist with various surgical tasks, including real-time identification of bleeding vessels, anatomical landmark recognition, and even tissue characterization.^88–93 For example, AI guidance systems for robotic surgery rely heavily on visual data to guide the robot's movements.^94–97 If the camera view is blocked or obscured (e.g., by debris on the lens), this could result in unintended collisions or other adverse outcomes, or a complete halt in the procedure dependent on fail-safes. If visual input is compromised, these AI tools could fail to identify bleeding, misinterpret anatomical landmarks, or incorrectly characterize tissue, all potentially leading to adverse patient outcomes or increased economic costs due to these surgical inefficiencies.

The increased use of AI in surgery will likely lead to more sophisticated tools that are heavily dependent on visual input. These could include enhanced imaging systems, robotic arms with more refined control, and AI systems providing real-time warnings and guidance to surgeons. However, if the basic quality of the visual input is poor, these advancements will not reach their full potential, potentially compromising patient safety and surgical outcomes and efficiency. The failure of AI-driven systems due to poor visualization might further lead to an increase in stalled procedures with longer operative times, or potentially a need for more staff and resources to compensate for these shortcomings.^98,99 These issues could further create overall higher healthcare expenditures. The future of surgery is bright, but seems unlikely to reach its threshold if suboptimal visualization standards remain the norm.

DISCUSSION

This comprehensive review of the literature highlights a critical yet often overlooked aspect of MIS: the impact of visualization on both patient outcomes and surgical performance. While MIS offers significant advantages over open surgery, our findings demonstrate that the current standard of care for visualization falls short of consistently ensuring optimal clarity and, consequently, contributes to preventable complications, increased costs, and disruptions in surgical workflow.

Our analysis revealed a concerning disconnect between the recognized importance of surgical image quality in MIS and the effectiveness of current practices in maintaining it. Surgeons frequently encounter challenges such as lens fogging, debris contamination, and inadequate camera stability, leading to a reported 40% of surgical time being spent with suboptimal visualization. These disruptions not only increase surgeon frustration and stress but also directly impact patient safety. The alarming statistic that nearly 1 in 5 surgical complications are linked to poor visualization underscores the urgent need for improved approaches. Lens contamination and cleaning interruptions stand to contribute to issues such as surgeon fatigue, increased stress levels, and potentially higher error rates.

The economic implications of inadequate visualization are equally significant. The act of laparoscope removal for lens cleaning translates to substantial financial burden. Our calculations, based on published data of OR time costs and cleaning frequencies, estimate that lens cleaning adds between $132 and $493 to the cost of a typical laparoscopic procedure. This adds up to about $1 billion in wasted time across the United States. Moreover, the increased risk of complications directly attributable to a poor field of view further amplifies the economic burden. Again leveraging existing peer reviewed literature, the United States is estimated to have 99,848 surgical cases with complications caused by suboptimal visualization. These complications lead to a cost increase of $251 per case and a total of $1.2 billion in complications in the United States. The increased costs of over $2.2 billion due to complications and wasted time highlight the shockingly high economic impact of poor visualization in MIS surgeries.

Achieving and maintaining optimal visualization is not just about improved surgical comfort; it is a fundamental requirement for the safe and effective integration of AI in the OR. Investing in better ways to ensure a clear field of view will be crucial in realizing the significant potential benefits of AI-assisted surgery. Improvements to surgical video imaging will be critical for maximizing the benefits of AI-driven advances in MIS and enhancing both patient safety and surgical efficiency.

While advancements in visualization technologies hold promise for the future, our findings emphasize the need for immediate action to improve current practices. Simple measures, such as standardizing lens cleaning protocols, adopting more effective techniques, and optimizing ergonomic factors in the OR, could yield substantial improvements in visualization quality and patient safety. Furthermore, a greater emphasis on training surgeons to recognize and manage associated image quality challenges may prove a valuable endeavor.

While this review highlights the critical impact of visualization in MIS, several limitations related to these results also require consideration. Notably, this study has focused nearly exclusively on volume and cost data and did not dive into many nuances for each different subspecialty across all relevant surgeries. Those variances, combined with the reliance to use results across medical research reports with different baselines (e.g., specific cases may include complications or costs for one type of patient, but is applied to a patient pool that has less relevance for the same result) implies more caution for how this report is viewed as a general assessment primarily for assessing correlation as opposed to causation. There is still opportunity to use this review to explore nuances and provide potential direction on how to best consider, approach, and leverage the importance and impact of quality visualization in laparoscopic surgery. Additionally, while there have been efforts to apply multiple filters during research that support data veracity, the limited availability of robust, comparable data for a variety of settings should be considered in relation to the overall conclusions that this study presents. Although the lack of robust, comparable data further suggests the value and need for review such as this. In conclusion, although this review accomplishes the goal of answering the relevant research question at hand, several specific and nuanced considerations throughout the work are still not able to concretely claim causality without further research with a high priority in these specific arenas. This makes the approach and findings most valuable for those engaged or concerned about the quality of intraoperative surgical vision and clarity for MIS and associated impacts it can have on stakeholders.

Regardless, this review underscores the urgent need for a paradigm shift in how we approach visualization in MIS. It is not merely a technical detail; it is a fundamental determinant of surgical success and patient well-being. A proactive, multifaceted approach encompassing technology, training, and a commitment to continuous improvement is essential to fully realizing the promise of both traditional and robotic MIS.

CONCLUSION

The imperative for optimal visualization in MIS is undeniable. This review has demonstrated that, despite the recognized importance of a clear field of view, current practices fall short, resulting in compromised patient outcomes, increased healthcare costs, and diminished surgical team performance.

Our findings reveal a compelling case for elevating the standard of care for visualization in MIS. On an individual scale, subpar visualization costs between $132 and $493 per lens cleaning and $251 for each surgical complication. On the broader economic scale in the United States, the economic burden alone totals approximately $2.2 billion in total costs, $1 billion from additional OR time due to cleaning disruptions and $1.2 billion from surgical complications attributable to poor visualization. This large amount of economic impact underscores the need for immediate action. The potential for preventable complications, including conversions to open surgery, should serve as a powerful call to action for the surgical community. Ensuring an optimal surgical field of view is not merely a matter of convenience, but a fundamental requirement for the safe and effective integration of AI in MIS. Addressing the limitations of current visualization practices is essential to fully realize the transformative potential of AI-assisted surgery and avoid both compromising patient safety and increasing costs.

The findings from this review call for a multifaceted approach to improving visualization in MIS:

• Advancing technological solutions by investing in research and development of more effective lens cleaning methods, advanced imaging technologies, and potentially AI-assisted systems to minimize disruptions and enhance consistent high quality for surgical video imaging.

• Refining training and protocols may enable standardization of lens cleaning techniques, promoting best practices and incorporating visualization-specific training into surgical curricula. Such efforts may empower surgical teams to proactively manage and mitigate visualization challenges.

• Fostering a culture of continuous improvement in ORs would encourage vigilance and ongoing evaluation of visualization practices, ideally driven by data towards better patient outcomes.

• Considering the impact beyond what is seen today’s OR is key. Addressing suboptimal visualization now could yield huge benefits for surgery in the future, especially when considering the rapidly developing implementation of AI into the OR.

By prioritizing optimal visualization as a fundamental pillar of MIS, we can ensure that patients fully benefit from the minimally invasive approach while also maximizing surgical efficiency and minimizing the economic burden on healthcare systems.