Gas leaks through laparoscopic energy devices and robotic instrumentation – a video vignette

Dear Editor,

The COVID‐19 pandemic has focused surgeons and healthcare systems on the hazards of minimally invasive surgery and its devices [1, 2]. Energy and articulating laparoscopic and robotic instruments contain hollow spaces in their shafts and handles to allow cabling to transmit electrical energy to the instrument tip and tissue. While much attention has been placed on the management of smoke that occurs during cautery by instrument activation [3, 4], it may be less obvious that such instruments may act as chimney flues for intraperitoneal gas to flow unfiltered directly into the operating room environment. This gas will contain smoke but also simply the carbon dioxide (CO₂) used to distend the abdominal cavity and any associated aerosolized cells and virions.

The associated Video S1 demonstrates this in both bench and clinical scenarios. High‐speed schlieren imaging in a high‐fidelity surgical model (porcine cadaver) shows how CO₂ is directly channelled to the exterior via the instrument shaft of a Ligasure device (Medtronic, Minneapolis, Minnesota, USA) and also a robotic instrument (da Vinci, Intutive Surgical, Sunnyvale, California, USA) (CO₂ is optically distinct from room air by its density and so is dynamically detectable by this assessment modality). Clinically, a specific thermographic camera (the FLIR GF 343, FLIR Systems Ltd, West Malling, UK) confirms this mechanism of CO₂ effluvium during actual operations for these instruments by its sensitive visualization of CO₂ gas via its specific near‐infrared absorption characteristic. In addition, it shows a greater tendency for the gas to move around the operating room versus the laboratory due probably to the impact of in‐theatre airflow around the operative field (a combination of positive pressure room ventilation and additional factors such as surgical movement and patient temperature). This confers the potential for pollutants and pathogens in microdroplets and vapour in the gas to contaminate the operating room team. Interestingly, hook diathermy instrumentation and an ultrasonic dissection device (Harmonic Scalpel, Johnson and Johnson Ethicon, New Brunswick, New Jersey, USA) did not carry gas through their instrument shafts but did still cause gas leaks at the level of the trocar. While smoke evacuation will reduce smoke within the peritoneal cavity, unfiltered gas and smoke can still escape via instrument accesses [5] and trocars [6] during minimally invasive surgery.

This information reinforces the rationale for personal protective equipment [7] alongside adherence to guidance regarding smoke management and trocar etiquette. While it also suggests a benefit in risk mitigation for more simple solid instrumentation like hook diathermy, it emphasizes that surgeons really need to understand the construction as well as performance of their instruments to make sure they provide due duty of care for their patients and operating room teams.

Conflicts of interest

RC receives speaker fees from Stryker (Visualisation), consultancy fees from Touch Surgery and Distal Motion, and holds research funding from Intuitive Corporation and with IBM Ireland (from the Irish Government). JD, FZ and KN have no conflicts of interest to declare.

Supporting information

Video S1. Video showing gas leaks occurring through instrumentation used at both standard laparoscopy and robotic‐assisted laparoscopic operation with assessment by both Schlieren and Thermographic Optical imaging.