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quiet while running are also important factors in choosing a system. The most
common barriers to adoption and implementation, however, are the least
mechanical. "In outpatient facilities, where reimbursement makes or breaks
you, case costs are a large issue," says Dr. Baxt. "Do you go disposable or
reusable? What's the cost of the tubing and the evacuation tip?"
There's also an issue of will. "Not enough people have that as a routine, to
hook up the unit while doing laparoscopy," says Guy Voeller, MD, FACS, a professor of surgery at the University of Tennessee in Memphis. "If the Joint
Commission came in and required the evacuation of smoke, people would do
it."
An automatic smoke evacuation system isn't the only solution for a polluted
pneumoperitoneum. "If you don't have a system set up, the most common solution is to open the valve on a port or trocar and vent it out," says Dr. Voeller.
While simple, this method presents a couple of difficulties on its own, he notes.
"When you have the valve open, you lose some of that pneumoperitoneum,"
he says. "By eliminating the smoke, you're losing the CO2. It's a double-edged
sword," since the deflation that clears the view leaves the laparoscopic surgeon
unable to see.
The other problem is that once the port has been opened, the inflated pneumoperitoneum expels the gases inside under pressure. "You're contaminating
the OR environment with the toxic fumes. Then everyone gets to breathe it,"
says Dr. Voeller.
The solution is compromise: Don't open the port too much or too fast, advises
Dr. Voeller. Partially opening the trocar to vent the smoke, while an insufflator is
replacing the lost gas and an external suction hose captures the escaping
smoke, can maintain a steady state. An even and continuous flow can prevent
the case from screeching to a halt while the cavity is re-insufflated.
Another solution is to utilize trocars that do the job for you. One manufacturer's trocar is part access port, part smoke evacuator and part pressure regulator.
The device incorporates an air curtain that not only provides a stable pneu-
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | J A N U A R Y 2014
