As we enter in the Modern day, we are witnessing dawn of the new trend in which closed body operating procedures are more often being performed through minimal access. This development is the consequence of vision and work of many dedicated individuals. They include early pioneers of endoscopy who planted the seed and lastly the current pioneers who pushed and expanded these frontiers to give rise the birth of modern laparoscopy. Therapeutic laparoscopic surgery was introduced into the surgical practice recently and within a short span of time, it has become established as defacto standard for the treatment of chronic cholelithiasis and many advanced laparoscopic procedures can be performed safely. Laparoscopic surgery, what we should witness today, may be the culmination of over a hundred years of painstaking efforts from the number of pioneers within the fields of optics, instrumentation and video laparoscopic camera. Few advances in medicine occur in isolation. The innate human curiosity to peer within the body cavities can be traced back to ancient times. However, due to primitive technology and crude instruments, several ambitions were not realized. It is probably safe to say that first laparoscopy would not have been performed had it not been for the efforts of many physicians in 1800s to develop endoscope. The device developed by Theodore Stein in mid 1880 contains all the aspects of the current endoscopic documentation system. There was a crude endoscope and a high intensity light source. Illumination was made by continuously feeding a magnesium wire into an ignition chamber utilizing a clockwise mechanism. Light from this combustion was reflected to the tube utilizing a mirror. Finally the look was focused on to some photographic plate through coupling optics.

1. PROF. SREEJOY PATNAIK
SHANTI OMNI SUPER SPECIALITY
HOSPITAL , CUTTACK ,ODISHA
ENDO-VISION SYSTEM
IT’S MAINTANENCE AND
TROUBLE SHOOTING

2. EVERY SURGEON SHOULD KNOW THESE BASICS PRIOR TO
STARTING A LAP. UNIT

3. ENDOVISION SYSTEM-‘EYE OF THE SURGEON’
• Revolution in optics & imaging technology helps to produce real
‘life like’ images in a magnified way, thereby helping accurate
dissection.
• ELECTRONIC EYE INSIDE THE ABDOMEN
• The imaging system includes-
– Laparoscope / Telescopes
– Light source
– Light cable
– Cameras
– Monitors
• For a ‘perfect image’ all of them should be of good quality.
• A GOOD ENDOVISION IMPROVES THE QUALITY &
PRECISION OF SURGERY & ITS OUTCOMES.

4. THE ENDOVISION EQUIPMENTS
THE ARMAMENTERIUM

5. 1.LAPAROSCOPE OR TELESCOPE
• Invented by Hopkins in 1953 Rod Lens system.
• Present day laparoscopes - series of rod lenses in
centre with a rim of optical fibers on the outer aspect.
• Optical fibers carry light into the abdominal cavity &
rod lens system transmits the image from abdomen to
the camera.
• From the camera (attached to the proximal end or eye
piece of the scope) the images are displayed on to a
monitor.

8. CONVENTIONAL VS OPTICAL LENSES

10. A TYPICAL ROD LENS SYSTEM

11. LAPAROSCOPES
( TELESCOPES)
Laparoscope may vary in size ( dia.)
Size 0.8mm - (Needlescope) to 15 mm in dia.
Angle of vision - 0° /30°/ 45°, 70. 0 & 120
Rigid, flexible or semi flexible
Brightness of the image reduces with the size of the scope
The angled scopes 30° / 45° provide
Flexible field of vision.
Unobstructed view from distance
More space for maneuverability of instruments
Ability to look around the corners

12. Normal Hopkins Forward Oblique Scope -300
Diameter – 10 mm
Length - 33 cm
Extra Long – 43 cm
Autoclavable

13. SEMI FLEXIBLE – TIP OF THE SCOPE [ SILS ]

14. 2. CAMERA SYSTEM
• It is the most important and vital part of the
imaging system and should be of good quality.
• It consists of 2 parts-
• Camera head connects to the prox. End or eye
piece of the laparoscope.
• Camera Microprocessor unit which receives,
processes and transmits the pictures to monitor.

15. Requirement of Cameras
Camera Specifications
Three important Features
1.Horizontal Resolution
2.Minimum Luminance
3.Signal to Noise Ratio

16. Horizontal Resolution (lines)
 It is a measure that shows to what extent
details can be distinguished on the monitor.
 It can be evaluated by establishing the limits
to which lines can be distinguished on a test
pattern.
 A larger resolution value means a broader
frequency band of the video signal.

17. Minimum Luminance (lux)
 It is a measure that shows to how
sensitive the camera can produce a
good picture.
 It is measured in lux or footcandle unit.
 1 Footcandle = 10 lux

18. Signal to Noise Ratio (dB)
 An S/N ratio is noise to actual total video
signal
 It shows how much higher the signal level is to
the level of noise
 It is expressed in decibels (dB)
 Bigger the value - better the picture

19. Features of Cameras
Horizontal resolution (lines)
Higher ---------> Better
Minimum luminance (lux)
Higher ---------> Worse
Signal to noise ratio (dB)
Higher ---------> Better

20. CAMERA SYSTEM
• Resolution of the camera directly proportionate to the
no. of pixels.
• Presently CCD cameras used – consists of tiny bits of
silicon (divided into multiple tiny sensors) called
‘pixels.’These are arranged in rows & columns and
are sensitive to light.
• When light strikes a pixel, the silicon emits
electricity, that is transmitted to the monitor.
• Electronic signals are sensed to provide the recording
image.

21. The resolution from the CCD is dependent upon the
quantity of the pixels on the sensor.
The resolution is defined as the amount of vertical lines
that may be discriminated separately in 3 quarters from
the width of the monitor screen.
The lap. Camera requires at a min. 300 lines of
resolution to supply a sufficient image.
CAMERA SYSTEM - RESOLUTION

22. TODAY’S LAPAROSCOPIC CAMERAS
Available in Single or 3 Chip
We all know the 3 Primary colours– R / G / B
All the colours are a mixture of these 3 Primary Colours in different
proportion.
Single Chip- All 3 primary colours are sensed by a single or 1 chip.
Three Chip- CCD- chips separately sense, capture and as well as
process the Primary colours.

23. TYPES OF CAMERA SYSTEMS
1. SINGLE CHIP
2. THREE CHIP OR CCD
3. HIGH DEFINITION
4. 3D
5. ROBOTIC PLATFORM

24. SINGLE CHIP CAMERA
– Multiple color sensors
provided in a single chip
providing a single image
– Monitor resolution needed
is usually 400 – 600 lines.
– Adequate for routine basic
surgeries.

25. Single Chip Camera

26. 3- CHIP CAMERA
– In 1989 , the field of surgery experienced a revolution
in the form of ‘Laparoscopic surgery ’ with the
introduction of CCD cameras (charged couple devices)
and better light sources.
– Captures light in its 3 components
– Unified light slit into its components ‘ red, green, &
blue’(RGB) by prism located in head of the camera
– Signals are then captured by separate CCD’s containing
multiple sensors & are processed and sent to monitor.
– Currently available cameras have ability of producing
videos of resolution of 950 lines i.e. ‘high quality
images’.
– Great help in advanced lap surgeries.

28. HD CAMERA
• The latest generation of cameras are high definition cameras
• They produce the resolution of 1080 horizontal lines per
inch.
• Require HD monitors to reproduce the same quality of
picture
• Offers a superior image with a wide, more natural 16:9
format and 1080p resolution for FULL HD with 2 million
pixels.
• That is the highest resolution in the medical industry.
• At present it is very costly.

30. HD CAMERA & IMAGING

32. 4 Types of Video Camera Outputs
1.RGB
Component signal
2.S-VHS or Y/C
Component signal
Chrominance & Luminance (color & light)
3.Composite video signal or BNC
-- All components of the picture combined
into one video signal
4.Digital Signals

33. 3 - D CAMERAS

34. POLARISATION GOGGLES
3 D MONITOR
CAMERA HEAD WITH PROCESSOR
DUAL CHANNELTELESCOPES

35. The human brain combines two images to one 3D impression
BINOCULAR EFFECT-WORKING PRINCIPLE
36
5-8 % of humans don‘t have the
binocular effect

36. STANDARD 2D- EFFECT
CCU
Camera
Head Object2D Endoscope
(one channel)
Sensor
2D HD Monitor (1080 lines x 1920 pixels)
one image (all lines/pixels can be seen with
both eyes)
left Eye
right Eye
37

37. THE 3D- EFFECT
CCU
Camera
Head Object
Dual
Channel
Endoscope
Sensor 1
Sensor 2
Sterile
Adapter
3D Full HD 32“ Monitor Odd lines (line 1,3,5,7…)
even lines (line 2,4,6,8…)
Polarisation
Glasses
38
Polarisation filter

38. Dual channel endoscope creates two live-images
Camera head has two sensors
Flat screen has a polaristion filter and shows two images simultaneously
Even-numbered-lines on screen (2,4,6….) show image 1
Odd-numbered-lines on screen (1,3,5 ….) show image 2
Polarisation glasses select from image 1to (right eye) from image 2 to (left eye)
39
THE POLARISATION EFFECT

39. Circular polarising glasses separate the two images in front of the eye:
- the even lines can be seen only with the right eye
- the odd lines can be seen only with the left eye
The human brain receives a true 3D impression from flat display
The displayed object seems to grow out of the flat screen
The surgeon gets a true depth percecption
40
Stereoscopic visual effect

40.  Restores the surgeon’s natural 3D vision and depth
perception.
 Provides depth cues and precise spatial orientation
 Shown to enhance dissection, grasping skills, suturing, stapling and
overall surgical efficiency.( Correct picking up of delicate tissues &
exact positioning of needles.)
 Requires no additional certification or training for those surgeons
certified to perform laparoscopic procedures.
 Reduced learning curve for young surgeons.
 Enhances task performance leading to lower procedure times and
costs.
Benefits of

41. Cameras -Advantages & Disadvantages
• All cameras need
– White balancing
– Focus – manual / auto
• Some cameras have options of
– Zooming – useful for finer dissection
– Digital enhancement – provides sharper images .
– Disadvantages – development of grains which may distort
– image quality
• HD cameras
– Provide stereoscopic vision
– Costly & no clear cut advantage over existing cameras
3D Cameras ( Disadvantages )
– No optical zoom
– Scope not rotatable
– Presently scope available only as 10 mm & 00
- Wearing of Polarisation glasses
- Costly

42. FLUORESCENCE IMAGING SYSTEM
STORZ

43. NIR/ ICG – FLUORESCENCE IMAGING
Near Infra Red & Indo Cyanine Green enables non-
radioactive visualization of the entire lymphatic system
surrounding a tumor in real time.
Advtg:
1. Non- radio active LN detection
2. Multi disciplinary use – Gyaenecology, Surgery ,
Urology
3. Easy switch over from standard to fluorescence
mode by a foot switch.
4. Accuracy in en-bloc dissection during radical
lymphadenectomy

44. 3.LIGHT SOURCES
• Thanks to Edison for inventing the Electric Bulb.
• MAS depends on artificial light to inspect the closed
body cavity.
• Quality of Image obtained depends on the quantity of
light at each step of Opto-Electronic system.
• Essential vital equipment for producing images.

45. 1.Halogen ( Quartz)
Highly efficient, Halogen Gas is used, excellent colour
rendering.Gives yellow coloured light.Economical..
Sufficient for Basic Lap. Surgeries.
Available in 150 watts.
Colour temp.- 5000-6000K
Av. Life- 2000 hrs.
2.Metal Halide-
Mix of a compound ( Rare salts of the earth + Halides)
Ex; Iron & Gallium Iodide Lamp .
Provides high intensity heat alongwith brighter
light.
250 W. Av. Life- 250 hrs.
TYPES OF LIGHT SOURCES

46. 3.Xenon-
Consists of quartz glass ( high grade fused silica)
But cold white light, its tip generate considerable heat, so direct
contact with the internal organs to be avoided.
Better visual clarity
175/300 watts, approx. life of bulb 500 hrs
Colour temp: 6000-6400 k
Slightly Costly
Av. Life – 500 hrs
Natural white light
4.LED-
TYPES OF LIGHT SOURCES

48. PARTS OF THE LIGHT SOURCE
1. Lamp / Bulb
2. 2.Heat Filter
3. 3.Condensing Lens
4. Manual/ Auto Intensity Control Unit

49. 1. LAMP:
Most important part .
Quality depends on the type of lamp used.
2. HEAT FILTER
Energy consumption of a Normal light source
98% heat / 2% light.
Filter reduces the heat & provides a cool light as heat gets
dissipated during transportation along the cable and the
telescope.
3. CONDENSING LENS:
Converges light emitted by the lamp to the area of the light
cable input to the scope.
It increases the light intensity per sq m area

50. 4.MANUAL/ AUTO INTENSITY CONTROL CIRCUIT
All light sources – in built circuit to adjust light intensity either
manually by the surgeon or automatically ( newer L S)
This AGC ( Auto Gain Control) of light source works
synchronously with the advanced camera systems.

51. 4.LIGHT CABLES
• Working Principle- light conducted through a curved
glass rod by total multiple internal reflections, from one
end to other end of the cable .
1. Fiber optic cables – more user friendly consists of
bundles of glass fibers, thread swaged at both ends.
Size of fibres- 10- 25 mm dia. High quality transm.
Disdv—fragile, breaks at bends ( dark spots )
2 Fluid filled cables
– Made of liq. Crystal gel, swaged at both ends.
– Transmits more light – 30% more.
– Disadvantages – stiff , fragile, cannot be autoclaved
Conducts more heat
- Use – Movies / TV as LCD /Photography

53. Light Cable

54. 4. MONITORS
• Final limb of imaging chain
• Quality of monitor essential for adequate quality of
image
• If monitor does not support resolution of camera,
then all the advantages of using high end camera is
lost.
• Principle-Horizontal linear scanning on the face of
the picture tube.Each picture frame consists of
several lines depending on the type of system used.

55. Final image on the Monitor depends on:
1. No. of lines of Resolution – denotes No.of B&W lines both
vertical & horizontal.
2. Pixels – denotes picture elements & details
3. Dot Pitch – denotes a restricting factor & represents the
phosphor element size.
INPUT CABLES INTO THE MONITOR
1. Composite- Video- via a BNC connector
2. Y/C or S- Video- via a 4-pin DIN connector.
3. RGB Video – via a multi head BNC cable connector.
4. DVI input- compatible to HD monitor / flat panel.
5. HDMI Input
Lap. Cameras supports 1 & 2 above.
New flat panel TV support – RGB input No.3

56. Monitor - Compatibility with Cameras
• Monitors with resolution of 600 lines for single
chip , > 900 lines for three chip & 1080 and above
for HD for optimal resolution are required
• High end analog digital and HD flat panel
monitors are now available,
– they can be placed at more ergonomically viable
positions,
– avoid various head, neck, shoulder ailments in Lap
surgeons

57. Monitors

58. HD MONITORS

59. Maintenance
• Light Cable – Handle with care. Do not twist.
• Outer surface should be cleaned with mild detergent.
• Periodical cleaning with moist alcohol swabs.
• Avoid pt. burns under drapes.
• Light Source-
• Xenon bulb has life of 500 hrs.
- Change bulb if intensity of light decreases.
- Don’t cover light source while working- excess heating can
cause damage to it
- Periodical check of Light source exhaust fan.
*****DO NOT SEARCH FOR THE BIOMEDICAL STAFF,
TRY TO LEARN AND SOLVE IT YOURSELF.

60. Maintainence
Telescopes-
-Avoid any thermal or mechanical injury to tip of telescope.
- Clean the eye piece, light cable slot and tip with warm water.
- Chemical sterilization with Glutaldehyde or Cidex solution is
done. Few scopes are autoclavable
Camera head-
-Avoid any injury to camera head and its cable.
- Camera cover should be used to avoid contamination of
operating field.

61. Trouble shooting
• Poor picture quality may be due to
- Fogging of scopes
– It is a big problem
– Gives a dull & hazy image
– Warm water/ betadine soaked gauze / anti fog soln. are
used to clean the telescope lens
*[Connecting the insufflations tube to the optical trocar
and passage of cold CO2 causes more fogging]

62. Trouble shooting
• Poor picture quality – needs cleaning of scope tips and
camera head.
Flickering electrical interface -caused by loose
connection.
- Moisture in camera cable connecting plug - dry it with
the help of drier
- Poor cable shielding - replace cables
- Insecure connections - reattach cables
• Blurring or Distortion of picture is due to
incorrect focus - adjust camera focus
- Cracked lens internal moisture - replace scope

63. Trouble shooting
-Inadequate Lighting may be - caused by loose
connection of light cable at source or with
scope - Adjust connector light on- man. to
auto.
- Bulb is burnt out- replace the bulb.
- Fiber optic cable are damaged - replace light
cable.
- Monitor brightness turned down- adjust settings.

64. Trouble shooting
-Light is too bright
-Light is on manual max- turn on to auto mode.
-Light boost activated- deactivate boost
-Monitor brightness up- readjust
-White balancing is mandatory for obtaining
natural colour – target against a white object.

65. Troubleshooting-
• No Picture on Monitor-
- Camera control unit or other components are
not on - check power supply to all the units and
turn on power.
- Cable connection between camera head to
camera control unit and/or monitor is not
attached properly - check all connections.

66. White Balancing
Warm up the light source
Gain in STANDARD position
Fill monitor with white surface
Focus so threads are visible (no glare)
Depress WHITE BALANCE for 3 sec.
Hold image steady on white surface until the tint on the monitor
stabilizes for 2 sec.
OR DEPRESS THE REMOTE ON THE CAMERA HEAD

69. BEST BUY FOR A LAP SET
1.Reputation of the Company
2.After sales and service ( Locality/ state )
3. List of installations ( Add / Contact No. )
4.Check in the Internet.
5.Ask for Demo for 2 weeks.
6.Ask for Invoice/ Quotation of supplied or cheques received
7.Bargain for the best price..
8.Ask for a Package.( Hand instrument set)
9. Ask for an extended warranty.
10. Lastly, ask for supply on a rental basis/ Payments in
Installments.