Three-dimensional vs standard laparoscopy: comparative assessment using a validated program for laparoscopic urologic skills

Laparoscopy training of novices with complex curved instruments using 2D- and 3D-visualization

PURPOSE

Beside many advantages, disadvantages such as reduced degrees of freedom and poorer depth perception are still apparent in laparoscopic surgery. 3D visualization and the development of complex instruments are intended to counteract the disadvantages. We want to find out whether the use of complex instruments and 3D visualization has an influence on the performance of novices.

METHODS

48 medical students with no experience in laparoscopic surgery or simulator-based laparoscopy training were included. They were randomized in four groups according to a stratification assessment. During a structured training period they completed the FLS-Tasks "PEG Transfer", "Pattern Cut" and "Intracorporeal Suture" and a transfer task based on these three. Two groups used conventional laparoscopic instruments with 3D or 2D visualization, two groups used complex curved instruments. The groups were compared in terms of their performance.

RESULTS

In 2D laparoscopy there was a better performance with straight instruments vs. curved instruments in PEG Transfer and Intracorporeal Suture. In the transfer task, fewer errors were made with straight instruments. In 2D vs. 3D laparoscopy when using complex curved instruments there was an advantage in Intracorporeal Suture and PEG Transfer for 3D visualization. Regarding the transfer exercise, a better performance was observed and fewer errors were made in 3D group.

CONCLUSION

We could show that learning laparoscopic techniques with complex curved instruments is more difficult with standard 2D visualization and can be overcome using 3D optics. The use of curved instruments under 3D vision seems to be advantageous when working on more difficult tasks.

3D laparoscopic treatment of bladder cancer with pelvic multi-organ invasion: a case report and literature review

Introduction

Radical cystectomy with dissection of pelvic lymph nodes and urethral diversion is the standard surgical treatment for muscle-invasive non-metastatic bladder cancer. In rare cases where patients with bladder cancer without distant metastasis have pelvic multi-organ invasion, the cancer compresses or invades the ureter and, in severe cases, leads to bilateral upper urinary tract obstruction and renal damage. The treatment recommended by guidelines often cannot improve the patients' clinical symptoms immediately, and patients cannot complete the treatment owing to severe side effects, resulting in poor survival benefits.

Case presentation

A 69-year-old woman with facial edema was treated at the First Affiliated Hospital of Jinan University. The serum creatinine and potassium values were 1244 umol/L and 5.86 mmol/L, respectively. Pelvic magnetic resonance and abdominal computed tomography revealed that the bladder tumor had infiltrated the uterus, anterior vaginal wall, rectum, right ureter, right fallopian tube, and right ovary and metastasized to multiple pelvic lymph nodes. Tumor invasion of the right ureter resulted in severe hydronephrosis of the right kidney and loss of function and obstructive symptoms in the left kidney. Four days later, the patient's creatinine level decreased to 98 u mol/L, the general condition significantly improved, and the patient and family members strongly desired surgical treatment of the tumor. Through a comprehensive preoperative discussion, possible intraoperative and postoperative complications were evaluated. Right nephrectomy, right ureterectomy, total pelvic organ resection, extended pelvic lymph node dissection, and bowel and urinary diversion were conducted under 3D laparoscopy-assisted treatment. The patient was followed-up for 1.5 years and showed good tumor control, self-care, and mental status.

Conclusion

Minimally invasive surgery is a curative option for patients with bladder cancer with pelvic multi-organ invasion without distant metastasis. Surgeons should strictly control the indications for surgery and warn patients about the occurrence of related post-surgical complications.

Development and Validation of a Homemade and Low-Cost Three-Dimensional Laparoscopic Simulator for Novices

Background: The aim of this study was to design a low-cost three-dimensional (3D) laparoscopic simulator and validate its training effectiveness. Materials and Methods: We designed a low-cost 3D laparoscopic simulator using magnifying glass and cardboard box. Thirty-two laparoscopic novices were randomly divided into 3D group and two-dimensional (2D) group. The 3D group was trained on 3D simulator four times with 24 hours interval, and the 2D group was trained on 2D simulator. Five standardized laparoscopic tasks were performed by novices in each training. In the second part, subjects were transferred to the opposite simulator for one test after 24 hours of the fourth training. The completing time and errors for each task were recorded to assess the construct validity of simulator. Finally, the face validity and the content validity were evaluated through a closed-ended questionnaire. Results: There was no significant difference between the two groups in demographic or psychometric variables (P > .05). Compared with the 2D group, novices using 3D simulator had a better performance in five laparoscopic tasks, including a faster completing time (P < .001) and lower errors during training (P < .05). Additionally, the increased laparoscopic skill involved with our 3D simulator could be transferred to subsequent performance in 2D simulator (P < .05). Meanwhile, the score of face validity and content validity in our 3D simulator was significantly higher than that in 2D simulator (P < .05). Conclusion: Our 3D laparoscopic simulator effectively improved laparoscopic skills of novice surgeons, suggesting that the low-cost 3D simulator had satisfactory performance to satisfy requirement for novice training.

Evaluation of Advanced Bimanual Skills in Novices Using the Wrist-Like FlexDex™ Articulating Laparoscopic Needle Holder in 2D and 3D Vision: A Randomised Trial

Aim

The aim of this study was to evaluate the novice performance of advanced bimanual laparoscopic skills using the articulating FlexDex^TM laparoscopic needle holder in two-dimensional (2D) and three-dimensional (3D) visual systems.

Methods

In this prospective randomised trial, novices (n=40) without laparoscopic experience were recruited from a university cohort and randomised into two groups, which used the FlexDex^TM and 2D or the FlexDex™ and 3D. Both groups performed 10 repetitions of a validated assessment task. Times taken and error rates were measured, and assessments were made based on completion times, error rates and learning curves.

Results

The intervention group that used FlexDex^TM and 3D visual output completed 10 attempts of the standardised laparoscopic task quicker than the control group that used FlexDex^TM with standard 2D visual output (268 seconds vs 415 seconds taken for the first three attempts and 176 seconds vs 283 seconds taken for the last three attempts, respectively). Moreover, each attempt was completed faster by the intervention group compared to the control group. The difference in average time for the first three and last three attempts reached statistical significance (P < 0.001).

Conclusion

Combination of 3D visual systems and the FlexDex^TM laparoscopic needle holder resulted in superior task performance speed, leading to shorter completion times and quicker learning effect. Although the 3D group demonstrated lower mean error rates, it did not reach statistical significance.

Key Statement

3D visual systems lead to faster task completion times when combined with an articulating laparoscopic needle holder compared to 2D vision. This effect however is not seen in error rates.

Comparison of 3D vs 2D laparoscopic-assisted anorectal pull-through (LAARP) for high anorectal malformations in children

INTRODUCTION

The limitation of two-dimensional (2D) laparoscopic techniques includes lack of stereoscopic vision and depth perception which can affect surgical performance, physical and mental comfort of the operating surgeon. 3D laparoscopic surgery is popular in adults; however, its application and experience in the pediatric age group have been limited. We did a comparison of 2D and 3D laparoscopic-assisted anorectal pull-through (LAARP) in male high anorectal malformations (ARM).

MATERIAL AND METHOD

This prospective cohort study included male children diagnosed with high anorectal malformation (recto-prostatic urethral fistula) who underwent LAARP in infancy after a neonatal colostomy between November 2019 to March 2020. The patients were randomized into a 2D group or 3D group at a 1:1 ratio. Patient demographics and operative/postoperative parameters were recorded. The effect of 3D laparoscopy was assessed in terms of laparoscopy visual parameters (image quality, depth perception, hand-eye coordination, and precision), physical discomfort (5-point Likert scale), and mental strain (State-Trait Anxiety Inventory scale). The statistical tests were performed on SPSS version 16.

RESULTS

The demographics of both groups, 20 (patients in each), were similar. There was a significant reduction of laparoscopy execution time, physical discomfort (for eye, hand and wrist strain), and overall mental strain in the 3D group. There were similar complications, blood loss, and hospital stay, and no open conversion in two groups.

CONCLUSION

3D LAARP is feasible and safe in the surgical treatment of ARM in children. Further studies with assessment by more than one observer are needed to investigate the wider application of 3D in pediatric surgery.

Role of the Laparoscopic Approach for Complex Urologic Surgery in the Era of Robotics

(1) Introduction: The advent of robotic surgery led to the assumption that laparoscopic surgery would be replaced entirely. However, the high costs of robotic surgery limit its availability. The aim of the current study was to assess the feasibility of the 3D laparoscopic approach for the most complex urological procedures. (2) Materials and methods: We included in the current study all patients who had undergone complex 3D laparoscopic procedures in our department since January 2017, including radical nephrectomy (LRN) using a dual combined approach (19 patients), radical nephroureterectomy (LRNU) with bladder cuff excision (13 patients), and radical cystectomy (LRC) with intracorporeal urinary diversion (ICUD) (21 patients). (3) Results: The mean operative time was 345/230/478 min, the complications rate was 26%/30.76%/23.8% and positive surgical margins were encountered in 3/1/1 patients for the combined approach of LRN/LRNU/LRC with ICUD, respectively. A single patient was converted to open surgery during LRN due to extension of the vena cava thrombus above the hepatic veins. After LRC, sepsis was the most common complication and 8 patients were readmitted at a mean of 15.5 days after discharge. (4) Conclusions: In the era of robotic surgery, laparoscopy remains a plausible alternative for most complex oncological cases.

Comparison of Perioperative, Oncological, and Functional Outcomes of Three-Dimensional Versus Robot-Assisted Laparoscopic Radical Prostatectomy: A Preliminary Study

Background: Radical prostatectomy (RP) is the first-line treatment modality for prostate cancer and can be performed using retropubic or minimally invasive techniques. New technologies such as the da Vinci robotic system and three-dimensional (3D) laparoscopic imaging system have been developed to overcome the challenges of conventional laparoscopy. This study aimed to compare the perioperative, oncological, and functional outcomes of robot-assisted laparoscopic RP (RALP) and 3D laparoscopic RP (3D LRP). Materials and Methods: The study was approved by the local ethics committee and included 65 patients (38 RALP, 27 3D LRP) who underwent RP with the diagnosis of localized prostate cancer between May 2019 and January 2020. All demographic, clinical, perioperative, pathological, and postoperative variables were recorded. Results: There was no statistically significant difference between the two groups in terms of preoperative patient characteristics. The mean operative times of the RALP and 3D LRP groups were 135.74 ± 11.51 and 165.37 ± 15.86 minutes, respectively, with a statistically significant difference between the two groups (P = .001). The mean estimated blood loss was 237 ± 71 mL in the RALP group and 257 ± 54 mL in the 3D LRP group, with no statistically significant difference between the two groups (P = .236). In the 6 months of follow-up, there was no statistically significant difference between the two groups in terms of biochemical recurrence, continence, and potency. Conclusion: RALP and 3D LRP have similar perioperative, short-term oncological and functional outcomes other than the operative time. There is a need for prospective, randomized studies with larger populations evaluating long-term oncological and functional outcomes.

Comparison between 3-dimensional and 2-dimensional endoscopic thyroidectomy for benign and malignant lesions: a meta-analysis

Background

The use of 3-dimensional (3D) endoscopic thyroidectomy (ET) has been increasing, but its feasibility and safety have not been well documented for thyroidectomy. Hence, to systematically investigate the comparative outcomes during 3D-ET and 2-dimensional (2D) ET for benign and malignant lesions, we conducted this meta-analysis.

Methods

Based on the PRISMA guidelines, a systematic database search of the PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Chinese Wanfang databases was performed. The eligible studies were published in English and Chinese up to October 2020. The major endpoints evaluated were procedure time, blood loss, postoperative drainage, postoperative hospitalization, postoperative complications, total number of lymph node dissections (LNDs), and total cost.

Results

A total of 15 relevant studies including 1190 patients (583 for 3D-ET and 607 for 2D-ET) compared the application of 3D and 2D laparoscopic systems in thyroid surgery, of which 8 were endoscopic benign thyroidectomy (EBT) and 7 were endoscopic malignant thyroidectomy (EMT). Our meta-analysis indicated that 3D-ET generally had advantages over 2D-ET in terms of procedure time (P = 0.000), blood loss (P = 0.000), postoperative drainage (P = 0.000), postoperative complications (P = 0.000), and LNDs (P = 0.006). However, there were no significant differences between the two systems in terms of total cost (P = 0.245) or postoperative hospitalization (P = 0.068). Subgroup analysis showed consistency of the overall outcomes in each subset, but a shorter postoperative hospitalization in 3D-EBT was revealed.

Conclusions

Compared to 2D-ET, 3D endoscopic thyroidectomy is an efficient, safe, and reliable method with better depth perception and stereoscopic vision, and an equally satisfactory outcome. More clinical RCTs with long-term follow-up are required to reproduce these promising results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02134-4.

Three-Dimensional (3D) Laparoscopy Versus Two-Dimensional (2D) Laparoscopy: A Single-Surgeon Prospective Randomized Comparative Study

Background:

Visual information is crucial for performing laparoscopic surgery. While surgeons lose depth perception and spatial orientation in conventional 2D laparoscopy, the 4^th generation 3D system gives a better depth perception.

Objective:

In this sstudy, we aimed to investigate the feasibility, safety, and short-term efficacy of 4th generation 3D-HD visualization technology applied in laparoscopic colon cancer surgery.

Methods:

One hundred and twenty patients with colon adenocarcinoma were recruited in this study. Patients were randomized on the day of surgery by a random computer-generated allocation list to undergo either a 3D-HD display or 2D-HD imaging system laparoscopic colon cancer surgery. In total, 60 patients underwent laparoscopic colon resection by 3D-HD laparoscope (3D group) and 60 patients underwent 2D-HD laparoscope (2D group). After the insertion of the access ports, both surgical procedures were divided in component tasks, and the execution times were compared. Data analysis was done using SPSS (version 15.0). Quantitative and qualitative variables were compared applying Student t test and Pearson’s chi-square test.

Results:

Two groups were homogenous in terms of demographic data. Operation time was significantly shorter for the 3D group than for the 2D group (123.2±34.2 min vs. 142.2±23.5 min, P=0.018). There was no statistically significant difference between two groups in terms of intraoperative blood loss, the number of retrieved lymph nodes, postoperative recovery, and postoperative complications (P>0.05).

Conclusion:

The 4^th generation 3D-HD vision system reduced the operating time compared to 2D-HD vision system. It seems that use of the 3D-HD technology can significantly enhance the possibility of achieving better intraoperative results.

Comparative Study of the Influence of Three-Dimensional Versus Two-Dimensional Urological Laparoscopy on Surgeons' Surgical Performance and Ergonomics: A Systematic Review and Meta-Analysis

Objective: The objective of this study is to compare the use of three-dimensional (3D) vision systems with traditional two-dimensional systems in laparoscopic urological surgery, analyzing the benefits, limitations, and impact of introducing this medical technology with regard to surgical performance and the surgeon's ergonomics. Methods: A systematic review with a structured bibliographic search was conducted in the electronic libraries (PubMed and EMBASE) until August 2019 and with no language restrictions. Studies on 3D visualization technology in laparoscopic urologic surgery, randomized controlled trials, and observational comparative studies were included. Relevant data were extracted and analyzed. Results: A total of 25 articles were obtained, of which 4 were clinical studies with patients, 2 studies were carried out in experimental animal models, and the remaining 19 were conducted in simulated environments. Regarding the European training program in basic laparoscopic urological skills, the results showed no significant differences in execution time using either imaging system. Three-dimensional vision led to a significant reduction in surgery time in pyeloplasty and radical nephrectomy. In addition, there was a reported decrease in blood loss in adrenalectomy, nephron-sparing nephrectomy, radical nephrectomy, simple nephrectomy, and pyeloplasty using 3D vision. Regarding ergonomics, the studies generally described no differences in side effects (headache, nausea, eye strain) when comparing the two types of visualization systems. Surgeons reported reduced workloads and stress with 3D vision than with traditional laparoscopy. Conclusions: Three-dimensional laparoscopic systems essentially advance surgical performance in less-experienced laparoscopic surgeons. Three-dimensional laparoscopy leads to improvements in surgery time, which is important for specific surgical procedures involving intracorporeal ligatures and sutures. The results achieved on the surgeons' ergonomics showed better depth perception and decreased stress and workloads during 3D vision with no differences in potential side effects.

Three-dimensional (3D) visualization provides better outcome than two-dimensional (2D) visualization in single-port laparoscopic distal gastrectomy: a propensity-matched analysis

PURPOSE

There are currently no reports on the application of three-dimensional (3D) vision to single-incision laparoscopic surgery. This study compared 3D vision to the previous two-dimensional (2D) system in single-incision laparoscopic distal gastrectomy (SIDG).

METHODS

Medical charts of 179 gastric cancer patients who underwent SIDG from February 2014 to December 2017 were retrospectively reviewed. Patients were grouped into either a 2D group or 3D group depending on the type of camera that was used. All operations were performed using a flexible camera (Olympus, Japan). Operative data and postoperative outcome were analyzed.

RESULTS

There were 90 patients in the 2D group and 89 patients in the 3D group. No differences were found in terms of the age, body mass index, staging, and other demographics of the patients. Operative time was significantly faster in the 3D group (115.6 ± 34.0 vs. 129.4 ± 38.5 min, p = 0.012), and estimated blood loss (EBL) was less in the 3D group (20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). Patients in the 3D group were able to start a small fluid diet earlier (2.5, range 1-6 vs. 3.0, range 2-8 postoperative days, p = 0.006) and were discharged faster (5.4, range 3-12 vs. 6.2, range 4-24 postoperative days, p = 0.024). There was no statistical difference between early and late complications.

CONCLUSION

The use of the 3D camera shortened operative time with possible clinical benefits for patients undergoing SIDG.

Three-dimensional laparoscopic vision improves forceps motion more in the depth direction than in the horizontal direction: An analysis of data from prospective randomized controlled trials

INTRODUCTION

Three-dimensional (3D) laparoscopic vision can improve depth perception. However, it is a question whether 3D vision can improve motion in the depth direction. The aim of this study was to compare the impact of 3D vision on forceps motion in the depth and horizontal directions.

METHODS

All data were obtained from our previous two studies, where, in total, 40 novices and 20 moderately experienced surgeons participated. A simple phantom task was performed in a training box. The participants were randomly assigned to two groups. Specifically, one group performed the task five times initially under a two-dimensional (2D) system, and the other group started under a 3D system. Both groups then performed the same task five times under the alternative system. Performances were recorded by an optical position tracker. We separately evaluated forceps motion in the x-, y-, and z-axis directions.

RESULTS

Compared with the findings for 2D vision, the forceps path lengths were significantly decreased among novices and moderately experienced surgeons in almost all tasks under 3D vision. In a comparison of the path length ratio (3D/2D) in each direction, larger reduction was observed for the depth direction among novices, whereas no significant directional difference was noted among moderately experienced surgeons.

CONCLUSIONS

For novices, 3D laparoscopic vision improves depth perception and may give shorter forceps movement in the depth direction even for simple tasks.

Comparison of clinical and oncologic effectiveness between flexible 3-dimensional and bidimensional video-thoracoscopic surgery for lung cancer

BACKGROUND

Three-dimensional (3D) vision systems are available for video-assisted thoracic surgery (VATS). It is unclear whether 3D-VATS is superior to bidimensional (2D) VATS systems.

METHODS

We analyzed patients who received 3D-VATS (n = 171) or 2D-VATS (n = 228) lobectomy in a single institutional retrospective comparative study of 399 patients with resectable lung cancer conducted from June 2012 to December 2017. The operative and perioperative data were compared between the 2 groups.

RESULTS

Operative time, length of hospital stay, number of dissected lymph nodes, and rate of postoperative complications were similar in both groups. In the 3D group, there was no conversion to thoracotomy for intraoperative major vascular injuries, while conversion to an open procedure for uncontrolled bleeding was recorded in 4 (1.7%) patients in the 2D group. Reoperation for hemostasis and/or aerostasis occurred in 6 (2.6%) patients of the 2D group (p = 0.04).

CONCLUSION

Nonrandomized comparison of different surgical approaches is challenging. In our experience, 3D-VATS was safe and effective and offered excellent operative perception and sensitivity, enabling safer dissection of hilar structures. The 3D-VATS system helped skilled surgeons beyond the boundaries of more oncologically aggressive surgery.

Basic Laparoscopic Skills Training Is Equally Effective Using 2D Compared to 3D Visualization: A Randomized Controlled Trial

Reduced depth perception due to two-dimensional (2D) visualization of a three-dimensional (3D) space represents a main challenge in acquiring basic laparoscopic skills (BLS); 3D visualization might increase training efficiency. This study aimed to assess whether BLS training on a standard box trainer using 2D is at least equally effective compared to 3D. Medical students were randomized to training of Fundamentals of Laparoscopic Surgery (FLS) tasks using either 2D or 3D for four weeks. Baseline and post-training tests were performed using the assigned visualization modality. Data of 31 participants were analyzed (n = 16 2D, n = 15 3D). Baseline test scores did not differ significantly between groups; only at the peg transfer task and total scores, the 3D group performed better than the 2D group. All scores improved significantly in both groups, with post training scores not differing significantly between groups. Non-inferiority of 2D compared to 3D was demonstrated for total score improvement and improvement in all individual FLS tasks except for suturing with extracorporeal knot tying. Post training test performance did not change significantly when changing to the unfamiliar modality. In conclusion, BLS training using standard 2D is at least equally effective as with 3D, without significant disadvantages when changing to the other modality.

Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.

Laparoscopic Versus Robotic-assisted Suturing Performance Among Novice Surgeons: A Blinded, Cross-Over Study

Robotic-assisted laparoscopy (RAL) presents several advantages over 3-dimensional conventional laparoscopy (3D-CL) that may facilitate laparoscopic suturing especially with novice surgeons. This study compares novice surgeons' suturing performance by 3D-CL and RAL using Objective Structured Assessment of Technical Skill (OSATS), an objective, validated scoring tool. Twenty-two surgeons with no robotic experience completed a standardized suturing task in an experimental setup by both 3D-CL and RAL in a randomized, cross-over design. Two experienced surgeons blindly assessed their performance using OSATS. Median (interquartile range) OSATS scores for 3D-CL and RAL were, respectively, 22.8 (17.4 to 25.8) versus 25.0 (21.9 to 26.5), P=0.032. There was no association between laparoscopic experience and robotic-assisted suturing performance. Thus, this study is, to our knowledge, the first to compare novice surgeons' suturing performance by 3D-CL and RAL using an objective, validated scoring tool and to show better suturing performance when assisted by the robot regardless of experience level.

The effect of three-dimensional visualisation on performance in endoscopic sinus surgery: A clinical training study using surgical navigation for movement analysis in a randomised crossover design

OBJECTIVES

Endoscopic imaging techniques and endoscopic endonasal surgery (EES) expertise have evolved rapidly. Only few studies have assessed the effect of three-dimensional (3D) endoscopy on endoscopic sinus surgery (ESS). The present study aimed to objectively and subjectively assess the additional value of 3D high-definition (HD) endoscopy in ESS.

DESIGN

A randomized crossover study of endoscopic surgery performance, using five ESS tasks of varying complexity, performed on Thiel embalmed human specimens.

SETTING

Simulated surgical environment.

PARTICIPANTS

Thirty participants, inexperienced in ESS.

MAIN OUTCOME MEASURES

Performance was assessed using video imaging, surgical navigation and questionnaires. Main outcome measures were as follows: efficiency (defined by time to task completion), distance covered inside the nose, average velocity towards target, accuracy (measured by error rate), and subjective assessment of endoscope characteristics.

RESULTS

During ESS tasks, both efficiency and accuracy did not differ significantly between 2D HD and 3D HD endoscopy. Subjectively, imaging characteristics of the 3D HD endoscope were rated significantly better.

CONCLUSIONS

ESS performance of inexperienced participants was not significantly improved by the use of 3D HD endoscopy during ESS tasks, although imaging characteristics of the 3D HD endoscope were rated significantly better. Surgical field characteristics and surgical techniques are likely to influence any additional value of 3D HD endoscopy.

Two-Dimensional Versus Three-Dimensional Laparoscopic Systems in Urology: A Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopy is widely used in the urological field. This systematic review and a meta-analysis were conducted to assess the clinical and surgical efficacy of the three-dimensional (3D) laparoscopic system in comparison with two-dimensional (2D) laparoscopy for treatment of different urological conditions.

METHODS

Following guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic literature search in Web of Science, PubMed, Cochrane Library, and EMBase was carried out to identify relevant studies published up to May 2018. Articles published in the English language of both randomized and observational studies comparing 3D and 2D laparoscopic systems in urological surgeries were included. Level of evidence and quality assessments of all included studies were conducted. Interested data were extracted for comparison and meta-analysis.

RESULTS

Our literature search generated 17 studies comparing 3D and 2D laparoscopic systems in different urological surgeries. Of these, 13 studies containing 548 and 449 patients operated on with 2D and 3D laparoscopic systems, respectively, were included for meta-analysis. These 13 studies were divided into three groups according to surgical type. Group 1: Partial nephrectomy (PN); operative time (p = 0.19), estimated blood loss (EBL) (p = 0.51), dissecting time (p = 0.58), and suturing time (p = 0.28) were not statistically significant between 2D and 3D laparoscopic systems. However, warm ischemia time during PN was significantly shorter during 3D laparoscopy (p < 0.00001). Group 2: Pyeloplasty; this procedure showed no significant difference between the two systems. Group 3: Radical prostatectomy (RP); shorter operative time (p < 0.0001) and lower EBL (p = 0.001) were associated with the 3D laparoscopic system.

CONCLUSION

Three-dimensional laparoscopy mainly improves the depth of perception, leading to better visibility, which is important for some complex urological surgeries such as PN, pyeloplasty, and RP. Based on our findings, 3D laparoscopy seems to provide better clinical and surgical outcomes in some urological procedures compared with conventional 2D laparoscopy.

Stereoscopic versus monoscopic displays: Learning fine manual dexterity skills using a microsurgical task simulator

We investigated the learning of fine manual dexterity with a microsurgical instrument and a new simulator in a context of microsurgery. 30 subjects were divided into two groups. One (3D group) interacted with a stereoscopic and the other (2D group) with a monoscopic display. Visual information for the displays was captured from a surgical stereomicroscope. In 20 trials, both groups performed the repetitive tasks of picking up small rods from a funnel-shaped cavity and placing them outside. In analysing learning curves, we found that the initial learning process for hand-eye coordination is easier with a 3D display, and that performance persists at a higher level of proficiency than with the 2D display option. Thus stereoscopic displays can be especially beneficial for novices, for those learning new procedures, or for providing orientation to operators facing a new or altered spatial situation. Simulators with few reliefs or spatial textures should not be used for comparison between 3D and 2D viewing conditions.

Comparison of enhanced laparoscopic imaging techniques in endometriosis surgery: a diagnostic accuracy study

Background

For surgical endometriosis, treatment key is to properly identify the peritoneal lesions. The aim of this clinical study was to investigate if advanced imaging improves the detection rate by comparing narrow-band imaging (NBI), near-infrared imaging with indocyanine green (NIR-ICG), or three-dimensional white-light imaging (3D), to conventional two-dimensional white-light imaging (2D) for the detection of peritoneal endometriotic lesions.

Methods

This study was a prospective, single-center, randomized within-subject, clinical trial. The trial was conducted at Amsterdam UMC—Location VUmc, a tertiary referral hospital for endometriosis. 20 patients with ASRM stage III–IV endometriosis, scheduled for elective laparoscopic treatment of their endometriosis, were included. During laparoscopy, the pelvic region was systematically inspected with conventional 2D white-light imaging followed by inspection with NBI, NIR-ICG, and 3D imaging in a randomized order. Suspected endometriotic lesions and control biopsies of presumably healthy peritoneum were taken for histological examination. The pathologist was blinded for the method of laparoscopic detection. Sensitivity and specificity rates of the enhanced imaging techniques were analyzed. McNemar’s test was used to compare sensitivity to 2D white-light imaging and Method of Tango to assess non-inferiority of specificity.

Results

In total, 180 biopsies were taken (117 biopsies from lesions suspected for endometriosis; 63 control biopsies). 3D showed a significantly improved sensitivity rate (83.5% vs. 75.8%, p = 0.016) and a non-inferior specificity rate (82.4% vs. 84.7%, p = 0.009) when compared to 2D white-light imaging. The single use of NBI or NIR-ICG showed no improvement in the detection of endometriosis. Combining the results of 3D and NBI resulted in a sensitivity rate of 91.2% (p < 0.001).

Conclusion

Enhanced laparoscopic imaging with 3D white light, combined with NBI, improves the detection rate of peritoneal endometriosis when compared to conventional 2D white-light imaging. The use of these imaging techniques enables a more complete laparoscopic resection of endometriosis.

Effects of the Three-Dimensional Vision System on Surgical Performance, Muscular Fatigue, and Pain During Urologic Laparoscopic Tasks: Results of Objective Assessments and a Mini Questionnaire Survey

BACKGROUND

The three-dimensional (3D) vision system was released to the medical market to improve laparoscopic outcomes. We analyzed the muscular pain and fatigue, and the performance outcomes after several laparoscopic urologic tasks were completed with the 3D vision system.

METHODS

A total of 49 participants with different surgical expertise levels were enrolled in the study. All the participants performed some laparoscopic urologic tasks using two-dimensional (2D) and 3D vision systems separately. A mini questionnaire survey was also completed by the participants. The duration and quality of the tasks and the muscular fatigue and pain were objectively determined. All the parameters were compared between the 2D and 3D systems.

RESULTS

Although all the tasks were completed in significantly shorter times with the 3D vision system in each expertise level, maximal shortening was seen in the residents. The overall quality scores were significantly higher with the 3D vision system. However, a maximal increase was seen in the residents. The muscular pain of the participants was lower with 3D vision system. The overall handgrip strength significantly increased from 41.2 to 42.4 kg after the tasks with the 3D vision system, but the difference was significant in only the residents. Twenty-seven participants (56.2%) declared that the 3D system contributed to their performance, and most of the participants (83.3%) preferred the 3D system in the questionnaire survey.

CONCLUSION

3D technology may be effective for use in urologic laparoscopic training programs of novice surgeons. It may also contribute to the skills of specialists and experts, shortening the surgical time, which may decrease the surgical morbidity.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018

BACKGROUND

The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.

RESULTS

9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.

CONCLUSION

We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018

BACKGROUND

The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.

RESULTS

9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.

CONCLUSION

We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

3D versus 2D laparoscopic radical prostatectomy for organ confined prostate cancer: Our experience

Objective:

Three-dimensional (3D) laparoscopy was developed to overcome the main limitations of traditional laparoscopy. The aim of our study was to compare operative, functional and oncological results of 3D and two-dimensional (2D) laparoscopic radical prostatectomy.

Materials and methods:

A total of 102 consecutive patients with clinically localised prostate cancer underwent laparoscopic radical prostatectomy. Patients were randomly assigned into two groups, 2D high definition (HD) camera (50 patients) for the first and 3D HD camera (52 patients) for the second group. Total operative time, anastomosis time, blood loss, complications and pentafecta rates for both groups were compared. All patients had at least one year of follow-up.

Results:

Total operative time was, respectively, 143 ± 17 and 118 ± 15 minutes, with a mean anastomosis time of 31± 12 and 23 ± 12 minutes. Mean blood loss was 230 ± 30 ml with 2D vision and 175 ± 40 with 3D vision. Pentafecta was reached, respectively, by 46% and 50% of patients at 3 months and 60% and 67.3% at 12 months. 3D vision offers an increased speed if compared with traditional vision ( P=0.02). Pentafecta results were significantly better in the 3D group ( P=0.03).

Conclusion:

We believe that 3D laparoscopy offers important advantages for surgeons and patients; its use should be encouraged.

Level of evidence:

1c

A Suggestion on How to Compare 2D and 3D Laparoscopy: A Qualitative Analysis of the Literature and Randomized Pilot Study

BACKGROUND AND AIMS

The results of studies comparing two-dimensional (2D) and three-dimensional (3D) laparoscopy have shown variable results. We aimed to review the literature and develop an appropriate instrument to compare 2D and 3D laparoscopy. We further aimed to use the data extracted to perform a pilot study.

METHODS

Sixty-seven recent articles on 3D laparoscopy were reviewed and data extracted on factors influencing outcome variables. These variables were used to design a pilot study of 28 novices using a randomized crossover design. The results were analyzed using descriptive statistics and the Wilcoxon signed-rank tests.

RESULTS

Seven themes were identified to influence the outcome of 3D studies: applied technique (1), experience of subjects (2), study design (3), learning curve (4), subjective qualitative reports (5), laparoscopic tasks (6), and chosen outcome variables (7). The consecutively developed five laparoscopic simulation tasks contained placing a rubber band over hooks, ring and pearl transfer, threading a pipe cleaner through loops, and placing a suturise. The pilot study showed a primary benefit of 3D laparoscopy that was unrelated to repetition. Two tasks served well to assess first-time performance, and two tasks promise to serve well to assess a learning curve if performed repeatedly.

CONCLUSION

We were able to identify important issues influencing the outcome of studies analyzing 3D laparoscopy. These may help evaluate future studies. The developed tasks resulted in meaningful data in favor of 3D visualization, but further studies are necessary to confirm the pilot test results.

Comparison of Short-Term Outcomes Between 3D and 2D Imaging Laparoscopic Colectomy with D3 Lymphadenectomy for Colon Cancer

BACKGROUND

Three-dimensional (3D) imaging for laparoscopy was introduced to overcome the limitations of conventional two-dimensional (2D) imaging that lacked depth perception and spatial orientation. This study aimed to evaluate the effect of 3D imaging in laparoscopic colectomy with D3 lymphadenectomy for colon cancer.

METHODS

From February 2014 to October 2016, the prospective database of 278 consecutive patients with colon cancer was analyzed retrospectively; these patients underwent laparoscopic surgery with 2D (n = 111) and 3D (n = 167) imaging, with curative intent.

RESULTS

No difference was found in sex, body mass index, history of abdominal surgery, and American Society of Anesthesiologists grade between the 3D and 2D groups. The estimated blood loss was less in the 3D group than in the 2D group (50 mL [30-100 mL] versus 100 mL [50-100 mL], P < .001). The number of resected lymph nodes was higher in the 3D group (n = 47 [37.5-60] versus 41 [32-51.5], P = .001). However, a difference in operative time was not observed in both groups (150 minutes [125-175 minutes] versus 155 minutes [135-177.5 minutes], P = .186). Postoperative morbidity was similar in both groups (7.8% versus 8.1%, P = 1.000). Time to pass first flatus (3 days [2-4 days] versus 3 days [3-4 days], P = .746) and postoperative hospital stay (6 days [6-8 days] versus 6 days [6-7 days], P = .087) were also similar.

CONCLUSIONS

This study shows that laparoscopic colectomy with D3 lymphadenectomy for colon cancer using 3D laparoscopic systems appears to be beneficial, with less blood loss, which should be addressed in prospective studies.

Comparison of 3-dimensional and 2-dimensional endoscopic thyroid lobectomy via the trans-thoracoareolar approach

Objectives:

To evaluate retrospectively the safety, efficacy, and feasibility of 3-dimensional (3D) endoscopic thyroid lobectomy via a trans-thoracoareolar approach in comparison with the 2-dimensional (2D) approach.

Methods:

We performed a retrospective and cross-sectional analysis of the data of 100 patients who underwent endoscopic thyroid lobectomy via the trans-thoracoareolar approach between January 2014 and November 2016. The patients were classified: into 2 equal groups depending on whether the 3D or 2D endoscopic approach was employed. The 2 groups were compared for various intraoperative and postoperative parameters.

Results:

The values of total operative time, lobectomy time, suture time, and intraoperative blood loss in the 3D endoscopy group were significantly less than those in the 2D endoscopy group. Additionally, the incidence rates of complications in the 3D endoscopy group were significantly less than those in the 2D endoscopy group. However, the groups were similar with regard to the incidence of transient hypocalcemia, subcutaneous congestion, subcutaneous effusion, and cough; postoperative drainage volume; extubation time; postoperative hospitalization time; and total hospitalization expenses.

Conclusions:

Three-dimensional endoscopic thyroid lobectomy required less operative time and entailed a low risk of injury to adjacent structures, without causing any increase in the rate of postoperative complications, indicating that the 3D endoscopic technique was superior to 2D endoscopy.

2D vs. 3D imaging in laparoscopic surgery-results of a prospective randomized trial

PURPOSE

3D imaging is an upcoming technology in laparoscopic surgery, and recent studies have shown that the modern 3D technique is superior in an experimental setting. However, the first randomized controlled clinical trial in this context dates back to 1998 and showed no significant difference between 2D and 3D visualization using the first 3D generation technique, which is now more than 15 years old.

METHODS

Positive results measured in an experimental setting considering 3D imaging on surgical performance led us to initiate a randomized controlled pragmatic clinical trial to validate our findings in daily clinical routine. Standard laparoscopic operations (cholecystectomy, appendectomy) were preoperatively randomized to a 2D or 3D imaging system. We used a surgical comfort scale (Likert scale) and the Raw NASA Workload TLX for the subjective assessment of 2D and 3D imaging; the duration of surgery was also measured.

RESULTS

The results of 3D imaging were statistically significant better than 2D imaging concerning the parameters "own felt safety" and "task efficiency"; the difficulty level of the procedures in the 2D and 3D groups did not differ. Overall, the Raw NASA Workload TLX showed no significance between the groups.

CONCLUSION

3D imaging could be a possible advantage in laparoscopic surgery. The results of our clinical trial show increased personal felt safety and efficiency of the surgeon using a 3D imaging system. Overall of the procedures, the findings assessed using Likert scales in terms of own felt safety and task efficiency were statistically significant for 3D imaging. The individually perceived workload assessed with the Raw NASA TLX shows no difference. Although these findings are subjective impressions of the performing surgeons without a clear benefit for 3D technology in clinical outcome, we think that these results show the capability that 3D laparoscopy can have a positive impact while performing laparoscopic procedures.

2D Versus 3D in Laparoscopic Surgery by Beginners and Experts: A Randomized Controlled Trial on a Pelvitrainer in Objectively Graded Surgical Steps

BACKGROUND AND OBJECTIVE

Progress in endoscopic surgery in the past few decades has led to the application of 3-dimensional (3D) procedures in operating rooms. This permits patient- and surgeon-friendly operations and also maximizes the superiority of laparoscopy over laparotomy. In this study, we compare 2-dimensional (2D) and 3D endoscopy techniques with regard to time, efficiency, optics, and handling by users with different degrees of experience at 4 difficulty levels.

DESIGN

A randomized controlled trial on a pelvitrainer in objectively graded surgical steps for students and postgraduates.

SETTING

The trials took place at the Kiel School of Gynaecological Endoscopy, a training unit of the Kiel University Department of Obstetrics and Gynecology, a tertiary academic medical center.

PARTICIPANTS

The 277 study participants, divided into students, residents, and specialists, worked on pelvitrainers with 2 different optical systems, the 2D full HD and the 3D mode. The following 4 exercises were performed with each optical system: (1) grasping and transferring of pins, (2) cutting predetermined marks, (3) vaginal closure with prevention of prolapse, and (4) sacrocolpopexy. The duration and success of the tasks were measured and compared. A self-assessment questionnaire was completed by the participants.

RESULTS

Overall, the 3D-system permitted a greater improvement in working speed, superior optical visualization, and better endoscopic handling in all groups, independent of surgical experience. All students improved in speed (exercises: 1-3) and made significantly fewer mistakes (exercise 2) on 3D compared with 2D. Residents made progress in time (exercises: 1-4) and task performance (exercise 3). Specialists improved significantly in the more challenging tasks 3 and 4. Subjectively, 68.8% of participants preferred 3D for performing laparoscopy.

CONCLUSION

Systematic training programs on pelvitrainers can improve endoscopic skills not only in beginners but also in experienced surgeons. The 3D system offered distinct advantages over 2D imaging and was well accepted by surgeons.

Evolution of stereoscopic imaging in surgery and recent advances

In the late 1980s the first laparoscopic cholecystectomies were performed prompting a sudden rise in technological innovations as the benefits and feasibility of minimal access surgery became recognised. Monocular laparoscopes provided only two-dimensional (2D) viewing with reduced depth perception and contributed to an extended learning curve. Attention turned to producing a usable three-dimensional (3D) endoscopic view for surgeons; utilising different technologies for image capture and image projection. These evolving visual systems have been assessed in various research environments with conflicting outcomes of success and usability, and no overall consensus to their benefit. This review article aims to provide an explanation of the different types of technologies, summarise the published literature evaluating 3D vs 2D laparoscopy, to explain the conflicting outcomes, and discuss the current consensus view.

Three-dimensional versus two-dimensional laparoscopy in urology: A randomized study

INTRODUCTION

Conventional two-dimensional (2D) laparoscopy systems have the drawback of poor depth perception and spatial orientation. Three-dimensional (3D) laparoscopic systems have stereoscopic vision in which depth perception is achieved by different unique images received by each eye. We evaluated 3D laparoscopy in comparison with conventional 2D laparoscopy in urological procedures in a prospective randomized study.

MATERIALS AND METHODS

Over a 19 month study period, 108 patients scheduled to undergo various urological procedures were randomized to either conventional 2D or 3D laparoscopy (2D n = 53; 3D n = 55). A single senior surgeon performed all the surgeries. Parameters such as total operative time, dissection and suturing time, blood loss, hospital stay, complications (Clavien-Dindo), and visual analog scale (VAS) score for pain were assessed. The subjective assessment of the operating surgeon of superiority and inferiority of either technology on parameters defining surgical skills was recorded using a Likert scale.

RESULTS

The total operative time (P < 0.0003), blood loss (P < 0.028), dissection, suturing and stenting time (P < 0.0001), and the State-Trait Anxiety Inventory for Adults score (P < 0.0001) was significantly in favor of 3D laparoscopy.

CONCLUSION

Our study showed significant advantages of the 3D system over 2D laparoscopy. These advantages include enhanced operative performance and greater surgeon comfort.

[Efficacy of three-dimensional laparoscopic total thyroidectomy combined with central lymph node dissection for thyroid cancer and its effect on inflammatory responses of the patients]

OBJECTIVE

To analyze the effect of three-dimensional (3D) laparoscopic total thyroidectomy combined with central lymph node dissection for thyroid cancer and its effect on the inflammatory response of the patients.

METHODS

The clinical data were analyzed in 90 patients with thyroid cancer undergoing radical thyroidectomy at our hospital between September, 2013 to April, 2016, including 30 receiving 3D laparoscopic surgeries, 30 with 2D laparoscopic surgeries and 30 with open surgeries. The surgical data, postoperative adverse reactions and the impact of the surgeries on the inflammatory responses of the patients were compared among the 3 groups.

RESULTS

Compared with the open surgery and 2D laparoscopic surgery, 3D laparoscopic surgery was associated with lowered blood loss during the surgery and a lowered incidence of adverse reactions. The operation time in 3D group was significantly shorter than that in 2D group (P<0.05), but the total hospitalization expenses were similar between the two groups. The postoperative drainage volume did not differ significantly between the 3D group and the other two groups. The postoperative hospital stay, number of lymph nodes dissected, positivity rate of lymph nodes and the inflammatory response showed no significant differences among the 3 groups (P>0.05).

CONCLUSION

3D laparoscopic total thyroidectomy combined with central lymph node dissection is safe and effective and reduces intraoperative blood loss and perioperative adverse reactions without significant influence on inflammatory response in patients with thyroid cancer.

Pentafecta Rates of Three-Dimensional Laparoscopic Radical Prostatectomy: Our Experience after 150 Cases

Introduction

Three-dimensional (3D) laparoscopy with a flexible camera was developed to overcome the main limitation of traditional laparoscopic surgery, which is two-dimensional (2D) vision. The aim of our article is to present the largest casistic of 3D laparoscopic radical prostatectomy (LRP) available in literature and evaluate our results in terms of pentafecta and compare it with the literature.

Methods

We retrospectively evaluated consecutive patients who underwent LRP with 3D technology between March 2014 and December 2015. Total operative time (TOT), anasthomosis time (AT), blood loss and complications were registered. All patients presented at least 3 months of follow-up. Surgical outcome was evaluated in terms of Pentafecta.

Results

One hundred fifty consecutive patients underwent 3D LRP. Mean follow-up was 16.9 months. Mean age was 67.7 ± 8.3 years (range 50-76). Mean preoperative PSA value was 8.3 ± 5.8 ng/ml and mean bioptic Gleason Score (GS) was 6.6. We had a mean TOT of 158 ± 23 minutes and a mean AT of 25 ± 12.6. Mean blood loss was 240 ± 40 ml. Eighteen (12%) postoperative complications occurred. Pathologic results: pT2 in 91 patients (58%) and pT3 in 59 (39.3%). Pentafecta was reached by 31.3% of patients at 3 months and 51.6% at 12 months.

Conclusions

Our oncological and functional results are comparable to those present in literature for laparoscopic and robotic surgery. We believe that our findings can encourage the use of 3D laparoscopy especially considering the increasing attention to healthcare costs.

Impact of simulated three-dimensional perception on precision of depth judgements, technical performance and perceived workload in laparoscopy

Background

This study compared precision of depth judgements, technical performance and workload using two‐dimensional (2D) and three‐dimensional (3D) laparoscopic displays across different viewing distances. It also compared the accuracy of 3D displays with natural viewing, along with the relationship between stereoacuity and 3D laparoscopic performance.

Methods

A counterbalanced within‐subjects design with random assignment to testing sequences was used. The system could display 2D or 3D images with the same set‐up. A Howard–Dolman apparatus assessed precision of depth judgements, and three laparoscopic tasks (peg transfer, navigation in space and suturing) assessed performance (time to completion). Participants completed tasks in all combinations of two viewing modes (2D, 3D) and two viewing distances (1 m, 3 m). Other measures administered included the National Aeronautics and Space Administration Task Load Index (perceived workload) and the Randot^® Stereotest (stereoacuity).

Results

Depth judgements were 6·2 times as precise at 1 m and 3·0 times as precise at 3 m using 3Dversus2D displays (P < 0·001). Participants performed all laparoscopic tasks faster in 3D at both 1 and 3 m (P < 0.001), with mean completion times up to 64 per cent shorter for 3Dversus2D displays. Workload was lower for 3D displays (up to 34 per cent) than for 2D displays at both viewing distances (P < 0·001). Greater viewing distance inhibited performance for two laparoscopic tasks, and increased perceived workload for all three (P < 0·001). Higher stereoacuity was associated with shorter completion times for the navigating in space task performed in 3D at 1 m (r = − 0·40, P = 0·001).

Conclusion

3D displays offer large improvements over 2D displays in precision of depth judgements, technical performance and perceived workload.

Many advantages for 3D

Training Performance of Laparoscopic Surgery in Two- and Three-Dimensional Displays

INTRODUCTION

This research investigated differences in the effects of a state-of-art stereoscopic 3-dimensional (3D) display and a traditional 2-dimensional (2D) display in simulated laparoscopic surgery over a longer duration than in previous publications and studied the learning effects of the 2 display systems on novices.

METHODS

A randomized experiment with 2 factors, image dimensions and image sequence, was conducted to investigate differences in the mean movement time, the mean error frequency, NASA-TLX cognitive workload, and visual fatigue in pegboard and circle-tracing tasks.

RESULTS

The stereoscopic 3D display had advantages in mean movement time ( P < .001 and P = .002) and mean error frequency ( P = .010 and P = .008) in both the tasks. There were no significant differences in the objective visual fatigue ( P = .729 and P = .422) and in the NASA-TLX ( P = .605 and P = .937) cognitive workload between the 3D and the 2D displays on both the tasks. For the learning effect, participants who used the stereoscopic 3D display first had shorter mean movement time in the 2D display environment on both the pegboard ( P = .011) and the circle-tracing ( P = .017) tasks.

CONCLUSIONS

The results of this research suggest that a stereoscopic system would not result in higher objective visual fatigue and cognitive workload than a 2D system, and it might reduce the performance time and increase the precision of surgical operations. In addition, learning efficiency of the stereoscopic system on the novices in this study demonstrated its value for training and education in laparoscopic surgery.

What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

3D Vision Provides Shorter Operative Time and More Accurate Intraoperative Surgical Performance in Laparoscopic Hiatal Hernia Repair Compared With 2D Vision

Background. The aim of this study is to evaluate if 3-dimensional high-definition (3D) vision in laparoscopy can prompt advantages over conventional 2D high-definition vision in hiatal hernia (HH) repair. Study design. Between September 2012 and September 2015, we randomized 36 patients affected by symptomatic HH to undergo surgery; 17 patients underwent 2D laparoscopic HH repair, whereas 19 patients underwent the same operation in 3D vision. Results. No conversion to open surgery occurred. Overall operative time was significantly reduced in the 3D laparoscopic group compared with the 2D one (69.9 vs 90.1 minutes, P = .006). Operative time to perform laparoscopic crura closure did not differ significantly between the 2 groups. We observed a tendency to a faster crura closure in the 3D group in the subgroup of patients with mesh positioning (7.5 vs 8.9 minutes, P = .09). Nissen fundoplication was faster in the 3D group without mesh positioning ( P = .07). Conclusions. 3D vision in laparoscopic HH repair helps surgeon’s visualization and seems to lead to operative time reduction. Advantages can result from the enhanced spatial perception of narrow spaces. Less operative time and more accurate surgery translate to benefit for patients and cost savings, compensating the high costs of the 3D technology. However, more data from larger series are needed to firmly assess the advantages of 3D over 2D vision in laparoscopic HH repair.

Laparoscopic pyeloplasty: Initial experience with 3D vision laparoscopy and articulating shears

INTRODUCTION

Laparoscopic reconstructive surgery is associated with a steep learning curve related to the use of two-dimensional (2D) vision and rigid instruments. With the advent of robotic surgery, three-dimensional (3D) vision, and articulated instruments, this learning curve has been facilitated. We present a hybrid alternative to robotic surgery, using laparoscopy with 3D vision and articulated shears.

OBJECTIVE

To compare outcomes of children undergoing pyeloplasty using 3D laparoscopy with articulated instruments with those undergoing the same surgery using standard laparoscopy with 2D vision and rigid instruments.

STUDY DESIGN

Medical charts of 33 consecutive patients with ureteropelvic junction obstruction who underwent laparoscopic pyeloplasty by a single surgeon from 2006 to 2013 were reviewed in a retrospective manner. The current 3D cohort was compared with the previous 2D cohort. Data on age, weight, gender, side, operative time, dimension (2D = 19 patients, 3D = 8 patients), presence of a crossing vessel, length of hospital stay, and complication rate were compared between the two groups. Articulating shears were used for pelvotomy and spatulation of the ureter in the 3D group. Statistical tests included linear regression models and chi square tests for trends using STATA software.

RESULTS

Operative time per case was decreased by an average of 48 min in the group undergoing 3D laparoscopic pyeloplasty compared with the group undergoing 2D laparoscopic pyeloplasty (p = 0.02) (Figure). Complication rate and length of hospital stay were not significantly affected by the use of 3D laparoscopy.

DISCUSSION

These favorable results are in accordance with previous literature emphasizing the importance of 3D vision in faster and more precise execution of complex surgical maneuvers. The use of flexible instruments has also helped overcome the well-described delicate step of a dismembered pyeloplasty, namely the pelvotomy and ureteral spatulation. Limitations of this study are those inherent to the retrospective study design.

CONCLUSION

The use of 3D vision endoscopy with articulating instruments blurs the distinction between current robotic-assisted and conventional laparoscopic technology, and provides a hybrid alternative deserving further attention.

Three-Dimensional Versus Two-Dimensional Imaging in Adult Versus Pediatric Laparoscopy: A Simulator Box Study

AIM

Three-dimensional (3D) imaging has been shown to enhance depth perception and facilitate operations in training box studies and in adult laparoscopy. However, there are no data on 3D vision in small working spaces, which are common pediatric surgery. Therefore, this study examined the impact of monoscopic versus stereoscopic visualization in large versus small working spaces in individuals with varying surgical expertise.

MATERIALS AND METHODS

Twenty-four individuals with varying surgical expertise (experts, surgical residents, and surgical novices) were involved in the study. Participants were asked to perform four tasks in large (24- × 30- × 50-cm) and small (9- × 11- × 18-cm) training boxes, using two-dimensional and 3D imaging. Sixteen standardized procedures were performed by each participant. Primary outcome measure was performance time. Secondary outcome parameters included the number of errors and subjective depth perception.

RESULTS

Surgical novices showed a shorter performance time and lesser total number of errors in large and small training boxes using 3D imaging. Residents achieved a significantly shorter performance time in the large and lesser number of errors in the small box. With 3D vision experts performed laparoscopic suturing in the small box and target touching in both boxes significantly faster. The overall performance time and total number of errors of experts were not different in the two boxes. Subjective depth perception with 3D vision in the small box in all groups and in the small box in surgical novices was significantly better.

CONCLUSIONS

We identified several advantages of 3D vision in individuals with varying surgical expertise. However, the benefits were rather experienced by surgical novices and residents than by experts. Differences in performance time and number of errors were similar in the large and small simulator boxes.