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

Phantom-based training of ultrasound-guided breast biopsy in medical education: a randomized controlled trial comparing handheld and high-end ultrasound

BACKGROUND

Modern handheld ultrasound devices (HUDs) are attractive for teaching programs in undergraduate medical education due to their miniaturization and portability along at relatively low cost. They offer high-resolution imaging and are easy to use, opening up new possibilities for training of novices in ultrasound (US)-guided percutaneous procedures. The objective of this study was to investigate if guidance by HUD is on par with a cart-based high-end ultrasound scanner (HEUS) regarding performance times and success rates in video- and phantom-based training of novices in US-guided freehand breast biopsy.

METHODS

32 medical students without any experience in performing US-guided percutaneous biopsies, who had previously completed a standardized diagnostic US training program, were randomized into either a HUD-group (n = 16) or a HEUS-group (n = 16). After a video training lecture participants performed US-guided biopsies of hypoechogenic and hyperechogenic target-lesions in a breast phantom using either a HUD or a HEUS. Performance times and success rates were primary outcomes. Participants were asked to complete a post-study questionnaire (Likert Scale and Raw NASA Workload Task Load Index) for subjective assessment of the operability and individually perceived workload of both US imaging tools and guidance-techniques as secondary outcomes.

RESULTS

Biopsy success rates were slightly higher using the HUD (79.7%) in comparison to the HEUS (68.8%, p = 0.045). Median performance times were similar for the HUD (0.63 min, interquartile range IQR = 0.37-1.08 min) compared to the HEUS (0.60 min, IQR = 0.30-2.09 min, p = 0.751). Operability and the individually perceived workload were rated equal.

CONCLUSIONS

Percutaneous biopsy performed by novices using HUDs is feasible, performance times, success rates, operability and the individually perceived workload were on par with HEUS-guidance. HUDs can be used as cost-effective tools for percutaneous biopsy training purposes in medical education.

Surgeon Preference and Clinical Outcome of 3D Vision Compared to 2D Vision in Laparoscopic Surgery: Systematic Review and Meta-Analysis of Randomized Trials

Objective

To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome.

Background

The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking.

Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool.

Results

Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (-8.0%; SMD, -0.22; 95% CI, -0.37 to -0.06; P = 0.007; n = 3003; 24 studies; I 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (-16.3%; 95% CI, -1.28 to -0.21; P = 0.006; 2 studies; n = 58; I 2 = 0%) and general surgery (-6.7%; 95% CI, -0.34 to -0.01; P = 0.036; 9 studies; n = 1056; I 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, -0.33; 95% CI, -0.68 to 0.017; P = 0.060; n = 1830; I 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision.

Conclusions

Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.

A Comparison of Three-Dimensional Visualization Systems and Two-Dimensional Visualization Systems During Laparoscopic Cholecystectomy: A Narrative Review

Background: Laparoscopic cholecystectomy is a common procedure for the definitive treatment for cholecystitis and symptomatic cholelithiasis. One advancement in minimally invasive surgery has been the development of three-dimensional (3D) visualization systems to provide stereopsis. It is yet to be determined whether this innovation is beneficial to the surgeon or simply just a gimmick. This narrative review aims to answer the following research question, what is the impact of 3D visualization systems on surgical efficiency compared with two-dimensional visualization systems in laparoscopic cholecystectomy? Methods: Through a broad literature search it was determined that operative time and intraoperative errors have been used in published research to assess intraoperative efficiency. Results: Studies published to date have used operative time, intraoperative errors, and intraoperative bleeding as current measures for intraoperative efficiency. Previous meta-analysis have shown a slight improvement in operative time for 3D visualization systems; however, subsequent randomized control trials have not shown a significant difference in operative time. Reporting of intraoperative errors has been quite subjective and a difference between visualisation modality has not been shown. Conclusion: 3D visualization systems have shown a minor improvement in operative time compared with traditional laparoscopic systems and it is unlikely to be of any clinical significance. Studies that measure intraoperative error vary greatly in what they report, and which assessment tool is used. Across existing literature, studies do not control for surgeon's experience, elective/emergent cases, and grade of gallbladder/difficulty. Further research is required, using novel tools for assessment in laparoscopic cholecystectomy to determine intraoperative differences through objective and quantitative variables.

Effect of 2D vs. 3D laparoscopy on postoperative complications and operation time in a propensity-score-matched real-world data analysis

BACKGROUND

Postoperative complication rates using 3D visualization are rarely reported. The primary aim of our study is to detect a possible advantage of using 3D on postoperative complication rates in a real-world setting.

METHOD

With a sample size calculation for a medium effect size difference that 3D reduces significantly postoperative complications, data of 287 patients with 3D visualization and 832 with 2D procedure were screened. The groups underwent an exact propensity score-matching to be comparable. Comprehensive complication index (CCI) for every procedure was calculated and Operation Time was determined.

RESULTS

Including 1078 patients in the study, 213 exact propensity score-matched pairs could finally be established. Concerning overall CCI (3D: 5.70 ± 13.63 vs. 2D: 3.37 ± 9.89; p = 0.076) and operation time (3D: 103.98 ± 93.26 min vs. 2D: 88.60 ±6 9.32 min; p = 0.2569) there was no significant difference between the groups.

CONCLUSION

Our study shows no advantage of 3D over 2D laparoscopy regarding postoperative complications in a real-world setting, the second endpoint operation time, too, was not influenced by 3D overall.

Operating room time savings in Germany- and UK-based hospitals with 3D- VS. 2D-imaging technology in laparoscopic surgery: Meta analysis and budget impact model - Health economic evaluation

AIMS

Opportunity cost (OC) analysis is key when evaluating surgical techniques. Operating room (OR) time is one potential source of OC in laparoscopic surgery. This study quantifies differences in OR time between 3D- and 2D-imaging technology in laparoscopic surgery, translates these into OC and models the economic impact in real-world hospitals.

METHODS

First a systematically performed literature review and meta-analysis were conducted. Then, methods to translate OR time savings into OC were theorised and a budget impact model was created. After that, the potential time savings of real-world hospital case mixes were extrapolated. Finally, the opportunity costs of not using 3D-imaging in laparoscopic surgery were evaluated.

RESULTS

Average OR time saving per laparoscopic procedure was -19.4 min (-24.3; -14.5) (-14%) in favour of 3D. The Budget Impact Model demonstrated an economic impact of using 3D-laparoscopy instead of 2D laparoscopy, ranging from £183,045-£866,316 in the British and 73,049€-437,829€ in German hospitals, modelling a mixture of cost savings and performing additional procedures (earning additional revenue).

CONCLUSION

The OC analysis revealed significant economic benefits of introducing 3D-imaging technology in laparoscopic surgery, on the basis that average procedure time is reduced. Utilising the saved OR time to perform additional procedures was the biggest driver of OC. Hospital case mix and procedure volume indicated the magnitude of the OC.

Comparison of surgical outcomes between 3-dimensional and 2-dimensional laparoscopy of ovarian cyst (LOOC): a randomised controlled trial

The purpose of this study was to compare the surgical outcomes and efficacy of 3-dimensional (3D) versus 2-dimensional (2D) imaging systems for the treatment of ovarian cyst. A total of 46 patients undergoing a laparoscopic ovarian cystectomy were randomly assigned to either the 3D or 2D laparoscopy group. The primary outcome measure was the operative blood loss. The secondary outcome measure was visually induced motion sickness (VIMS), task efficacy during laparoscopy, and postoperative complication. There were no differences in baseline demographics between the two groups. The operative blood loss was significantly smaller in the 3D groups (28.7 ± 11.6 mL) than in the 2D groups (46.5 ± 24.4 mL) (p = .012). VIMS score was significantly higher in the 3D groups than the 2D groups (p < .001). 3D laparoscopy was superior to 2D in terms of the task efficacy of ovarian cyst enucleation (p < .001), adhesiolysis or dissection (p < .001), and ovarian suturing (p = .008). None of the patients in both groups developed operative complications. In conclusion, a 3D imaging system showed a more favourable surgical outcome and improved task efficacy than 2D in laparoscopic ovarian cystectomy. However, 3D laparoscopy tends to cause more frequent VIMS in surgeons.Impact statementWhat is already known on this subject? Several studies examining the possible benefits and drawbacks of a 3D imaging system versus 2D in laparoscopic surgery have brought about conflicting results. However, there have been few studies comparing the surgical outcomes of 3D and 2D laparoscopic ovarian cystectomy.What do the results of this study add? 3D laparoscopy showed favourable surgical outcomes and improved task efficacy than 2D laparoscopy in ovarian cystectomy.What are the implications of these findings for clinical practice and/or further research? More complex procedures, such as suturing and adhesiolysis, might be easier to perform with 3D laparoscopy than with 2D laparoscopy. Therefore, further large studies of 3D gynaecologic laparoscopy with different complexities and for surgeons with different surgical skills are needed.

Short Term Postoperative and Oncological Outcomes of Two-Dimensional Versus Three-Dimensional Laparoscopic Transanal Total Mesorectal Excision of Rectal Cancer

Background: Transanal total mesorectal excision (TaTME) carried out synchronously with laparoscopy is a useful surgical technique in rectal cancer patients who are overweight or who have a narrow pelvis. This retrospective study aims to compare the safety and efficacy of two-dimensional (2D) and three-dimensional (3D) laparoscopic TaTME of rectal cancer based on the short-term postoperative and oncological outcomes of 40 patients in Singapore who underwent laparoscopic TaTME. Materials and Methods: Forty patients underwent laparoscopic TaTME for rectal cancer in one of three centers in Singapore from October 2015 to August 2018. Out of these patients, 23 underwent 3D laparoscopic TaTME with the Olympus Flexible Tip™ 10 mm scope. Data on patient demographics, operative details, and postoperative and oncological outcomes were collected retrospectively by going through soft copy patient records, analyzed and compared. Results: The operative time for 3D group was significantly shorter (340 versus 419 minutes, P = .04). Complete TME grade and R0 resection was achieved in a higher percentage of patients in the 3D group although this was not statistically significant. There were no other significant differences between the two groups in terms of oncological outcomes and other short-term postoperative outcomes. Discussion and Conclusion: TaTME is overall a safe technique. Three-dimensional TaTME for rectal cancers is as safe and feasible as 2D TaTME, with the advantage of a shorter operative time.

Utility of a three-dimensional printed pelvic model for lateral pelvic lymph node dissection

PURPOSE

In patients with advanced lower rectal cancer, the complex pelvic anatomy renders lateral pelvic lymph node dissection to be challenging. Therefore, we evaluated the utility of printing a three-dimensional (3D) pelvic model for lateral pelvic lymph node dissection.

METHODS

We included 22 patients who underwent lateral pelvic lymph node dissection for rectal cancer between June 2017 and February 2019. Using CT scans, 3D pelvic images and models were constructed and printed, respectively. Thirty colorectal surgeons subjectively evaluated the utility of 3D pelvic models based on a 5-point Likert scale questionnaire (1 = strongly disagree, 5 = strongly agree).

RESULTS

The average Likert score for the question "Would a 3D model be useful for understanding pelvic anatomy?" was 4.68. Cases with clinically diagnosed metastatic lymph nodes (4.79 ± 0.44) scored higher than those without them (4.38 ± 0.77, p = 0.02). For spatial comprehension of pelvic anatomy, 3D models scored higher (4.83) than 3D images (4.36, p < 0.001). The ease of use of 3D models and images was scored 4.60 and 4.20, respectively (p = 0.015). With experience, the 3D image reconstruction time decreased from 900 to 150 min.

CONCLUSION

The 3D pelvic models may be helpful for experienced surgeons to understand the pelvic anatomy in lateral pelvic lymph node dissection.

3-D endoscopy in surgery of pituitary adenomas, prospective evaluation of patient gain using basic outcome parameters

The present prospective cohort study evaluates the effect of three-dimensional (3-D) endoscopy on outcome in transphenoidal endoscopic surgery of pituitary adenomas compared to conventional two-dimensional (2-D) endoscopy. Prospective data was collected from patients undergoing endoscopic surgery for pituitary adenomas before and after the introduction of 3-D endoscopy. Patients, grouped by having 2-D or 3-D endoscopic surgery, were compared in regard to procedure time, intraoperative blood loss, complications, hospital stay, grade of resection and quality of life (QoL). Twenty-six patients having surgery with 2-D endoscopy were compared with 29 patients having surgery with 3-D endoscope. Only primary procedures were included. There were no significant differences in baseline characteristics between the two groups. No statistically significant differences in outcome were noted with 3-D endoscopy. Procedure time, complication rate, hospital stay, rate of gross total resection and post-operative QoL were unaffected by surgical technique though there were non-significant increases in new pituitary insufficiency with 3-D endoscopy and diabetes insipidus with 2-D endoscopy. This prospective cohort study fails to show obvious outcome advantages with 3-D endoscopy in pituitary surgery using basic parameters including post-operative QoL. To our knowledge this is the first prospective study published on the matter, thus corroborating results from previous retrospective studies with similar results on 3-D neuroendoscopy and 3-D endoscopy in general. The main advantage of increased depth perception is more likely found in more complex extended transphenoidal skull base procedure.

4K ultra HD technology reduces operative time and intraoperative blood loss in colorectal laparoscopic surgery

Background: HD systems are routinely used in laparoscopic surgery, 4K ultra HD monitors are mainly available within specialized, high-volume laparoscopic centers. The higher resolution of 4K ultra HD video could upgrade the surgical performance improving intraoperative and post-operative outcomes. Methods: We performed a retrospective comparative analysis of intraoperative parameters and post-operative outcomes in a cohort of patients operated on for elective laparoscopic procedures for colo-rectal cancer during two different time frames: 2017 procedures performed using the Visera Elite full HD technology (® Olympus America, Medical) and the 2018 procedures performed the Visera 4K Ultra HD System (® Olympus America, Medical). Results: There was a statistically significant reduction in operative time in patients operated on with the 4K ultra HD technology compared to HD technology (p < 0.05). Intraoperative blood loss was significantly reduced in patients operated in 2018 (p < 0.05). There were no statistically significant differences in complication rate and postoperative outcomes between the two groups.

Assessment of 3-Dimensional vs 2-Dimensional Imaging and Technical Performance Using a Multiport Intraoperative Data Capture and Analytic System for Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery

IMPORTANCE

Errors and adverse events occur frequently in health care. Three-dimensional (3-D) laparoscopic systems claim to provide more realistic depth perception and better spatial orientation compared with their 2-D counterparts.

OBJECTIVE

To compare the association of 3-D vs 2-D systems with technical performance during laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures using a multiport intraoperative data capture system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was performed between May and December 2018, with a total of 50 LRYGB procedures performed in an academic tertiary care center; recordings of the operations were evaluated with a 30-day follow-up. All procedures were performed by the same surgical team.

EXPOSURE

Surgical teams used 2-D or 3-D laparoscopic systems.

MAIN OUTCOMES AND MEASURES

Technical performance was evaluated using the Objective Structured Assessment of Technical Skill and surgical errors and events using the Generic Error Rating Tool.

RESULTS

Of the 50 patients who underwent LRYGB procedures, 42 (86%) were women, with a median (interquartile range) age of 42 (35-47) years and a median (interquartile range) body mass index of 46 (42-48), with no significant demographic differences between the groups whose operations were performed using the 2-D and 3-D systems. The mean (SD) number of errors per case was significantly lower in procedures using the 3-D laparoscopic system than in those using the 2-D system (17 [6] vs 33 [2]; P < .001). The mean (SD) number of error-related events was significantly lower in procedures using the 3-D system than in those using the 2-D system (6 [2] vs 11 [4]; P < .001). Mean (SD) Objective Structured Assessment of Technical Skill scores were significantly higher when the 3-D system was used than when the 2-D system was used (28 [4] vs 22 [3]; P < .001).

CONCLUSIONS AND RELEVANCE

In this limited sample of LRYGB procedures, the use of a 3-D laparoscopic system was associated with a statistically significant reduction in errors and events as well as higher Objective Structured Assessment of Technical Skill scores compared with 2-D systems.

Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC.

METHODS

A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion.

RESULTS

A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods.

DISCUSSION

This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.

Fruitful first experience with an 8K ultra-high-definition endoscope for laparoscopic colorectal surgery

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

Clinical value of 3D SPECT/CT imaging for assessing jaw bone invasion in oral cancer patients

PURPOSE

This study compared the diagnostic accuracy of jaw bone invasion (JBI) of oral cancer observed with three-dimensional (3D) SPECT/CT, CT, and MRI, and evaluated the clinical advantages of 3D SPECT/CT compared to conventional two-dimensional (2D) SPECT/CT.

MATERIALS AND METHODS

From April 2014 to January 2018, consecutive 16 oral cancer patients with suspected JBI, who had preoperatively undergone the imaging tests, were retrospectively enrolled. The likelihood of JBI was independently scored by a radiologist and oral surgeon. Using 2D or 3D SPECT/CT images, 20 oral surgeons delineated virtual surgical areas on 3D-printed jaws for 3 cases in which the extent of JBI was fully pathologically confirmed. The surgeons completed questionnaires regarding surgical planning and explanations for patients using Likert scales.

RESULTS

JBI was found in 9 patients including 5 (56%) with initial bone invasion. 3D SPECT/CT showed very high negative predictive value (100%) and inter-observer agreement (kappa = 0.917). 3D SPECT/CT was more sensitive than CT and MRI when inconclusive findings for JBI were considered negative. Compared to 2D SPECT/CT, 3D SPECT/CT had greater clinical advantages such as surgical planning and explanation to patients (p < 0.005).

CONCLUSION

3D SPECT/CT is useful not only for detecting JBI but also for surgical planning.

SICE national survey: current state on the adoption of laparoscopic approach to the treatment of colorectal disease in Italy

The real diffusion of laparoscopy for the treatment of colorectal diseases in Italy is largely unknown. The main purpose of the present study is to investigate among surgeons dedicated to minimally invasive surgery, the volume of laparoscopic colorectal procedures, the type of operation performed in comparison to traditional approach, the indication for surgery (benign and malignant) and to evaluate the different types of technologies used. A structured questionnaire was developed in collaboration with an international market research institute and the survey was published online; invitation to participate to the survey was issued among the members of the Italian Society of Endoscopic Surgery (SICE). 211 surgeons working in 57 surgical departments in Italy fulfilled and answered the online survey. A total of 6357 colorectal procedures were recorded during the year 2015 of which 4104 (64.1%) were performed using a minimally invasive approach. Colon and rectal cancer were the most common indications for laparoscopic approach (83.1%). Left colectomy was the operation most commonly performed (41.8%), while rectal resection accounted for 23.5% of the cases. Overall conversion rate was 5.9% (242/4104). Full HD standard technology was available and routinely used in all the responders' centers. The proportion of colorectal resections that are carried out laparoscopically in dedicated centers has now reached valuable levels with a low conversion rate.

Exploration of assistive technology for uniform laparoscopic surgery

INTRODUCTION

Laparoscopic surgery is less invasive than open surgery and is now common in various medical fields. However, laparoscopic surgery is more difficult than open surgery and often requires additional time for the operator to achieve mastery. Therefore, we investigated the use of assistive technology for uniform laparoscopic surgery.

METHODS

We used the OpenCV2 library for augmented reality with an ArUco marker to detect and estimate forceps positioning. We used Sense HAT as the gyro sensor. The development platforms used were Mac OS X 10.11.3 and Raspberry Pi 3, model B.

RESULTS

By attaching the ArUco marker to the needle holder, we could draw a line vertically to the marker. When the needle was held, a cube could be imagined, and both the needle and lines could be used to determine the appropriate position. By attaching the gyro sensor to the camera, we could detect its angle of rotation. We obtained stabilized images by rotating the image by the detected degrees; this was possible for any camera position.

CONCLUSIONS

Assistive technology allowed us to obtain consecutive converted images in real time and may be readily applicable to clinical practice.

[3 D laparoscopy versus 2 D laparoscopy : An up to date evaluation]

BACKGROUND

The 3D laparoscopy is currently under intensive discussion. At the moment the majority of newly acquired laparoscopy systems include the 3D technique. New 4K systems, which will be offered in combination with 3D, are complicating the decision-making when buying new laparoscopic systems. The aim of the article is to show the advantages and possible limitations of 3D laparoscopy. Furthermore, the position of 3D laparoscopy in the current video market is evaluated.

MATERIAL AND METHODS

This study was based on an up to date literature search in PubMed. Concerning the question whether the 3D is replacing the 2D laparoscopy, observations from the industry and a personal evaluation were included in the analysis.

RESULTS

The current studies show clear advantages of 3D laparoscopy concerning operation time, efficiency and workload. A major proportion of the studies were conducted on simulation trainers; however, some clinical trials also confirmed these results. The learning curve in laparoscopic surgery is clearly improved with the 3D technique and 3D also seems be useful for operations by experts. The limitation is that not every surgeon can see three dimensionally. Furthermore, the set-up in the operation room needs to be optimized so that a 3D system can be successfully implemented with the nursing staff and side effects, such as exhaustion, dizziness or headache can be prevented.

CONCLUSION

The choice of video system will depend on the personal interest of the surgeon and the ability to see 3D. It can be assumed that the majority of the systems will include 3D laparoscopy but 2D laparoscopy will not be completely replaced. A dynamic development of 3D in association with 4K and robotics can be expected.

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction

OBJECTIVE

The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision.

INDICATIONS

Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis.

CONTRAINDICATIONS

Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions.

SURGICAL TECHNIQUE

The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung.

POSTOPERATIVE MANAGEMENT

Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.