Comparison of two- and three-dimensional camera systems in laparoscopic performance: a novel 3D system with one camera. Surg Endosc. 2010;24:1132-1143. [PMID: 19911222 DOI: 10.1007/s00464-009-0740-8]

Comparison of 3D and 2D laparoscopy: Initial experience of perioperative outcomes and clinical assessment

INTRODUCTION

This study was designed to compare three-dimensional (3D) laparoscopy and conventional two-dimensional (2D) laparoscopy in surgical performance and clinical assessment during laparoscopic radical hysterectomy with pelvic lymphadenectomy (LRHND) for treating early-stage cervical cancer.

MATERIAL AND METHODS

In this study, we included 67 consecutive patients underwent LRHND for treating early-stage cervical cancer by the experienced laparoscopic surgeons between August 2018 and December 2020. amongst these patients, 32 patients underwent 3D laparoscopy (2D group) and 35 patients underwent 2D laparoscopy (2D group). Demographic data, clinical and surgical parameters were obtained from each patient. An end-of-operation questionnaire was administered regarding subjective perception of 3D laparoscopy system.

RESULTS

Patient characteristics, including age, BMI, FIGO stage, and histology, were comparable between the two groups. Compared with 2D imaging system, 3D system significantly shortened the operation time, especially bilateral lymph node dissection time. Blood loss was lower in 3D group compared with 2D group. There were no significant differences regarding pelvic nodes retrieved, incidence of complications, hospital stay, the recovery time of bowel, abdominal drainage fluid, hospitalization costs and visual symptoms. In addition, 3D system significantly improved depth perception and precision, and reduced surgical strain and eye strain for surgeon. No statistical difference was observed in visual symptoms and adverse events between the two groups. The surgeon was more willing to accept 3D laparoscopy.

CONCLUSION

The 3D laparoscopy is safe, feasible and comfortable, with obvious advantage in depth perception, precision and surgical strain. It triggered no increase in the complications and adverse events.

Comparison of perioperative, oncologic, and functional outcomes between 3D and 2D laparoscopic radical prostatectomy: a systemic review and meta-analysis

Objectives

Literature regarding experience with 3D laparoscopy about prostatectomy has remained scanty, and this could be related to the rise of robotic assisted laparoscopic surgery. This study aimed to perform a systemic review and meta-analysis to evaluate the perioperative, functional, and oncologic outcomes between 3D and 2D laparoscopic radical prostatectomy (LRP).

Methods

We systematically searched the PubMed, Embase, and Cochrane Library databases for studies that compared perioperative, functional, or oncologic outcomes of both 3D and 2D LRP. The Newcastle-Ottawa Scale (NOS) tool and Jadad scale were used to assess the risk of bias in the included studies. Review Manager 5.3 was used for the meta-analysis.

Results

Seven studies with a total of 542 patients were included in the analysis. Among them, two were RCTs. There was no difference between groups in terms of preoperative characteristics. Anastomosis time, hospital day, and overall complication rates were similar in 3D than 2D group. However, operative time [mean difference (MD) -36.96; 95% confidence interval [CI] -59.25 to -14.67; p = 0.001], blood loss (MD -83.5; 95% CI -123.05 to -43.94; p <0.0001), and days of drainage (MD -1.48; 95% CI -2.29 to -0.67; p = 0.0003) were lower in 3D LRP. 2D and 3D LRP showed similarity in the positive surgical margin (PSM) rate and biochemical recurrence (BCR) rate at 3, 6, and 12months postoperatively. Additionally, there was no significant differences in continence and potency recovery rate between two group except higher continence rate of 3D LRP at 3 months.

Conclusion

Current evidence shows that 3D LRP offers favorable outcomes compared with 2D LRP, including operative time, blood loss, days of drainage, and early continence. However, there was no conclusive evidence that 3D LRP was advantaged in terms of oncologic and functional outcomes (except for continence rate at 3 months).

Systematic review registration

The study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023426403).

Comparison of 2D and autostereoscopic 3D visualization during mixed reality simulation

PURPOSE

In general minimally invasive surgical procedures, surgeons are tied to 2D visualization, leading to the loss of depth perception. This can lead to large mental load for the surgeons and may be responsible for the long learning curve. To restore the sense of depth, this study investigated the use and benefits of an autostereoscopic (3D) display during a simulated laparoscopic task.

METHODS

A mixed reality simulator was developed for comparing the performance of participants while using 2D and autostereoscopic 3D visualization. An electromagnetic sensor was mounted on a physical instrument, and its pose was mapped to the virtual instrument. The virtual scene was developed using Simulation Open Framework Architecture (SOFA). Finite element modeling was used to calculate interaction forces, which were then mapped to visual soft tissue deformation.

RESULTS

Ten non-expert participants completed a virtual laparoscopic task, where the subjects were asked to contact eighteen target areas distributed on the surface of the vagina, both in 2D and 3D. Results showed an improvement with 3D vision in task completion time (-16%), total traveled distance (-25%) and errors made (-14%). There was no difference in the average contact forces between the vagina and the instrument. Only the difference in time and forces were shown to be statistically significant.

CONCLUSION

Overall, autostereoscopic 3D showed superiority over conventional 2D visualization. The traveled trajectory increased in 2D as the instrument was retracted more between the targets to avoid contact. The 2D and 3D deformation upon contact seems not to contribute differently to force perception. However, the participants only had visual feedback, but no haptic feedback. Therefore, it could be interesting to include haptic feedback in a future study.

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.

Augmented reality-based autostereoscopic surgical visualization system for telesurgery

PURPOSE

The visualization of remote surgical scenes is the key to realizing the remote operation of surgical robots. However, current non-endoscopic surgical robot systems lack an effective visualization tool to offer sufficient surgical scene information and depth perception.

METHODS

We propose a novel autostereoscopic surgical visualization system integrating 3D intraoperative scene reconstruction, autostereoscopic 3D display, and augmented reality-based image fusion. The preoperative organ structure and the intraoperative surface point cloud are obtained from medical imaging and the RGB-D camera, respectively, and aligned by an automatic marker-free intraoperative registration algorithm. After registration, preoperative meshes with precalculated illumination and intraoperative textured point cloud are blended in real time. Finally, the fused image is shown on a 3D autostereoscopic display device to achieve depth perception.

RESULTS

A prototype of the autostereoscopic surgical visualization system was built. The system had a horizontal image resolution of 1.31 mm, a vertical image resolution of 0.82 mm, an average rendering rate of 33.1 FPS, an average registration rate of 20.5 FPS, and average registration errors of approximately 3 mm. A telesurgical robot prototype based on 3D autostereoscopic display was built. The quantitative evaluation experiments showed that our system achieved similar operational accuracy (1.79 ± 0.87 mm) as the conventional system (1.95 ± 0.71 mm), while having advantages in terms of completion time (with 34.11% reduction) and path length (with 35.87% reduction). Post-experimental questionnaires indicated that the system was user-friendly for novices and experts.

CONCLUSION

We propose a 3D surgical visualization system with augmented instruction and depth perception for telesurgery. The qualitative and quantitative evaluation results illustrate the accuracy and efficiency of the proposed system. Therefore, it shows great prospects in robotic surgery and telesurgery.

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.

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.

Learning curves, potential and speed in training of laparoscopic skills: a randomised comparative study in a box trainer

Background

The effectiveness of practical surgical training is characterised by an inherent learning curve. Decisive are individual initial starting capabilities, learning speed, ideal learning plateaus, and resulting learning potentials. The quantification of learning curves requires reproducible tasks with varied levels of difficulty. The hypothesis of this study is that the use of three-dimensional (3D) vision is more advantageous than two-dimensional vision (2D) for the learning curve in laparoscopic training.

Methods

Forty laparoscopy novices were recruited and randomised to a 2D Group and a 3D Group. A laparoscopy box trainer with two standardised tasks was used for training of surgical tasks. Task 1 was a positioning task, while Task 2 called for laparoscopic knotting as a more complex process. Each task was repeated at least ten times. Performance time and the number of predefined errors were recorded. 2D performance after 3D training was assessed in an additional final 2D cycle undertaken by the 3D Group.

Results

The calculated learning plateaus of both performance times and errors were lower for 3D. Independent of the vision mode the learning curves were smoother (exponential decay) and efficiency was learned faster than precision. The learning potentials varied widely depending on the corresponding initial values and learning plateaus. The final 2D performance time of the 3D-trained group was not significantly better than that of the 2D Group. The final 2D error numbers were similar for all groups.

Conclusions

Stereoscopic vision can speed up laparoscopic training. The 3D learning curves resulted in better precision and efficiency. The 3D-trained group did not show inferior performance in the final 2D cycle. Consequently, we encourage the training of surgical competences like suturing and knotting under 3D vision, even if it is not available in clinical routine.

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.

Potential of the glasses-free three-dimensional display system in shortening the learning curve of video-assisted endoscopic surgery: a self-controlled ex-vivo study

Background

One of the largest challenges in endoscopic surgical training is adapting to a two-dimensional (2D) view. The glasses-free three-dimensional (GF-3D) display system was designed to integrate the merits of both 2D and conventional 3D (C-3D) displays, allowing surgeons to perform video-assisted endoscopic surgery under a stereoscopic view without heavy and cumbersome 3D glasses.

Methods

In this study, 15 junior thoracic surgeons were divided to test one routine and one complex task three times each via traditional high-definition 2D (HD-2D) and GF-3D to determine whether there was any advantage when using the GF-3D system to acquire endoscopic skills. The duration, numbers of stitches, and distance between every two stitches were recorded for every procedure.

Results

Seven participants were enrolled in the HD-2D group and eight participants were enrolled in the GF-3D group. All 15 participants successfully completed porcine skin continuous suture and tracheal continuous anastomosis procedures three times each. For skin continuous suture, there was no significant difference between the two groups in terms of the learning curve for speed (P=0.683) and accuracy (P=0.556). For tracheal continuous anastomosis, there was a significant difference between the two groups in terms of the learning curve for speed (P=0.001), but no significant difference was observed between the two groups in terms of the learning curve for accuracy (P=0.211).

Conclusions

In summary, both HD-2D and GF-3D display systems are efficient for routine and complex endoscopic surgery. With the help of GF-3D, surgeons can acquire new complex endoscopic skills faster than HD-2D and be free from burdensome polarized glasses. More comparative studies in a clinical setting are needed to further explore the feasibility, necessity, and economic aspects of the GF-3D display system.

Is three-dimensional laparoscopic spleen preserving splenic hilar lymphadenectomy for gastric cancer better than that of two-dimensional? Analysis of a prospective clinical research study

BACKGROUND

Three-dimensional (3D) systems for laparoscopy provide surgeons with additional information on spatial depth not found in two-dimensional (2D) systems.

METHODS

This study enrolled 156 spleen-preserving splenic hilar lymphadenectomy (LSPSHL) patients in a randomized controlled trial (ClinicalTrials.gov Identifier NCT02327481) at the department of gastric surgery at Fujian Medical University Union Hospital between January 2015 and April 2016. The short-term efficacies were compared between the treatment groups. The unedited videos of 80 LSPSHL (40 procedures each for 3D and 2D) were rated for technical performance using the Generic Error Rating Tool.

RESULTS

The data for 156 LSPSHL patients indicate that the estimated blood loss (EBL) (3D vs 2D = 66.3 vs. 99.0, P = 0.046) was significantly less in the 3D group. The postoperative recovery and complication rates were similar (P > 0.05). And there were no deaths within 30 days of surgery. Two observers analyzed 80 videos of LSPSHL. The results showed that there were fewer grasping-errors made in the 3D group than in the 2D group when dissecting the inferior pole region of spleen (IPRS) (P = 0.016) and the superior pole region of spleen (SPRS) (P = 0.022). Additionally, the inter-rater reliability was high regarding grasping-errors in the IPRS (intraclass correlation coefficient (ICC) 0.92) and in the SPRS (ICC 0.83). The ICC for the total number of errors was 0.82. The mean of errors in the 3D group (3D vs. 2D = 20.7 vs. 23.5, P = 0.022) was less than the 2D group.

CONCLUSIONS

Compared with 2D LSPSHL, 3D technology reduces EBL and technical errors during splenic hilar dissection.

3D presentation in surgery: a review of technology and adverse effects

A systematic review was undertaken to assess the technology used to create stereovision for human perception. Adverse effects associated with artificial stereoscopic technology were reviewed with an emphasis on the impact of surgical performance in the operating room. MEDLINE/PubMed library databases were used to identify literature published up to Aug 2017. In the past 60 years, four major types of technologies have been used for reconstructing stereo images: anaglyph, polarization, active shutter, and autostereoscopy. As none of them can perfectly duplicate our natural stereoperception, user exposure to this artificial environment for a period of time can lead to a series of psychophysiological responses including nausea, dizziness, and others. The exact mechanism underlying these symptoms is not clear. Neurophysiologic evidences suggest that the visuo-vestibular pathway plays a vital role in coupling unnatural visual inputs to autonomic neural responses. When stereoscopic technology was used in surgical environments, controversial results were reported. Although recent advances in stereoscopy are promising, no definitive evidence has yet been presented to support that stereoscopes can enhance surgical performance in image-guided surgery. Stereoscopic technology has been rapidly introduced to healthcare. Adverse effects to human operators caused by immature technology seem inevitable. The impact on surgeons working with this visualization system needs to be explored and its safety and feasibility need to be addressed.

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).

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.

Application of a three-dimensional video system in the training for uniportal thoracoscopic surgery

Background

Three-dimensional (3D) video systems offer better depth perception and are associated with improved performance during endoscopic or robotic surgery. We compared the impact of a 3D video system with a two-dimensional (2D) video system on a simulation program for uniportal thoracoscopic surgery.

Methods

We launched an endoscopic simulation program for uniportal surgery using a 3D high-definition video system for training surgeons and medical students. This program included three basic surgical skills: (I) peg transfer, (II) passing a needle through a 3-mm hole, and (III) suturing on a tailor-made skin model. We evaluated the impact of 3D vision during simulation for uniportal surgery in each task. Overall, 113 trainees (85 surgeons in training and 28 medical students) who had not experienced a 3D video system were registered in the program. The three surgical simulation skills were evaluated under 2D and 3D video systems.

Results

The 3D video system allowed for shorter procedural times [92 participants (80.0%) in task 1, 102 (86.4%) in task 2, and 88 (74.6%) in task 3] and improved performance. Moreover, 65 s in task 1, 145 s in task 2, and 32 s in task 3 were shortened using the 3D video system. Post-simulation survey revealed improved depth perception (n=71, 60.2%) and handling of instruments on the uniportal surgical module (n=39, 33.1%) as advantages of the 3D video system during simulation. Sixty (50.8%) trainees were not negatively affected by the use of the 3D glasses; however, 53 (44.9%) felt eye discomfort during simulation.

Conclusions

We concluded that the 3D video system has potential advantages, such as improved procedure time and handling of instruments, during basic simulation of uniportal surgery for surgical trainees.

How Much Stereoscopic Effect Does Laparoscopy Need? Controlled, Prospective Randomized Trial on Surgical Task Efficiency in Standardized Phantom Tasks

Background. To regain 2-eyed vision in laparoscopy, dual-channeled optics have been introduced. With this optics design, the distance between the 2 front lenses defines how much stereoscopic effect is seen. This study quantifies the impact of an enhanced and a reduced stereo effect on surgical task efficiency. Methods. A prospective single-blinded study was performed with 20 laparoscopic novices in an inanimate experimental setting. A standard bichannelled stereo system was used to perform a suturing and knotting task. The working distance and the task size were scaled to vary the stereo effect and, thereby, simulate hypothetic stereo optics with enhanced and reduced optical bases. The task performances were timed, and the number of trials for stitching out was counted. The participants finally filled out a questionnaire to collect subjective impressions. Results. The increase of the stereo effect by 50% caused no objective improvement in laparoscopic knotting compared with typical 3D (control group with stereo basis of 4.5 mm). But ergonomic disadvantages (headache) were subjectively reported in 1 of 20 cases in the questionnaire. The reduction of the stereo effect by one-third led to a significantly longer average execution time. There was no significant dependence found between stereo effect and number of stich-out trials, stitching precision, or knotting quality. Conclusions. Considering laparoscopy, it does not seem advisable to enhance the stereo effect because of ergonomic problems. Otherwise, a miniaturization of the 3D scope (5 mm version) is problematic because its benefit mostly shrinks with the reduced stereo effect.

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems

Three-dimensional (3D) laparoscopic surgical systems have been developed to account for the lack of depth perception, a known disadvantage of conventional 2-dimensional (2D) laparoscopy. In this study, we retrospectively compared the outcomes of total laparoscopic hysterectomy (TLH) with 3D versus conventional 2D laparoscopy. From November 2014, when we began using a 3D laparoscopic system at our hospital, to December 2015, 47 TLH procedures were performed using a 3D laparoscopic system (3D-TLH). The outcomes of 3D-TLH were compared with the outcomes of TLH using the conventional 2D laparoscopic system (2D-TLH) performed just before the introduction of the 3D system. The 3D-TLH group had a statistically significantly shorter mean operative time than the 2D-TLH group (119±20 vs. 137±20 min), whereas the mean weight of the resected uterus and mean intraoperative blood loss were not statistically different. When we compared the outcomes for 20 cases in each group, using the same energy sealing device in a short period of time, only mean operative time was statistically different between the 3D-TLH and 2D-TLH groups (113±19 vs. 133±21 min). During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vaginal cuff dehiscence in each group, which was not statistically different. The surgeon and assistant surgeons did not report any symptoms attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache. Therefore, we conclude that the 3D laparoscopic system could be used safely and efficiently for TLH.

Why laparoscopists may opt for three-dimensional view: a summary of the full HTA report on 3D versus 2D laparoscopy by S.I.C.E. (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie)

Background

Three-dimensional view in laparoscopic general, gynaecologic and urologic surgery is an efficient, safe and sustainable innovation. The present paper is an extract taken from a full health technology assessment report on three-dimensional vision technology compared with standard two-dimensional laparoscopic systems.

Methods

A health technology assessment approach was implemented in order to investigate all the economic, social, ethical and organisational implications related to the adoption of the innovative three-dimensional view. With the support of a multi-disciplinary team, composed of eight experts working in Italian hospitals and Universities, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaire and self-reported interviews, applying a final MCDA quantitative approach, and considering the dimensions resulting from the EUnetHTA Core Model.

Results

From systematic search of literature, we retrieved the following studies: 9 on general surgery, 35 on gynaecology and urology, both concerning clinical setting. Considering simulated setting we included: 8 studies regarding pitfalls and drawbacks, 44 on teaching, 12 on surgeons’ confidence and comfort and 34 on surgeons’ performances. Three-dimensional laparoscopy was shown to have advantages for both the patients and the surgeons, and is confirmed to be a safe, efficacious and sustainable vision technology.

Conclusions

The objective of the present paper, under the patronage of Italian Society of Endoscopic Surgery, was achieved in that there has now been produced a scientific report, based on a HTA approach, that may be placed in the hands of surgeons and used to support the decision-making process of the health providers.

Electronic supplementary material

The online version of this article (10.1007/s00464-017-6006-y) contains supplementary material, which is available to authorized users.

Technical problems during laparoscopy: a systematic method of troubleshooting for surgeons

Background:

Laparoscopic surgery has progressed rapidly since the early 1990s. For some surgical operations, it has become the standard of care to the extent where open surgery is sometimes looked down upon by some surgical colleagues as well as by patients.

Current status:

Despite this widespread adoption and acceptance, many surgeons struggle to understand how the laparoscopy stacks work despite having the skills to perform the operation. Most hospitals rely on operating theatre assistants to troubleshoot in the event of problems. This could be potentially unsafe for patients if laparoscopic vision or pneumoperitoneum is lost at a critical point of the operation.

Discussion:

There are a number of approaches that have been published for troubleshooting laparoscopy stack. We explore and discuss some of them along with their advantages and disadvantages and how they relate to our methodology and approach. As a product of the discussion, we suggest a systematic way forward to troubleshooting laparoscopic tower equipment problems.

Conclusion:

The technical knowledge of surgeons and trainees varies widely in the area of laparoscopy-related troubleshooting. This systematic, practical algorithm would help and guide all surgeons to adopt a uniform approach, thereby improving patient safety.

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.

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.

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 Laparoscopic Sleeve Gastrectomy: Improved Patient Safety and Surgeon Convenience

One of the aims of laparoscopic surgery is to improve upon the results obtained by open surgery. This clearly appears to have been achieved in bariatric surgery. Two-dimensional (2-D) systems have been used to date, though new 3-dimensional (3-D) technologies have been introduced in an attempt to improve surgeon vision and thus increase the safety of the surgical techniques. Sixty obese patients underwent sleeve gastrectomy using a device equipped with 3-D optics allowing surgery to be viewed by the surgeon in 3 dimensions by using a specific monitor and wearing appropriate glasses. The mean patient age was 48.1 years. The mean weight was 114 kg (range, 92-172), with a mean body mass index (BMI) of 44 ± 5.21 kg/m(2). All surgeries were performed using the 3-D system, with a mean surgical time of 71 ± 49.6 minutes and a mean hospital stay of 3.0 ± 1.2 days. Only 1 intraoperative complication was recorded: retroperitoneal bleeding on insertion of the optical trocar. Over a mean follow-up period of 12 months, the mean body weight of the patients was 88 kg (range, 71-121), with a BMI of 30.56 ± 3.98 kg/m(2) and a percentage excess weight loss of 68.14% ± 7.89%. There was clear improvement of both the blood pressure and glucose levels. Three-dimensional sleeve gastrectomy is safe, viable, and fully reproducible compared with 2-D surgery, improving visualization of the surgical field, safety, and surgeon convenience. Randomized studies involving larger patient samples are needed for the comparison of results.

Laparoscopic hysterectomy in the overweight and obese: does 3D imaging make a change?

PURPOSE

To evaluate the influence of three-dimensional (3D) high-definition (HD) visualisation in laparoscopic hysterectomy in normal weight, overweight and obese women.

METHODS

A retrospective analysis of 180 patients undergoing total laparoscopic hysterectomy (TLH: n = 90) or laparoscopic supracervical hysterectomy (LASH: n = 90) was performed. The study collective consisted of 90 women (TLH: n = 45, LASH: n = 45), who underwent laparoscopic hysterectomy with a 3D HD laparoscopic system. Ninety matched (uterine weight, previous surgeries) women with hysterectomy (TLH: n = 45, LASH: n = 45) performed by the same surgeon with conventional two-dimensional laparoscopy formed the control group. Statistical analysis was accomplished stratifying patients according to body mass index (BMI) (≤24.9, 25-29.9, ≥30.0 kg/m²). In each BMI, collective subtypes of surgery (TLH, LASH) as well as hysterectomies as a whole were analysed. Demographic data and surgical parameters were evaluated.

RESULTS

In all BMI subgroups, there were no significant differences concerning demographic parameters. Number of trocar site incisions needed was significantly less in women undergoing 3D compared to 2D laparoscopy independent of BMI. Furthermore, a significantly lower blood loss was revealed using 3D visualisation in LASH subgroups of the normal and overweight collectives. Three-dimensional laparoscopy was additionally associated with a significantly shorter duration of surgery in the TLH subgroup in overweight patients and a lower haemoglobin drop in the LASH subgroup of the obese.

CONCLUSION

The need of less trocar site incisions concerning all weight groups as well.

3D Laparoscopy in Neonates and Infants

BACKGROUND

This study focuses on the successful application of three-dimensional (3D) laparoscopic surgeries in the treatment of congenital anomalies and acquired diseases in the young pediatric population. The purpose of this scientific work consists in highlighting the spectrum, indications, applicability, and effectiveness of 3D endosurgery in children.

METHODS

Our experience is based on 110 endosurgical procedures performed in neonates and infants in the 3D format between January 2014 and May 2015. Depending on the type of operations, all patients were divided into the following groups: (1) inguinal herniorrhaphy (IH)-63 patients; (2) Nissen fundoplication (NF)-22 patients; (3) pyeloureteral anastomosis (PUA)-15 patients; (4) nephrectomy (NE)-5 patients; and (5) ovarian cystectomy (OC)-5 patients. The patients of the first three groups were compared with babies who underwent standard laparoscopic surgery, performed in the two-dimensional (2D) format during the same time period. The groups were organized according to patient demographics, operative report, and postoperative parameters.

RESULTS

The patients were similar in terms of demographics and other preoperative parameters. There were significant differences in mean operative time between 3D and 2D procedures in the groups of patients with hydronephrosis and gastroesophageal reflux, which used manipulation with internal sutures (NF-37.95 minutes versus 48.42 minutes, P = .014; PUA-61.31 minutes versus 78.75 minutes, P = .019), but not in group after IH (15.88 minutes versus 15.57 minutes, P = .681). Postoperative parameters such as length of hospital stay and the number of complications were equivalent between groups.

CONCLUSION

In this study, we demonstrated the success of 3D laparoscopy in small babies with inguinal hernia, gastroesophageal reflux, hydronephrosis, ovarian cyst, and multicystic kidney. Laparoscopy in 3D format lessens the duration of complex procedures, which utilize the use of the suture technique into the abdominal cavity. The perception of depth and the presence of tactile feedback make 3D laparoscopic surgery more acceptable when compared to traditional laparoscopy.

3D vs 2D laparoscopic systems: Development of a performance quantitative validation model

BACKGROUND

The new technology ensures 3D laparoscopic vision by adding depth to the traditional two dimensions. This realistic vision gives the surgeon the feeling of operating in real space. Hospital of Treviglio-Caravaggio isn't an university or scientific institution; in 2014 a new 3D laparoscopic technology was acquired therefore it led to evaluation of the of the appropriateness in term of patient outcome and safety. The project aims at achieving the development of a quantitative validation model that would ensure low cost and a reliable measure of the performance of 3D technology versus 2D mode. In addition, it aims at demonstrating how new technologies, such as open source hardware and software and 3D printing, could help research with no significant cost increase. For these reasons, in order to define criteria of appropriateness in the use of 3D technologies, it was decided to perform a study to technically validate the use of the best technology in terms of effectiveness, efficiency and safety in the use of a system between laparoscopic vision in 3D and the traditional 2D.

METHODS

30 surgeons were enrolled in order to perform an exercise through the use of laparoscopic forceps inside a trainer. The exercise consisted of having surgeons with different level of seniority, grouped by type of specialization (eg. surgery, urology, gynecology), exercising videolaparoscopy with two technologies (2D and 3D) through the use of a anthropometric phantom. The target assigned to the surgeon was that to pass "needle and thread" without touching the metal part in the shortest time possible. The rings selected for the exercise had each a coefficient of difficulty determined by depth, diameter, angle from the positioning and from the point of view.

RESULTS

The analysis of the data collected from the above exercise has mathematically confirmed that the 3D technique ensures a learning curve lower in novice and greater accuracy in the performance of the task with respect to 2D.

Laser visual guidance versus two-dimensional vision in laparoscopy: a randomized trial

Background

During laparoscopy, the surgeon’s loss of depth perception and spatial orientation is problematic. Laser visual guidance (LVG) is an innovative technology that improves depth perception to enhance the visual field. In this trial, we examined the effect of LVG on surgical novices’ motor skills, quality of task performance, and cognitive workload.

Methods

We designed a randomized controlled trial following the CONSORT statement. Thirty-two surgical novices completed the Training and Assessment of Basic Laparoscopic Techniques (TABLT) test. The first attempt allowed participants to familiarize themselves with the exercises. We then randomized the participants, and they completed a test session using either LVG or conventional two-dimensional vision.

Results

We found no significant difference between using the LVG tool and conventional 2D vision; however, both the mean completion time and movements used were less in the LVG group: Mean time used in the LVG group was 1288 s (95 % CI 1188–1388) versus 1354 s (95 % CI 1190–1518) (p = 0.45); mean angular path length used in the LVG group was 24,049° (95 % CI 20,761–27,336) versus 26,014° (95 % CI 22,059–29,970) (p = 0.42); mean path length in the LVG group was 4560 cm (95 % CI 3971–5,149 cm) versus 5062 cm (95 % CI 4328–5797), (p = 0.26). Moreover, the mean TABLT performance score was higher in the LVG group compared with the 2D group, although not significant: 379 (95 % CI 352–405) versus 338 (95 % CI 288–387) (p = 0.14). No significant difference was found between the groups’ cognitive workloads.

Conclusion

We found no significant improvement of laparoscopic motor skills when using LVG, although a tendency toward improved performance was seen. LVG could have the potential to help novice surgeons acquire basic laparoscopic; however, further development of the concept and validation is needed to confirm this.

Single incision gastrectomy for gastric cancer

Based on rapid development of laparoscopic techniques and instruments, single-incision laparoscopic surgery (SILS) is expected to be the next step of "more" minimally invasive surgery. A few institutions gradually started to report their experience of single incision gastrectomy (SIG) for gastric cancer, but it is still difficult to accept that SIG can be performed as a popular procedure because of its technical difficulty. For wide adoption of SIG, the simplicity, safety and reproducibility of not only lymph node dissection but also reconstruction should be evaluated compared to a conventional procedure. With a thorough understanding of unique characteristics of SILS, single incision distal gastrectomy (SIDG) for early gastric cancer performed by laparoscopic surgeons with advanced technique is expected to have promising potential about excellent cosmesis, comparable morbidity and mortality in carefully selected patients. For appropriate adoption and steady progress of this state-of-the art surgery, scientific evaluation with healthy critics is necessary with new generation of SILS instrument platform.

Three-dimensional Laparoscopy: Does Improved Visualization Decrease the Learning Curve Among Trainees in Advanced Procedures?

PURPOSE

Complex laparoscopy is difficult to master because it involves 3-dimensional (3D) interpretation on a 2-dimensional (2D) viewing screen. The use of 3D technology has an uncertain effect on training surgeons. We aim to evaluate the effectiveness of 3D on learning and performing laparoscopic tasks.

METHODS

Medical students without laparoscopic experience (novices) were evaluated doing inanimate object transfer and laparoscopic suturing. Tasks were repeated using 2D and 3D cameras with standard instruments. Time and error rates (missed attempts, dropped objects, and failure to complete the task) were recorded.

RESULTS

Twenty-nine novice medical students experienced a 45.5% decrease in the time to complete PEG transfer using 3D (mean 207 s with 2D vs. 113 s with 3D). Error rate was reduced to 50% (2D, 4 errors vs. 3D, 2 errors) and mean drop rate was reduced to 0. Similar decreases in suture time (46.5%) were seen (mean 403 s with 2D vs. 220 s with 3D).

CONCLUSIONS

Our results indicate that 3D significantly improved visualization and ability to perform complex tasks in the skills laboratory setting. This technology may be very effective in teaching advanced laparoscopic skills in the era of work-hour restrictions.

The Conflicting Evidence of Three-dimensional Displays in Laparoscopy: A Review of Systems Old and New

OBJECTIVE

To describe studies evaluating 3 generations of three-dimensional (3D) displays over the course of 20 years.

SUMMARY BACKGROUND DATA

Most previous studies have analyzed performance differences during 3D and two-dimensional (2D) laparoscopy without using appropriate controls that equated conditions in all respects except for 3D or 2D viewing.

METHODS

Databases search consisted of MEDLINE and PubMed. The reference lists for all relevant articles were also reviewed for additional articles. The search strategy employed the use of keywords "3D," "Laparoscopic," "Laparoscopy," "Performance," "Education," "Learning," and "Surgery" in appropriate combinations.

RESULTS

Our current understanding of the performance metrics between 3D and 2D laparoscopy is mostly from the research with flawed study designs. This review has been written in a qualitative style to explain in detail how prior research has underestimated the potential benefit of 3D displays and the improvements that must be made in future experiments comparing 3D and 2D displays to better determine any advantage of using one display or the other.

CONCLUSIONS

Individual laparoscopic performance in 3D may be affected by a multitude of factors. It is crucial for studies to measure participant stereoscopic ability, control for system crosstalk, and use validated measures of performance.

Depth Perception of Surgeons in Minimally Invasive Surgery

Minimally invasive surgery (MIS) poses visual challenges to the surgeons. In MIS, binocular disparity is not freely available for surgeons, who are required to mentally rebuild the 3-dimensional (3D) patient anatomy from a limited number of monoscopic visual cues. The insufficient depth cues from the MIS environment could cause surgeons to misjudge spatial depth, which could lead to performance errors thus jeopardizing patient safety. In this article, we will first discuss the natural human depth perception by exploring the main depth cues available for surgeons in open procedures. Subsequently, we will reveal what depth cues are lost in MIS and how surgeons compensate for the incomplete depth presentation. Next, we will further expand our knowledge by exploring some of the available solutions for improving depth presentation to surgeons. Here we will review the innovative approaches (multiple 2D camera assembly, shadow introduction) and devices (3D monitors, head-mounted devices, and auto-stereoscopic monitors) for 3D image presentation from the past few years.

Effect of alternative video displays on postures, perceived effort, and performance during microsurgery skill tasks

Physical work demands and posture constraint from operating microscopes may adversely affect microsurgeon health and performance. Alternative video displays were developed to reduce posture constraints. Their effects on postures, perceived efforts, and performance were compared with the microscope. Sixteen participants performed microsurgery skill tasks using both stereo and non-stereoscopic microscopes and video displays. Results showed that neck angles were 9-13° more neutral and shoulder flexion were 9-10° more elevated on the video display than the microscope. Time observed in neck extension was higher (30% vs. 17%) and neck movements were 3x more frequent on the video display than microscopes. Ratings of perceived efforts did not differ among displays, but usability ratings were better on the microscope than the video display. Performance times on the video displays were 66-110% slower than microscopes. Although postures improved, further research is needed to improve task performance on video displays.

[Skills comparison using a 2D vs. 3D laparoscopic simulator]

BACKGROUND

The development and application of 3D images in laparoscopic surgery has brought the benefit of in-depth perception that traditional laparoscopic surgery lacked. Previous studies in surgical populations have demonstrated the advantages of 3D technology. To limit bias of the previous experiences of participants, this study was performed in a population without any experience in this area.

MATERIAL AND METHODS

An experimental, open, cross-sectional, comparative study between surgical skills achievements using 2D and a 3D laparoscopy equipment, using each subject as their own control. Six skills were evaluated in 2D and 3D modalities.

RESULTS

Of the 40 participants included, 20 began the skills in the 2D modality and then performed them in 3D, and the other 20 began in 3D. Of the 118 skills evaluated there was a time improvement in 72% in the 3D group compared to 37% in the 2D modality (P=.000). The accomplishment percentage using the 3D laparoscopy was greater for both groups. There was a statistically significant difference in the better time for the 3D performed tasks. Just over half (52.5%) of participants preferred 3D laparoscopy, 15% preferred 2D, and 32.5% had no preferences.

DISCUSSION

As other studies have demonstrated, there was improvement in the overall performance using the 3D laparoscope. Bias was limited by using a population without surgical experience.

CONCLUSIONS

3D laparoscopic surgical skills showed superior to 2D, with higher percentages of tasks completion, less time in performing them, and a shorter learning curve.

Three-dimensional versus two-dimensional vision in laparoscopy: a systematic review

BACKGROUND

Laparoscopic surgery is widely used, and results in accelerated patient recovery time and hospital stay were compared with laparotomy. However, laparoscopic surgery is more challenging compared with open surgery, in part because surgeons must operate in a three-dimensional (3D) space through a two-dimensional (2D) projection on a monitor, which results in loss of depth perception. To counter this problem, 3D imaging for laparoscopy was developed. A systematic review of the literature was performed to assess the effect of 3D laparoscopy.

METHODS

A systematic search of the literature was conducted to identify randomized controlled trials that compared 3D with 2D laparoscopy. The search was accomplished in accordance with the PRISMA guidelines using the PubMed, EMBASE, and The Cochrane Library electronic databases. No language or year of publication restrictions was applied. Data extracted were cohort size and characteristics, skill trained or operation performed, instrument used, outcome measures, and conclusions. Two independent authors performed the search and data extraction.

RESULTS

Three hundred and forty articles were screened for eligibility, and 31 RCTs were included in the review. Three trials were carried out in a clinical setting, and 28 trials used a simulated setting. Time was used as an outcome measure in all of the trials, and number of errors was used in 19 out of 31 trials. Twenty-two out of 31 trials (71%) showed a reduction in performance time, and 12 out of 19 (63%) showed a significant reduction in error when using 3D compared to 2D.

CONCLUSIONS

Overall, 3D laparoscopy appears to improve speed and reduce the number of performance errors when compared to 2D laparoscopy. Most studies to date assessed 3D laparoscopy in simulated settings, and the impact of 3D laparoscopy on clinical outcomes has yet to be examined.

3D visualization reduces operating time when compared to high-definition 2D in laparoscopic liver resection: a case-matched study

OBJECTIVE

To evaluate the effect of three-dimensional (3D) visualization on operative performance during elective laparoscopic liver resection (LLR).

BACKGROUND

Major limitations of conventional laparoscopy are lack of depth perception and tactile feedback. Introduction of robotic technology, which employs 3D imaging, has removed only one of these technical obstacles. Despite the significant advantages claimed, 3D systems have not been widely accepted.

METHODS

In this single institutional study, 20 patients undergoing LLR by high-definition 3D laparoscope between April 2014 and August 2014 were matched to a retrospective control group of patients who underwent LLR by two-dimensional (2D) laparoscope.

RESULTS

The number of patients who underwent major liver resection was 5 (25%) in the 3D group and 10 (25%) in the 2D group. There was no significant difference in contralateral wedge resection or combined resections between the 3D and 2D groups. There was no difference in the proportion of patients undergoing previous abdominal surgery (70 vs. 77%, p = 0.523) or previous hepatectomy (20 vs. 27.5%, p = 0.75). The operative time was significantly shorter in the 3D group when compared to 2D (225 ± 109 vs. 284 ± 71 min, p = 0.03). There was no significant difference in blood loss in the 3D group when compared to 2D group (204 ± 226 in 3D vs. 252 ± 349 ml in 2D group, p = 0.291). The major complication rates were similar, 5% (1/20) and 7.5% (3/40), respectively, (p ≥ 0.99).

CONCLUSION

3D visualization may reduce the operating time compared to high-definition 2D. Further large studies, preferably prospective randomized control trials are required to confirm this.

3-Dimensional (3D) laparoscopy improves operating time in small spaces without impact on hemodynamics and psychomental stress parameters of the surgeon

BACKGROUND AND PURPOSE

Three-dimensional (3D) imaging, a recent technical innovation in laparoscopic surgery, has been postulated to enhance depth perception and facilitate operations. However, it has never been evaluated in conditions where the focus is close to the optical system. Thus, it is unclear whether 3D cameras can improve laparoscopic surgical performance in neonates and infants. We tested 3D versus two-dimensional (2D) vision during laparoscopic surgery in rabbits, mimicking the size of a neonatal patient.

MATERIALS AND METHODS

Cadaver New Zealand white rabbits (mean weight 2,755 g) were operated by two surgeons experienced in 2D laparoscopic surgery and two surgical residents (with basic skills in 2D laparoscopy). All surgeons had never performed 3D laparoscopic surgery. Animals underwent six operations: Nissen fundoplication, small bowel anastomosis, and closure of a diaphragmatic defect using either 2D or 3D. Primary endpoint was cumulative operating time and operating time of each operation. Secondary endpoints included the hemodynamic response and psychomental stress level of the surgeons. Finally, subjective data on depth perception were assessed by questionnaires.

RESULTS

Cumulative operating time of all three types of operations was significantly shorter with 3D laparoscopy in experts (3D: 23.01 ± 5.65 min vs 2D: 29.51 ± 7.51 min, p < 0.01) and residents (3D: 27.95 ± 3.69 min vs 2D: 33.95 ± 6.21 min, p < 0.05). This effect could be shown for each operation in the expert group and the Nissen fundoplication in the resident group. There were no differences in the hemodynamic response as well as the psychomental stress level between 2D and 3D imaging. 3D provided better depth perception.

CONCLUSION

3D laparoscopy in small spaces is associated with a significant shorter operating time. It induces no additional physical or psychomental stress in surgeons naive to 3D imaging. 3D may therefore facilitate minimal invasive surgery in neonates and infants.

Comparative effectiveness of 3-dimensional vs 2-dimensional and high-definition vs standard-definition neuroendoscopy: a preclinical randomized crossover study

BACKGROUND:

Although the potential benefits of 3-dimensional (3-D) vs 2-dimensional (2-D) and high-definition (HD) vs standard-definition (SD) endoscopic visualization have long been recognized in other surgical fields, such endoscopes are generally considered too large and bulky for use within the brain. The recent development of 3-D and HD neuroendoscopes may therefore herald improved depth perception, better appreciation of anatomic details, and improved overall surgical performance.

OBJECTIVE:

To compare simultaneously the effectiveness of 3-D vs 2-D and HD vs SD neuroendoscopy.

METHODS:

Ten novice neuroendoscopic surgeons were recruited from a university hospital. A preclinical randomized crossover study design was adopted to compare 3-D vs 2-D and HD vs SD neuroendoscopy. The primary outcomes were time to task completion and accuracy. The secondary outcomes were perceived task workload using the NASA (National Aeronautics and Space Administration) Task Load Index and subjective impressions of the endoscopes using a 5-point Likert scale.

RESULTS:

Time to task completion was significantly shorter when using the 3-D vs the 2-D neuroendoscopy (P = .001), and accuracy of probe placement was significantly greater when using the HD vs the SD neuroendoscopy (P = .009). We found that 3-D endoscopy significantly improved perceived depth perception (P < .001), HD endoscopy significantly improved perceived image quality (P < .001), and both improved participants’ overall impression (P < .001).

CONCLUSION:

Three-dimensional neuroendoscopy and HD neuroendoscopy have differing but complementary effects on surgical performance, suggesting that neither alone can completely compensate for the lack of the other. There is therefore strong preclinical evidence to justify 3-D HD neuroendoscopy.

ABBREVIATIONS:

HD, high definition

SD, standard definition

The role of the posterior parietal cortex in stereopsis and hand-eye coordination during motor task behaviours

The field of 'Neuroergonomics' has the potential to improve safety in high-risk operative environments through a better appreciation of the way in which the brain responds during human-tool interactions. This is especially relevant to minimally invasive surgery (MIS). Amongst the many challenges imposed on the surgeon by traditional MIS (laparoscopy), arguably the greatest is the loss of depth perception. Robotic MIS platforms, on the other hand, provide the surgeon with a magnified three-dimensional view of the environment, and as a result may offload a degree of the cognitive burden. The posterior parietal cortex (PPC) plays an integral role in human depth perception. Therefore, it can be hypothesized that differences in PPC activation between monoscopic and stereoscopic vision may be observed. In order to investigate this hypothesis, the current study explores disparities in PPC responses between monoscopic and stereoscopic visual perception to better de-couple the burden imposed by laparoscopy and robotic surgery on the operator's brain. Fourteen participants conducted tasks of depth perception and hand-eye coordination under both monoscopic and stereoscopic visual feedback. Cortical haemodynamic responses were monitored throughout using optical functional neuroimaging. Overall, recruitment of the bilateral superior parietal lobule was observed during both depth perception and hand-eye coordination tasks. This occurred contrary to our hypothesis, regardless of the mode of visual feedback. Operator technical performance was significantly different in two- and three-dimensional visual displays. These differences in technical performance do not appear to be explained by significant differences in parietal lobe processing.