Is 3D faster and safer than 4K laparoscopic cholecystectomy? A randomised-controlled trial

Three-dimensional versus two-dimensional laparoscopy for cholecystectomy in a canine cadaveric study

OBJECTIVE

To compare the effect of three-dimensional (3D) and two-dimensional (2D) laparoscopy on surgical time and intraoperative complications during cholecystectomies in canine cadavers.

STUDY DESIGN

Experimental prospective study.

ANIMALS

Twelve canine cadavers.

METHODS

The laparoscopic cholecystectomies were performed in canine cadavers with four cannulas and with either 2D or 3D cameras by a single surgeon. The following surgical times were recorded: time from insertion of laparoscopic instruments to first endoclip placement, time from first endoclip placement to second endoclip placement, time from second endoclip placement to complete gall bladder dissection, and total surgical time. The cystic duct length distal to the first endoclip, intraoperative complications, and the amount of liver attached to the gall bladder were also recorded.

RESULTS

Time from the insertion of the instruments to the application of the first endoclip was shorter for the 3D group than for the 2D group (p = .016). Other surgical times were not different between groups. There was no difference in the cystic duct length distal to the first endoclip, intraoperative complications, or the amount of liver attachment.

CONCLUSION

Three-dimensional laparoscopy shortened the time from insertion of the laparoscopic instruments to placement of the first endoclip. However, total surgical time was not affected by the type of camera in laparoscopic cholecystectomy.

CLINICAL SIGNIFICANCE

Three-dimensional laparoscopy may be beneficial when performing procedures requiring enhanced spatial orientation. However, this technique did not shorten the total surgical time in this cadaveric study. Further studies in a clinical setting are necessary for the optimization of the future use of 3D laparoscopy.

Comparison of 2D 4K vs. 3D HD laparoscopic imaging systems in bariatric surgery: study protocol for a randomized controlled prospective trial

BACKGROUND

Vision is an important and defining element of laparoscopy and significantly affects the outcome of surgery in terms of time, error, and precision. Several new imaging systems have become available for laparoscopic surgery, including three-dimensional (3D) high-definition (HD) and two-dimensional (2D) ultra-high-resolution (4K) monitors. 3D HD systems offer a number of potential benefits to surgeons and patients over traditional 2D systems, including reduced operating time, blood loss, and hospital stay. However, the performance of 3D systems against the new, ultra-high definition 4K systems is barely known and highly controversial. There is a paucity of studies comparing them in clinical settings. The aim of this study is to compare 2D 4K and 3D HD perspectives in gastric bypass surgery.

METHODS

Forty-eight patients with an indication for gastric bypass will be randomized to receive laparoscopic gastric bypass surgery using either 2D 4K or 3D HD systems. The operations will be performed by a well-coordinated team of three senior surgeons. The primary outcome is operative time. Secondary outcomes include intraoperative complications, blood loss, operator workload as assessed by the validated Surg-TLX questionnaire, and postoperative complications according to the Clavien-Dindo classification. An interim analysis is planned after enrollment of 12 participants for each group.

DISCUSSION

This prospective, randomized trial is designed to test the hypothesis that the use of a 3D HD system will result in a significant improvement in operative time compared to a 2D 4K system in bariatric surgery. The objective is to provide clinical evidence for new laparoscopic imaging systems and to evaluate potential benefits.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov under the identifier NCT05895058. Registered 30 May 2023. BASEC2023-D0014 [Registry ID Swissethics, approved 3 May 2023]. SNCTP000005489 [SNCTP study register, last updated 13 July 2023].

Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review

Laparoscopy offers numerous advantages over open procedures, minimizing trauma, reducing pain, accelerating recovery, and shortening hospital stays. Despite other technical advancements, pneumoperitoneum insufflation has received little attention, barely evolving since its inception. We explore the impact of pneumoperitoneum on patient outcomes and advocate for a minimally invasive approach that prioritizes peritoneal homeostasis. The nonlinear relationship between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV) is discussed, emphasizing IAP titration to balance physiological effects and surgical workspace. Maintaining IAP below 10 mmHg is generally recommended, but factors such as patient positioning and surgical complexity must be considered. The depth of neuromuscular blockade (NMB) is explored as another variable affecting laparoscopic conditions. While deep NMB appears favorable for surgical stillness, achieving a balance between IAP and NMB depth is crucial. Temperature and humidity management during pneumoperitoneum are crucial for patient safety and optical field quality. Despite the debate over the significance of temperature drop, humidification and the warming of insufflated gas offer benefits in peritoneal homeostasis and visual clarity. In conclusion, there is potential for a paradigm shift in pneumoperitoneum management, with dynamic IAP adjustments and careful control of insufflated gas temperature and humidity to preserve peritoneal homeostasis and improve patient outcomes in minimally invasive surgery.

Investigation of the optimal indocyanine green dose in real-time fluorescent cholangiography during laparoscopic cholecystectomy with an ultra-high-definition 4K fluorescent system: a randomized controlled trial

This study aimed to investigate the indocyanine green (ICG) dose in real-time fluorescent cholangiography during laparoscopic cholecystectomy (LC) with a 4K fluorescent system. A randomized controlled clinical trial was conducted in patients who underwent LC for treatment of cholelithiasis. Using the OptoMedic 4K fluorescent endoscopic system, we compared four different doses of ICG (1, 10, 25, and 100 µg) administered intravenously within 30 min preoperatively and evaluated the fluorescence intensity (FI) of the common bile duct and liver background and the bile-to-liver ratio (BLR) of the FI at three timepoints: before surgical dissection of the cystohepatic triangle, before clipping the cystic duct, and before closure. Forty patients were randomized into four groups, and 33 patients were fully analyzed, with 10 patients in Group A (1 µg), 7 patients in Group B (10 µg), 9 patients in Group C (25 µg), and 7 patients in Group D (100 µg). The preoperative baseline characteristics were compared among groups (p > 0.05). Group A showed no or minimal FI in the bile duct and liver background, while Group D showed extremely high FIs in the bile duct and in the liver background at the three timepoints. Groups B and C presented with visible FI in the bile duct and low FI in the liver background. With increasing ICG doses, the FIs in the liver background and bile duct gradually increased at the three timepoints. The BLR, however, showed no increasing trend with an increasing ICG dose. A relatively high BLR on average was found in Group B, without a significant difference compared to the other groups (p > 0.05). An ICG dose ranging from 10 to 25 µg by intravenous administration within 30 min preoperatively was appropriate for real-time fluorescent cholangiography in LC with a 4K fluorescent system. Registration: This study was registered in the Chinese Clinical Trial Registry (ChiCTR No: ChiCTR2200064726).

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.

Which video technology brings the higher cognitive burden and motion sickness in laparoscopic colorectal surgery: 3D, 2D-4 K or 3D-4 K? a propensity score study

BACKGROUND

Technological development has offered laparoscopic colorectal surgeons new video systems to improve depth perception and perform difficult task in limited space. The aim of this study was to assess the cognitive burden and motion sickness for surgeons during 3D, 2D-4 K or 3D-4 K laparoscopic colorectal procedures and to report post-operative data with the different video systems employed.

METHODS

Patients were assigned to either 3D, 2D-4 K or 3D-4 K video and two questionnaires (Simulator Sickness Questionnaire-SSQ- and NASA Task Load Index -TLX) were used during elective laparoscopic colorectal resections (October 2020-August 2022) from two operating surgeons. Short-term results of the operations performed with the three different video systems were also analyzed.

RESULTS

A total of 113 consecutive patients were included: 41 (36%) in the 3D Group (A), 46 (41%) in the 3D-4 K Group and 26 (23%) in the 2D-4 K Group (C). Weighted and adjusted regression models showed no significant difference in cognitive load amongst the surgeons in the three groups of video systems when using the NASA-TLX. An increased risk for slight/moderate general discomfort and eyestrain in the 3D-4 K group compared with 2D-4 K group (OR = 3.5; p = 0.0057 and OR = 2.8; p = 0.0096, respectively) was observed. Further, slight/moderate difficulty focusing was lower in both 3D and 3D-4 K groups compared with 2D-4 K group (OR = 0.4; p = 0.0124 and OR = 0.5; p = 0.0341, respectively), and higher in the 3D-4 K group compared with 3D group (OR = 2.6; p = 0.0124). Patient population characteristics, operative time, post-operative staging, complication rate and length of stay were similar in the three groups of patients.

CONCLUSIONS

3D and 3D-4 K systems, when compared with 2D-4 K video technology, have a higher risk for slight/moderate general discomfort and eyestrain, but show lower difficulty focusing. Short post-operative outcomes do not differ, whichever imaging system is used.

A multicenter survey of effects and challenges of an 8K ultra-high-definition endoscopy system compared to existing endoscopy systems for endoscopic surgery

INTRODUCTION

8K ultra-high-definition (UHD) images enabling clearer recognition of anatomical structures could contribute to further development of surgical techniques and advanced applications in endoscopic surgery fields. This study aimed to clarify effects and challenges of endoscopic surgery with 8K UHD endoscopy compared to existing endoscopy systems.

METHODS

In this multicenter, cross-sectional, questionnaire survey, data were collected from surgical participants who newly used and observed 8K UHD endoscopy in patients undergoing surgery from February 2020 to February 2021. Survey items included sense of presence, reality, depth perception, visibility of tissue, eyestrain, and degree of satisfaction for operators and observers, and weight, operability, focus adjustment, physical fatigue, eyestrain, and satisfaction for camera assistants. Participants rated each 8K UHD endoscopic surgery on a one-to-five scale (definitively inferior, relatively inferior, equivalent, relatively superior, definitively superior) compared to the existing endoscopy system of each facility.

RESULTS

Overall, questionnaire responses from 139 participants assessing 8K UHD endoscopic surgery were collected from surgeries performed in 46 patients. Respective ratings of operators and observers included sense of presence: "superior or relatively superior", 97.8% and 91.5%; reality: "superior or relatively superior", 76.1% and 72.3%; and visibility of tissue: "superior or relatively superior", 93.5% and 87.2%. Weight was rated as "inferior or relatively inferior" by 73.9% of camera assistants and focus adjustment as "inferior" by 60.9% of them.

CONCLUSIONS

8K UHD endoscopic surgery enabled identification of surgical anatomies more clearly, provided a sense of presence and reality, and might improve educational effect. Technological development is expected to reduce the burden of camera assistants.

Comparison of 2K and 4K imaging systems for laparoscopic repair of choledochal cyst in children

AIM

The safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.

METHODS

LapCC were performed at a single institution by the same team using a 2 K system (2009-2018; n = 26) and a 4 K system (2018-2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.

RESULTS

LapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p<0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p < 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22). There was one HJA leak with 2 K (3.8%) and no complications with 4 K.

CONCLUSIONS

Improved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.

LEVEL OF EVIDENCE

III.

Performance of three-dimensional and ultra-high-definition (4K) technology in laparoscopic surgery: A systematic review and meta-analysis

Background:

Methods:

Results:

Conclusion:

Choledochoscopy: An update

Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Comparison of 2D 4K vs. 3D HD laparoscopic imaging systems using a pelvitrainer model: a randomized controlled study

Laparoscopic surgery provides well-known benefits, but it has technological limitations. Depth perception is particularly crucial, with three-dimensional (3D) imaging being superior to two-dimensional (2D) HD imaging. However, with the introduction of 4K resolution monitors, 2D rendering is capable of providing higher-quality visuals. Therefore, this study aimed to compare 3D HD and 2D 4K imaging using a pelvitrainer model. Eight experts and 32 medical students were performing the same four standardized tasks using 2D 4K and 3D HD imaging systems. Task completion time and the number of errors made were recorded. The Wilcoxon test and mixed-effects models were used to analyze the results. Students were significantly faster in all four tasks when using the 3D HD perspective. The median difference ranged from 18 s in task 3 (P < 0.003) up to 177.5 s in task 4 (P < 0.001). With the exception of task 4, students demonstrated significantly fewer errors in all tasks involving 3D HD imaging. The experts’ results confirmed these findings, as they were also faster in all four tasks using 3D HD, which was significant for task 1 (P < 0.001) and task 4 (P < 0.006). The expert group also achieved better movement accuracy using the 3D HD system, with fewer mistakes made in all four tasks, which was significant in task 4 (P < 0.001). Participants in both groups achieved better results with the 3D HD imaging system than with the 2D 4K system. The 3D HD image system should be used when available. Trial registration: this trial is registered at research registry under the identifier researchregistry6852.

Learning Pattern of Two-Dimensional, Three-Dimensional, and Ultra-High-Definition Endovision System on Standardized Phantom Tasks: An Ex Vivo Randomized Study

Introduction: Three-dimensional (3D), high-definition (HD), and ultra-high-definition (4K HD) are recent additions over regular HD technology for laparoscopic surgery. The aim of this study was to evaluate the learning pattern of these systems on standardized phantom tasks. Methodology: Forty-five stereo-enabled resident doctors were randomly assigned into three groups. They performed three validated tasks, precision touch on flat surface, precision touch on uneven surface, surgical knot on rubber tube using either two-dimensional (2D) HD, 3D HD, or 4K HD Endovision systems. Each task was repeated 20 times. Data from four consecutive repetitions were pooled to make five blocks. Split group analysis by comparing the consecutive blocks in execution time and errors were made to see the learning pattern. A significant difference was accepted as continuous learning while no significant difference was accepted as learning stabilization. Result: Operating time was stabilized in two tasks after third block in 2D HD, one task after fourth block in 4K HD. There was continuous learning in all tasks with 3D HD. The 3D HD group was significantly faster than 2D HD and 4K HD in most of the tasks on fifth block. The error scores were similar between the consecutive blocks in 4K HD. It was stabilized after second block in 2D HD group and third block on 3D HD. Conclusion: The 3D HD Endovision system has more potential of faster execution of a task, but need more practice to reach similar safety profile. The 4K HD reached the safety plateau with minimal repetitions.

Diagnosis of advanced gastric cancer using image enhancement and autofluorescence imaging systems

INTRODUCTION

The indication of laparoscopic gastrectomy for advanced cases such as serosal invasion or peritoneal dissemination is still controversial. We report the clinical experiences of laparoscopic diagnosis with image enhancement and autofluorescence (AF) systems for laparoscopic gastric cancer surgery.

METHODS

The image enhancement system was introduced to 164 patients who underwent laparoscopic gastric cancer surgery as the AF group. The control group was defined as 165 cases who underwent bright light observation without the image enhancement system. The operative findings were recorded during surgery. All image findings were retrospectively compared with the pathological findings. Furthermore, the relationship between the image and pathological findings for peritoneal dissemination and subserosal invasion was evaluated.

RESULTS

This study included 329 patients, divided into the control group of 165 patients (50.2%) and the AF group of 164 patients (49.8%). There was no statistically significant difference in patient background between the two groups. In seven cases of peritoneal dissemination, AF was positive, and macroscopic abnormal vascularization was detected. The sensitivity, specificity, and positive and negative predictive values were 100%, 99.4%, 87.5%, and 100%, respectively. In 29 cases of serosal invasion, AF was positive, and macroscopic abnormal vascularization was detected. In the detection accuracy of subserosal invasion, the sensitivity, specificity, and positive and negative predictive values were 75.7%, 97.6%, 90.3%, and 93.2%, respectively.

CONCLUSION

The image enhancement with the AF system is useful for the laparoscopic intraoperative diagnosis of serosal invasion and peritoneal dissemination for advanced gastric cancer.

4K versus 3D total laparoscopic hysterectomy by resident in training: a prospective randomised trial

Background

The introduction of ultra-high-definition laparoscopic cameras (4K), by providing stronger monocular depth perception, could challenge the existing 3D technology. There are few available studies on this topic, especially in gynaecological setting.

Objectives

Prospective, single institution, randomised clinical trial (NCT04209036).

Materials and Methods

The two laparoscopes utilised were the 0°ULTRA Telescopes with 4K technology and the 0°3D-HD by Olympus. The surgeons were all trainees and in their last year of residency and who had obtained the certificate of first or second level of the Gynaecological Endoscopic Surgical Education and Assessment program - GESEA program. Twenty-nine patients with benign uterine pathology were enrolled.

Main outcome measures

To compare if the use three-dimensional (3D) versus ultra-high-definition laparoscopic vision system (4K) for total laparoscopic hysterectomy performed by trainees was associated with a shorter operative time.

Results

The 3D vision system did not prove to be superior to the 4K vision system. Operators reported significantly more vision-related side effects when using 3D than 4K. Completing the GESEA training program was the only factor with a positive and statistically significant impact on the overall time of the procedure, especially when greater dexterity and tissue handling were required.

Conclusions

Neither technology used proved superior to the other, although operators showed a preference for 4K over 3D due to the lower number of visual side effects. Attendance at courses on laparoscopic simulators and training programs allowed trainees to demonstrate excellent surgical skills.

Comparison of laparoscopic gastrectomy with 3-D/HD and 2-D/4 K camera system for gastric cancer: a prospective randomized control study

PURPOSE

We conducted a prospective clinical control study to identify the best imaging technology among three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4 K) technology and confirm their effects on surgical outcomes of laparoscopic gastrectomy for gastric cancer.

METHODS

From April 2018 to August 2019, 50 patients were randomly classified into two groups based on the imaging technology (3-D/HD group = 25, 2-D/4 K = 25). After excluding eight patients based on laparoscopic findings, 42 patients were analyzed (3-D/HD group = 21, 2-D/4 K = 21). The primary endpoint was the operative time; the secondary endpoints were blood loss, postoperative infectious complications, and postoperative hospital stay.

RESULTS

The patients' backgrounds were similar (sex, age, body mass index [BMI], stage, procedure, and extent of lymph node dissection). There were no significant differences in operative time (252 vs. 238 min, P = 0.70), total blood loss, postoperative infectious complications, and postoperative hospital stay between the two groups. However, video analysis of surgeries revealed a significantly shortened median operative time (18 vs. 25 min, P = 0.04) in the suturing step with 3-D/HD; the median number of camera cleaning procedures during suprapancreatic lymph node dissection was significantly lower with 2-D/4 K than with 3-D/HD (n = 4.4 vs. 2.8, P = 0.02).

CONCLUSION

3-D/HD and 2-D/4 K laparoscopic radical gastrectomies provide similar surgical outcomes. However, the 3-D monitor reduces suturing time during reconstruction, while the 4 K monitor reduces the number of camera cleaning procedures during lymphadenectomy.

TRIAL REGISTRATION

Registered in the University Hospital Medical Information Network Clinical Trials Registry (identification number 000029227).

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard. From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Comparison of three-dimensional (3D) endovision system versus ultra-high-definition 4K endovision system in minimally invasive surgical procedures: a randomized-open label pilot study

BACKGROUND

Experimental work comparing 3-Dimensional (3D) and 4K ultra-high-definition endovision system (4K) indicates that the latter with double the resolution of standard 2D high-definition systems may provide additional visual cues to compensate for the lack of stereoscopic vision. There is paucity of studies comparing 3D and 4K system in clinical settings. This randomized study compares 3D and 4K systems in three laparoscopic procedures of increasing complexity.

METHODS

139 patients undergoing laparoscopic cholecystectomy (60 patients), transabdominal preperitoneal (TAPP) repair (49 patients) and laparoscopic Heller's cardiomyotomy with anti- reflux procedure (30 patients) between May 2018 and February 2020 were randomized to undergo surgery using either 3D or 4K systems. Primary objective was to measure total operative time. Secondary objectives were to compare workload perceived by surgeons using SURG-TLX and surgeon satisfaction score. Timings of key surgical steps and peri-operative course of the patients was also recorded. Data were analyzed using Stata Corp. 2015.

RESULTS

Patients undergoing surgery with 3D and 4K systems were comparable in their clinical and demographic profiles. The mean total operative time in 3D and 4K groups was comparable in cholecystectomy (52.7 vs 56.2, p = 0.50), TAPP (63.8 vs 69.6, p = 0.25) and Heller's cardiomyotomy (124.7 vs 143.3, p = 0.14) with faster hiatal dissection in 3D group (8 min, p = 0.02). Operative time was better in patients undergoing Heller's myotomy with Angle of His accentuation with 3D by 28 min (p = 0.03). Total workload was similar in 3D and 4K groups in all the procedures but mental & physical demand was lower in 3D group in Heller's cardiomyotomy (p = 0.03, p = 0.01), Surgeon satisfaction score was comparable in all three procedures.

CONCLUSION

Overall, 3D HD and 4K systems are comparable in performing laparoscopic cholecystectomy, TAPP and Heller's Cardiomyotomy. Hiatal dissection time, mental and physical task load was better with 3D in Heller's Cardiomyotomy.

Learning Laparoscopic Surgery Skills With a 4K Ultra-High Definition 2D vs a Three-Dimensional HD Laparoscopic System: Results From a Prospective Randomized Trial

Background. In minimally invasive surgery (MIS), the loss of stereoscopic depth perception in a two-dimensional (2D) representation is most challenging. Recently introduced 4K ultrahigh definition (UHD) 2D optical systems could potentially facilitate the learning and use of compensation mechanisms for the loss of depth perception. However, the role of the new 4K technology against three dimensional (3D) in learning and implementation of MIS remains unknown. The aim of this trial was to determine the influence of 4K UHD 2D vs 3D HD representation on the acquisition of MIS skills. Methods. This was a prospective randomized study involving 62 MIS-inexperienced study participants. We compared a laparoscopic 4K UHD 2D (system A) vs a laparoscopic 3D HD system (system B) for differences in learning MIS skills using the Lübeck Toolbox (LTB) video box trainer. We evaluated participants' performance regarding the repetitions required to reach the goal of each LTB task. Results. Comparing systems A and B, participants using the laparoscopic 3D system required fewer repetitions to achieve goals of LTB tasks No. 1 (P = .0048) and No. 3 (P = .0014). In contrast, for LTB tasks No. 2 and No. 4, no significant difference could be determined between both groups. Conclusion. Our results indicated that MIS basic skills can be learned quicker using a 3D HD system vs a 4K UHD 2D system. However, for MIS tasks in confined spaces, the learning speed with 4K UHD 2D imaging seems to be comparable to a 3D HD system.

Short term outcomes of three dimensional versus two-dimensional laparoscopic cholecystectomy

Objective:

To compare the short-term outcomes of three dimensional (3D) versus two dimensional (2D) laparoscopic procedures used for cholecystectomy.

Methods:

This study was conducted at minimally invasive surgery center of Liaquat University of Medical Health and Sciences (LUMHS) Jamshoro Pakistan, between 15^th May 2017 to 16^th December 2017 after taking informed consent. All patients were diagnosed cases of cholelithiasis without any complications. Patients having risk factors for inability to get access to gall bladder via laparoscope and in whom the chances of conversion to open cholecystectomy were greater were not included as part of study. One group of patients underwent cholecystectomy under 3D laparoscopy while other group underwent 2D laparoscopy. Surgeons included in the study were all well-trained. The short-term outcome noted were intraoperative and postoperative complications, conversion to open, operative time, mortality and hospital stay. Visual strain and headache for the surgeon in three D laparoscopic cholecystectomy.

Results:

A total of one hundred forty patients were included in the study. Group-A consists of sixty two females and eleven males whereas Group-B comprised of fifty eight females and fifteen males. Eight percent of patients in Group-A whereas in Group-B two percent had gallbladder rupture. Fifteen percent of patients in Group-A whereas 5.4% from Group-B had bleeding from liver bed. One patient from Group-A had CBD (Common Bile Duct) injury. Post-operatively two (2.73%) patients from Group-A had port site bleeding. Six (8.21%) patients had port site infection in Group-A.

Conclusion:

Three dimensional was found to have low incidence of intra-operative and post-operative complications compared to 2D laparoscopic cholecystectomy.

3D Versus 4K Display System - Influence of "State-of-the-art"-Display Technique on Surgical Performance (IDOSP-study) in Minimally Invasive Surgery: A Randomized Cross-over Trial

Objective:

To evaluate if “state-of-the-art” 3D- versus 4K-display techniques could influence surgical performance.

Background:

High quality minimally invasive surgery is challenging. Therefore excellent vision is crucial. 3D display technique (3D) and 2D-4K technique (4K) are designed to facilitate surgical performance, either due to spatial resolution (3D) or due to very high resolution (4K).

Methods:

In randomized cross-over trial the surgical performance of medical students (MS), non-board certified surgeons (NBC), and board certified surgeons (BC) was compared using 3D versus 4K display technique at a minimally invasive training Parkour.

Results:

One hundred twenty-eight participants were included (February 2018 through October 2019, 49 MS, 39 NBC, 40 BC). The overall Parkour time (s) 3D versus 4K was 712.5 s ± 17.5 s versus 999.5 s ± 25.1 s (P < 0.001) for all levels of experience. It was (3D vs 4K) for MS (30 tasks) 555.4 s ± 28.9 s versus 858.7 s ± 41.6 s, (P < 0.0001), for NBC (42 tasks) 935.9 s ± 31.5 s versus 1274.1 s ± 45.1 s (P =< 0.001) and for BC (42 task) 646.3 s ± 30.9 s versus 865.7 s ± 43.7 s (P < 0.001). The overall number of mistakes was (3D vs 4K) 10.0 ± 0.5 versus 13.3 ± 0.7 (P < 0.001), for MS 8.9 ± 0.9 versus 13.1 ± 1.1 (P < 0.001), for NBC 12.45 ± 1.0 versus 16.7 ± 1.2 (P < 0.001) and for BC 8.8 ± 1.0 versus 10.0 ± 1.2 (P = 0.18). MS, BC, and NBC showed shorter performance time in 100% of the task with 3D (significantly in 6/7 tasks). For number of mistakes the effect was less pronounced for more experienced surgeons. The National Aeronautics and Space Administration-task load index was lower with 3D.

Conclusion:

3D laparoscopic display technique optimizes surgical performance compared to the 4K technique. Surgeons benefit from the improved visualization regardless of their individual surgical expertise.

Comparison of two-dimensional high-definition, ultra high-definition and three-dimensional endovision systems: an ex-vivo randomised study

BACKGROUND

Two-dimensional high-definition (2D HD) endovision system is preferred for laparoscopic surgery. Recently, new generation three-dimensional (3D) HD and ultra-HD (4K) endovision systems are introduced to improve the safety and efficacy of laparoscopic surgery. There is limited evidence on superiority of one technology over the others. This experimental trial was designed to evaluate 2D HD, 3D HD and 4K HD endovision systems in performance of standardized tasks.

METHODS

This was a randomized, cross-over experimental study. Twenty-one surgical residents who were exposed to laparoscopic surgery were enrolled. Participants were randomly assigned into three groups. Each group performed standardised tasks i.e. peg transfer, precision cutting, navigating in space and intra-corporeal suturing using 2D HD, 4K HD and 3D HD endovision systems on a box trainer. Procedures were recorded as 2D HD videos and analysed later. Participant's perceived workload was assessed using Surg-TLX questionnaire. Primary endpoints were execution time in seconds and error score. Secondary endpoint was workload assessment.

RESULTS

The 3D HD had shorter execution time compared to 2D HD and 4K HD in all tasks except precision cutting (p = 0.004, 0.03, 0.001, 0.001 and p = 0.002, 0.191, 0.006, 0.005 in peg transfer, precision cutting, navigating in space and intra-corporeal suturing respectively). The 4K HD was significantly faster than 2D HD only in navigating in space task (p = 0.002). The error score between 3D HD and 4K HD were comparable in all tasks. The 2D HD had significantly more error scores compared to 4K HD, 3D HD in peg transfer task (p = 0.005, 0.014, respectively). 3D HD had significantly less workload than 2D HD and 4K HD in most of the dimensions of Surg-TLX CONCLUSIONS: 3D HD endovision system in comparison to 2D HD and 4K HD, may lead to faster execution without compromising safety of a task and is associated with less workload.

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.