A secondary learning curve in 3D versus 2D imaging in laparoscopic training of surgical novices

Impact of 3D Endovision System on Learning Process of Laparoscopic Transabdominal Preperitoneal Repair of Groin Hernia

Background: Laparo-endoscopic hernia surgery is recommended by various international bodies. However, its uptake by general surgeon is low. We aim to assess the impact of Three Dimensional (3D) endovision system in learning laparoscopic transabdominal preperitoneal (TAPP) repair of groin hernia and transferability of skills acquired from 3D to the Two Dimensional (2D) environment. Methodology: Senior resident doctor with no previous experience in laparoscopic hernia surgery did 20 consecutive cases of TAPP repair using 3D endovision system followed by another five cases of TAPP repair using 2D endovision system. Total operating time, operating time during different phases of hernia surgery, faculty take over time, path length of needle holder, and scissors were recorded. Cumulative sum (CUSUM) and split group analysis were done to assess the learning process. Trainee's operating time was compared with that of experts' from previously published study of the same group. Data were compared between last block of five cases done using 3D system and cases done using 2D system for skill transferability. Results: CUSUM method provided inflection points of total operating time, hernia dissection and mesh placement at 9th case, and peritoneal suturing at 11th case in learning TAPP hernia. After 10th case, trainee's operating time was within the middle 50 percentage of experts operating time. Total operating time in last block of cases done under 3D vision and that of 2D endovision comparable, although peritoneal closure was significantly longer in 2D vision (P = .074, .2, .145, .001). Conclusion: Reduction on operating time appears after ninth case of TAPP hernia repair using the 3D endovision system. The skills acquired under 3D endovision system are transferable to perform the procedure under 2D endovision system, albeit incompletely. Use of 3D technology may facilitate adaptation of TAPP hernia repair by young surgeons.

Transferability of laparoscopic skills acquired from three-dimensional high-definition and ultra-high definition endovision system to two-dimensional high-definition endovision system: an ex-vivo randomized study

Three-dimensional high-definition (3D HD) and ultra-high-definition (4 K HD) endovision systems are rapidly adopted in academic setting. However, transferability of laparoscopic skills acquired from these systems to two-dimensional high-definition (2D HD) endovision system is not known. Forty stereo-enabled surgical residents were randomized into two groups. They performed three standardized surgical tasks, Task 1(Peg transfer), Task 2(Precision touch on uneven surface) and Task 3(Surgical knotting on rubber tube) for 15 repetitions using either 3D HD or 4 K HD. Both groups then performed the same tasks using 2D HD for 5 repetitions. Their performances were evaluated for execution time (speed) and error scores (safety). The residents in 3D HD group performed all three tasks significantly faster than residents in 4 K HD group with comparable error scores. The time taken to complete the tasks on 2D HD were comparable between residents trained in 3D HD and 4 K HD in two out of three tasks (p = 0.027, P = 0.115, p = 0.368 in task 1, 2 and 3 respectively). However, in two out of three tasks, residents trained on 3D HD committed significantly more errors than residents trained on 4 K HD (p < 0.0001, p < 0.001 in task 1 and task 2 respectively). Skill acquired on 4 K HD seems transferable to 2D HD environment. Participants trained in 3D HD made more errors while performing the tasks in 2D HD. It may be prudent to offer additional training on 2D HD to residents trained on 3D HD for safer laparoscopic surgical practice.

3D versus 2D laparoscopic distal gastrectomy in patients with gastric cancer: a systematic review and meta-analysis

BACKGROUND

While laparoscopic gastrectomy is a prominent therapeutic approach for distal gastric cancer, the clinical benefits of 3D laparoscopy over 2D laparoscopy remain unclear. We aimed to compare the clinical outcomes of 3D laparoscopy and 2D laparoscopy for distal gastric cancer resection through a systematic review and meta-analysis.

METHODS

We searched PubMed/MEDLINE, EMBASE, and Cochrane Library databases for studies published from inception through January 2023, according to the PRISMA guidelines. The MD or RR was used to compare 3D and 2D distal gastrectomy. Random-effects meta-analysis was estimated using the inverse variance and Mantel-Haenszel method for binary outcomes and the DerSimonian-Laird estimator for continuous outcomes.

RESULTS

After reviewing 559 studies, 6 manuscripts met the inclusion criteria. The analysis included 689 patients, with 348 (50.5%) in the 3D group and 341 (49.5%) in the 2D group. 3D laparoscopic gastrectomy reduces the operative time (WMD - 28.57 min, 95% CI - 50.70 to - 6.44, p = 0.011), intraoperative blood loss (WMD - 6.69 mL, 95% CI - 8.09 to - 5.29, p < 0.001), and postoperative hospital stay (WMD - 0.92 days, 95% CI - 1.43 to - 0.42, p < 0.001). There were no significant differences in time to first postoperative flatus (WMD - 0.22 days, 95% CI - 0.50 to 0.05, p = 0.110), postoperative complications (Relative Risk 0.56, 95% CI 0.22 to 1.41, p = 0.217), and the number of retrieved lymph nodes (WMD 1.25, 95% CI - 0.54 to 3.03, p = 0.172) between 3 and 2D laparoscopic distal gastrectomy.

CONCLUSION

Our study highlights the potential advantages of 3D laparoscopy in distal gastrectomy, including shorter operative time, postoperative hospital stay, and decreased intraoperative blood loss.

Three-dimensional vision versus two-dimensional vision on laparoscopic performance of trainee surgeons: a systematic review and meta-analysis

Laparoscopic surgery underwent great improvements during the last few years. This review aims to compare the performance of Trainee Surgeons using 2D versus 3D/4 K laparoscopy. A systematic review of the literature was done on Pubmed, Embase, Cochrane's Library and Scopus. The following words and key phrases have been searched: "Two-dimensional vision", "Three-dimensional vision", "2D and 3D laparoscopy", "Trainee surgeons". This systematic review was reported according to the PRISMA statement 2020. PROSPERO registration No. CRD42022328045. Twenty-two randomized controlled trials (RCTs) and two observational studies were included in the systematic review. Two trials were carried out in a clinical setting, and twenty-two trials were performed in a simulated setting. In studies involving the use of a box trainer, the number of errors in the 2D laparoscopic group was significantly higher than in the 3D laparoscopic group during the performance of FLS skill tasks: peg transfer (MD: -0.82; 95% CI - 1.17 to - 0.47; p < 0.00001), cutting (MD: - 1.09; 95% CI - 1.50 to - 0.69 p < 0.00001), suturing (MD: - 0.48; 95% CI - 0.83 to - 0.13 p = 0.007), However, in clinical studies, there was no significant difference in the time taken for laparoscopic total hysterectomy (MD: 8.71; 95% CI - 13.55 to 30.98; p = 0.44) and vaginal cuff closure (MD: 2.00; 95% CI - 0.72 to - 4.72; p = 0.15) between 2D group and 3D group. 3D laparoscopy facilitates learning for novice surgeons and shows improvements in their laparoscopic performance.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.