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.

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).

6G Networks for Next Generation of Digital TV Beyond 2030

This paper prosed a novel 6G QoS over the future 6G wireless architecture to offer excellent Quality of Service (QoS) for the next generation of digital TV beyond 2030. During the last 20 years, the way society used to watch and consume TV and Cinema has changed radically. The creation of the Over The Top content platforms based on Cloud Services followed by its commercial video consumption model, offering flexibility for subscribers such as n Video on Demand. Besides the new business model created, the network infrastructure and wireless technologies also permitted the streaming of high-quality TV and film formats such as High Definition, followed by the latest widespread TV standardization Ultra-High- Definition TV. Mobile Broadband services onset the possibility for consumers to watch TV or Video content anywhere at any time. However, the network infrastructure needs continuous improvement, primarily when crises, like the coronavirus disease (COVID-19) and the worldwide pandemic, creates immense network traffic congestions. The outcome of that congestion was the decrease of QoS for such multimedia services, impacting the user's experience. More power-hungry video applications are commencing to test the networks' resilience and future roadmap of 5G and Beyond 5G (B5G). For this, 6G architecture planning must be focused on offering the ultimate QoS for prosumers beyond 2030.

Cervical spine microsurgery with the high-definition 3D exoscope: advantages and disadvantages

OBJECTIVE

The aim of this study was to evaluate our experience with a high-definition three-dimensional (3D) exoscope (EX) for cervical spine surgery versus a binocular operating microscope (OM).

METHODS

A retrospective review of patients undergoing a single-level anterior cervical discectomy and fusion (ACDF) procedure for the treatment of cervical myelopathy from March 2019 to May 2020 was performed. Demographic, perioperative, and clinical outcomes of 50 patients were included, 23 of whom received assistance from the 3D exoscope (EX group) and 27 of whom received assistance from the OM (OM group). Operative baseline and postoperative outcome parameters were evaluated. Periprocedural handling, visualization, and illumination by the EX, as well as surgeons' ergonomics, were scored using a questionnaire and rapid upper limb assessment (RULA).

RESULTS

Baseline characteristics were similar between the two groups. There were no significant differences between groups in mean operative time, blood loss, duration of admission, or postoperative improvement of symptoms. Both groups showed similar clinical improvements after surgery. There were no intraoperative complications in either group. According to the attending surgeons, the intraoperative handling of instruments for the EX was rated to be comparable to that of the OM. Surgeons rated the comfort level of the intraoperative posture for the EX as very high on the subjective questionnaire and equal to the OM on the objective RULA. When compared with the OM, depth perception, image quality, and illumination for the EX were rated as inferior in ACDF procedures with long approaches. The operative education and training function of the EX was rated to be superior to that of the OM.

CONCLUSIONS

Overall, our study showed that the EX appears to be a safe alternative for common ACDF with the unique advantage of excellent comfort and also serves a useful educational tool for the surgical team. However, our investigation revealed several important limitations of this system, including slightly inferior visualization and illumination quality compared with the OM.

Application Value of 4K High-Definition System in Laparoscopic Gastrectomy: Preliminary Results and Initial Experience

Background: To investigate the application value of 4K high definition (HD) in laparoscopic gastrectomy by comparing the short-term outcomes and subjective perception with three-dimensional (3D) and HD vision systems. Materials and Methods: A retrospective study was conducted between September 2018 and February 2019; a total of 87 patients who underwent laparoscopic gastrectomy were enrolled and divided into three groups in terms of different type of vision system used for surgery: 4K, 3D, and HD. Demographic and clinicopathological data as well as short-term outcomes were collected and analyzed. A questionnaire survey was completed by the team of surgeons to evaluate the subjective perception of different vision systems. Results: There was no significant difference in gender, body mass index, age, American Society of Anesthesiologists (ASA) score and history of abdominal surgery, tumor location as well as type of operation, and anastomosis between the 4K, 3D, and HD groups. All patients underwent laparoscopic gastrectomy without conversion to laparotomy. There was no difference between the three groups regarding operation time (4K versus 3D versus two-dimensional (2D), 183.60 ± 52.5 versus 189.69 ± 69.87 versus 211.00 0 ± 49.33, P = .145) and estimated blood loss (4K versus 3D versus 2D, 123.60 ± 119.51 versus 150.62 ± 105.46 versus 129.00 ± 103.57, P = .602), no difference was found in time to first flatus and postoperative hospital stay between the three groups. No significant difference was found in postoperative complications between the three groups. As for pathological results, there was no difference in tumor size and tumor-node-metastasis (TNM) stage. In 4K group, the number of lymph node harvested was 32.60 ± 10.28, no difference was found compared with that of 3D (29.81 ± 8.94) and HD groups (27.69 ± 10.96). The score of group 3D was the lowest concerning asthenopia and motion sickness. On the contrary, 3D group achieved the highest score in topographical orientation and depth description. 4K group was graded the highest in terms of control co-ordination of visual angle, visual acuity, radiance, resolution ratio and frames, and refresh rate. HD group was graded significantly lower in sense of control compared with that of 4K and 3D group. No significant difference was found in color resolution and contrast. Conclusions: In conclusion, the short-term effect of 4K HD laparoscopic system is comparable with that of HD and 3D laparoscopy, whereas 4K could reduce adverse effect than traditional instrument and improve quality of surgery. The Clinical Trial Registration number is NCT01441336.

A high-definition 3D exoscope as an alternative to the operating microscope in spinal microsurgery

OBJECTIVE

Since the 1970s, the operating microscope (OM) has been a standard for visualization and illumination of the surgical field in spinal microsurgery. However, due to its limitations (e.g., size, costliness, and the limited movability of the binocular lenses, in addition to discomfort experienced by surgeons due to the posture required), there are efforts to replace the OM with exoscopic video telescopes. The authors evaluated the feasibility of a new 3D exoscope as an alternative to the OM in spine surgeries.

METHODS

Patients with degenerative pathologies scheduled for single-level lumbar or cervical spinal surgery with use of a high-definition 3D exoscope were enrolled in a prospective cohort study between January 2019 and September 2019. Age-, sex-, body mass index-, and procedure-matched patients surgically treated with the assistance of the OM served as the control group. Operative baseline and postoperative outcome parameters were assessed. Periprocedural handling, visualization, and illumination by the exoscope, as well as surgeons' comfort level in terms of posture, were scored using a questionnaire.

RESULTS

A 3D exoscope was used in 40 patients undergoing lumbar posterior decompression (LPD) and 20 patients undergoing anterior cervical discectomy and fusion (ACDF); an equal number of controls in whom an OM was used were studied. Compared with controls, there were no significant differences for mean operative time (ACDF: 132 vs 116 minutes; LPD: 112 vs 113 minutes) and blood loss (ACDF: 97 vs 93 ml; LPD: 109 vs 55 ml) as well as postoperative improvement of symptoms (ACDF/Neck Disability Index: p = 0.43; LPD/Oswestry Disability Index: p = 0.76). No intraoperative complications occurred in either group. According to the attending surgeon, the intraoperative handling of instruments was rated to be comparable to that of the OM, while the comfort level of the surgeon's posture intraoperatively (especially during "undercutting" procedures) was rated as superior. In cases of ACDF procedures and long approaches, depth perception, image quality, and illumination were rated as inferior when compared with the OM. By contrast, for operating room nursing staff participating in 3D exoscope procedures, the visualization of intraoperative process flow and surgical situs was rated to be superior to the OM, especially for ACDF procedures.

CONCLUSIONS

A 3D exoscope seems to be a safe alternative for common spinal procedures with the unique advantage of excellent comfort for the surgical team, but the drawback is the still slightly inferior visualization/illumination quality compared with the OM.

3D vs. 4K Display System - Influence of "State-of-the-art"-Display Technique On Surgical Performance (IDOSP-Study) in minimally invasive surgery: protocol for a randomized cross-over trial

Background

Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual task. The reduction from real life 3D to virtual two-dimensional (2D) sight is a major challenge in minimally invasive surgery (MIS). A 3D display technique has been shown to reduce operation time and mistakes and to improve the learning curve. Therefore, the use of a3D display technique seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics, a 4K display technique was recently introduced to MIS. Due to its high resolution and zoom effect, surgeons should benefit from it. The aim of this study is to evaluate if “state-of-the-art” 3D- vs. 4K-display techniques could influence surgical performance.

Methods

A randomized, cross-over, single-institution, single-blinded trial is designed. It compares the primary outcome parameter “surgical performance”, represented by “performance time ”and “number of mistakes”, using a passive polarizing 3D and a 4K display system (two arms) to perform different tasks in a minimally invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (National Aeronautics and Space Administration (NASA) Task Load Index) and the learning curve. Unexperienced novices (medical students), non-board-certified, and board-certified abdominal surgeons participate in the trial (i.e., level of experience, 3 strata). The parkour consists of seven tasks (for novices, five tasks), which will be repeated three times. The 1st run of the parkour will be performed with the randomized display system, the 2nd run with the other one. After each run, the mental stress load is measured. After completion of the parkour, all participants are evaluated by an ophthalmologist for visual acuity and stereoscopic vision with five tests. Assuming a correlation of 0.5 between measurements per subject, a sample size of 36 per stratum is required to detect a standardized effect of 0.5 (including an additional 5% for a non-parametric approach) with a power of 80% at a two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled.

Discussion

Complex surgical procedures are performed in a minimally invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance.

Trial registration

ClinicalTrials.gov, NCT03445429. Registered on 7 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3330-7) contains supplementary material, which is available to authorized users.

Preliminary experience with 4K ultra-high definition endoscope: analysis of pros and cons in skull base surgery

During the last two decades endoscopic skull base surgery observed a continuous technical and technological development 3D endoscopy and ultra High Definition (HD) endoscopy have provided great advances in terms of visualisation and spatial resolution. Ultra-high definition (UHD) 4K systems, recently introduced in the clinical practice, will shape next steps forward especially in skull base surgery field. Patients were operated on through transnasal transsphenoidal endoscopic approaches performed using Olympus NBI 4K UHD endoscope with a 4 mm 0° Ultra Telescope, 300 W xenon lamp (CLV-S400) predisposed for narrow band imaging (NBI) technology connected through a camera head to a high-quality control unit (OTV-S400 – VISERA 4K UHD) (Olympus Corporation, Tokyo, Japan). Two screens are used, one 31" Monitor – (LMD-X310S) and one main ultra-HD 55" screen optimised for UHD image reproduction (LMD-X550S). In selected cases, we used a navigation system (Stealthstation S7, Medtronic, Minneapolis, MN, US). We evaluated 22 pituitary adenomas (86.3% macroadenomas; 13.7% microadenomas). 50% were not functional (NF), 22.8% GH, 18.2% ACTH, 9% PRL-secreting. Three of 22 were recurrences. In 91% of cases we achieved total removal, while in 9% near total resection. A mean follow-up of 187 days and average length of hospitalisation was 3.09 ± 0.61 days. Surgical duration was 128.18± 30.74 minutes. We experienced only 1 case of intraoperative low flow fistula with no further complications. None of the cases required any post- or intraoperative blood transfusion. The visualisation and high resolution of the operative field provided a very detailed view of all anatomical structures and pathologies allowing an improvement in safety and efficacy of the surgical procedure. The operative time was similar to the standard 2D HD and 3D procedures and the physical strain was also comparable to others in terms of ergonomics and weight.

The effect on surgical skills of expert surgeons using 3D/HD and 2D/4K resolution monitors in laparoscopic phantom tasks

BACKGROUND

Recently, several new imaging technologies, such as three-dimensional (3D)/high-definition (HD) stereovision and high-resolution two-dimensional (2D)/4K monitors, have been introduced in laparoscopic surgery. However, it is still unclear whether these technologies actually improve surgical performance.

METHODS

Participants were 11 expert laparoscopic surgeons. We designed three laparoscopic suturing tasks (task 1: simple suturing, task 2: knotting thread in a small box, and task 3: suturing in a narrow space) in training boxes. Performances were recorded by an optical position tracker. All participants first performed each task five times consecutively using a conventional 2D/HD monitor. Then they were randomly divided into two groups: six participants performed the tasks using 3D/HD before using 2D/4K; the other five participants performed the tasks using a 2D/4K monitor before the 3D/HD monitor. After the trials, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and compared performance scores across all monitors.

RESULTS

Surgical performances of participants were ranked in decreasing order: 3D/HD, 2D/4K, and 2D/HD using the total scores for each task. In task 1 (simple suturing), some surgical performances using 3D/HD were significantly better than those using 2D/4K (P = 0.017, P = 0.033, P = 0.492 for operative time, path length, and technical errors, respectively). On the other hand, with operation in narrow spaces such as in tasks 2 and 3, performances using 2D/4K were not inferior to 3D/HD performances. The high-resolution images from the 2D/4K monitor may enhance depth perception in narrow spaces and may complement stereoscopic vision almost as well as using 3D/HD.

CONCLUSIONS

Compared to a 2D/HD monitor, a 3D/HD monitor improved the laparoscopic surgical technique of expert surgeons more than a 2D/4K monitor. However, the advantage of 2D/4K high-resolution images may be comparable to a 3D/HD monitor especially in narrow spaces.

Use of narrow band imaging and 4K technology in otology and neuro-otology: preliminary experience and feasibility study

The advent of the endoscope has facilitated otological surgery in recent years. Advances in optical technology have led to the development of high definition visualisation, such as 4K magnification. Narrow band imaging (NBI) has been shown to improve visualisation of tissue based on varying degrees of vascularity. This is a feasibility study, the first of its kind, aiming to investigate the appearances of middle ear anatomy and pathology (tympanic membrane, tympanosclerosis, cholesteatoma, granulation, endolymphatic sac hydrops, otosclerosis) under the NBI filter, using a high definition 4K endoscope. Qualitative analysis of image detail and operating time in minutes were recorded. The study demonstrates that these two technologies can be implemented with ease into practice, and show a clear differentiation between pathology and normal anatomy. NBI and 4K magnification prove to be useful adjuncts to the surgeon during endoscopic ear surgery.

Capturing and displaying microscopic images used in medical diagnostics and forensic science using 4K video resolution - an application in higher education

To analyze, interpret and evaluate microscopic images, used in medical diagnostics and forensic science, video images for educational purposes were made with a very high resolution of 4096 × 2160 pixels (4K), which is four times as many pixels as High-Definition Video (1920 × 1080 pixels). The unprecedented high resolution makes it possible to see details that remain invisible to any other video format. The images of the specimens (blood cells, tissue sections, hair, fibre, etc.) are recorded using a 4K video camera which is attached to a light microscope. After processing, this resulted in very sharp and highly detailed images. This material was then used in education for classroom discussion. Spoken explanation by experts in the field of medical diagnostics and forensic science was also added to the high-resolution video images to make it suitable for self-study.