Full High-definition Three-dimensional Gynaecological Laparoscopy – Clinical Assessment of a New Robot-assisted Device

Discussion

Due to a steady increase in the number of minimally-invasive procedures, surgeons are increasingly faced with the disadvantages of 2D imaging systems. The loss of depth perception is of particular interest in complex procedures, such as laparoscopic intracorporeal suturing or dissection of pelvic and para-aortic lymph nodes. The first report of a 3D laparoscopic device in human surgery was published in 1993 by Becker et al. (5). The first 3D laparoscopic systems were limited by poor image quality, eyestrain and cumbersome laparoscopic devices. In 1996, Volz et al. stated that the 3D laparoscopic system of that time had advantages for microsurgical procedures but was unsuitable for surgery of the uterus or adnexal masses (6). This conclusion can be attributed to the low quality of the early generation of 3D laparoscopic systems. In our study, all surgeries were completed successfully, with consistently positive assessment by surgeons, and no conversion to laparotomy or 2D visualisation was necessary. This reflects the development of better visual and laparoscopic techniques and the fact that previous technical flaws were eliminated. Our investigation shows that the full-HD 3D laparoscopic device used here is comfortable and suitable even for extensive laparoscopic surgery. The loss of spatial depth using a 2D system can be compensated for by the experience of the surgeon and by the ability of the human brain to process additional information (secondary spatial depth cues) to achieve spatial orientation (4). In the 3D visualisation, the mental workload previously required for transformation of indirect references, such as motion of the laparoscope, size of anatomic structures and changes in shading and texture, can be used for enhanced concentration. This may result in a significant gain in precision for difficult surgical tasks and significantly increase the speed of tasks, as shown by Storz et al. in an ex vivo setting (4). In the future full-HD 3D approaches might offer the possibility not only of performing surgery faster but also performing them with more safety due to easier identification of anatomical structures. Phantom task setups simulate partial surgical procedures but do not reflect the complexity of real clinical conditions. To the best of our knowledge, this is the first clinical report of gynaecological laparoscopic surgeries performed with a 3D robot-assisted laparoscopic system in HD quality. Previous studies showed that the error rates in in vitro settings were increased and that more movements of the laparoscopic instruments were necessary to complete laparoscopic tasks successfully using 2D visualisation (2, 7). Interestingly, the more complex the tasks, the more 3D visualisation enhanced task performance, independently of the laparoscopic experience of the surgeon (8). Kong et al. stated that 3D systems could help physicians to perform surgical procedures more accurately and safely, which is confirmed by our findings that all participants rated, 3D visualisation as improving detection of anatomical structures and facilitating complex laparoscopic procedures. Except for one person in our study, who was affected by headache and eye fatigue, no one felt visual discomfort or suffered nausea. These favourable results regarding visual comfort may be partially attributed to the full-HD visualisation. Higher dizziness rates were reported in earlier studies dealing with 3D laparoscopy but without the usage of full-HD visualisation (2). The beneficial results in our study regarding full HD visualisation in 3D are consistent with the results of other investigations dealing with HD quality both for 2D and 3D laparoscopy (4, 9). Hagiike et al. showed that HD visualisation compared to conventional standard visualisation provides a superior image and leads to a reduced time for laparoscopic knot tying (9). The combination of full HD and 3D visualisation is favourable regarding time and error rate compared to full-HD 2D laparoscopy, as shown by Storz et al. (4). The physicians who were negatively-affected by wearing the special glasses for 3D vision did not wear glasses in daily life. Therefore, it is not surprising that wearing glasses in the unusual setting of the operation theatre during surgery was rated as disturbing. As previously shown by Honeck et al., the use of a laparoscopic device, as also used in our series, leads to a significant benefit regarding missed grasps and the loss of working materials in an in vitro setting (1). So it is not surprising that the majority of surgeons felt an improvement of the hand-to-eye coordination and all of them believed that 3D imaging may widen the operative spectrum of laparoscopic surgery. Additionally, the robotic camera arm is particularly useful for performing complex tasks when more than two hands are needed. On the occasions in which the assistant physician would normally have to handle the camera, they can now assist actively with two laparoscopic instruments or in other ways. Besides these advantages, there are some disadvantages to be noted. A major drawback of the system used in this study is the significantly higher acquisition costs compared to standard laparoscopic systems. Studies dealing with 3D laparoscopy report inconsistent results and investigations in clinical settings with 3D full-HD laparoscopy are scarce (4, 10). Our results show that a broad range of gynaecological surgery could be performed successfully and 3D visualisation in combination with a robot-assisted laparoscope holder reached high satisfaction rates. We are aware of the limitations of our study. The questionnaire used in the present study reflects subjective impressions of the participating surgeons and no direct comparison of 2D versus 3D approaches were performed. Moreover, the evaluation of a novel technique is affected by the surgeon's level of experience and their subjective attitude towards innovation. Nevertheless our study included surgeons with different levels of training, giving a detailed assessment of a novel laparoscopic system. We believe that this technique seems to be a promising and innovative alternative to conventional laparoscopic devices. This is strengthened by the fact that all participants stated they would prefer 3D in standard gynaecological laparoscopic procedures and that 3D visualisation should be used more frequently. Nevertheless, it remains debatable if robot-assisted 3D systems should be used in short, uncomplicated or purely diagnostic procedures, bearing in mind the time required for attachment of the robotic arm, costs of the system and tight surgical schedules. Whether this technique will become more popular, as has already been shown in the steadily-increasing number of 3D cinema movies and 3D products in the home entertainment segment, remains to be seen.