ORIGINAL ARTICLE
Three-dimensional Laparoscopy: Does Improved Visualization Decrease the Learning Curve Among Trainees in Advanced Procedures? Kyle G. Cologne, MD, Joerg Zehetner, MD, Loriel Liwanag, BA, Christian Cash, MD, Anthony J. Senagore, MD, and John C. Lipham, MD
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.
advantage for a 3D over a 2D system, the need to wear goggles for the surgeon as well as assistant and scrub tech to see the same image, as well as the current slightly heavier equipment for 3D, while the latest cameras are similar in handling. While the benefits of 3D visualization are obvious and touted by most of the surgeons performing robotic surgery with the DaVinci system (Intuitive Surgical Inc., Sunnyvale, CA), the expense of this system has limited more widespread use. It remains unclear whether visualization alone or increased degrees of freedom is the primary determinant of improved task performance. While other studies have shown different results of 2D versus 3D laparoscopy on surgical performance, there are very little data on novices and skills training regarding the use of 2D versus 3D systems. It remains unclear exactly what effect the use of 3D technology has on the training of a surgeon. Our aim is to evaluate the effectiveness of 3D on learning and performing advanced laparoscopic tasks in the laboratory and in more complex laparoscopic cases to see what effect (if any) 3D has on the ability to learn laparoscopic surgery and shorten the learning curve.
Key Words: advanced laparoscopy, laparoscopy, surgical training, simulation, 3-dimentional laparoscopy
(Surg Laparosc Endosc Percutan Tech 2015;25:321–323)
S
ince the introduction of laparoscopic surgery 25 years ago, residents and novice laparoscopic interested surgeons have to adapt to interpret a 3-dimensional (3D) environment on a 2-dimensional (2D) viewing screen. While picture quality has increased from standard definition to high-definition monitors in most institutions, there has been little correlation with improved laparoscopic performance measures. In fact, some studies demonstrate worse performance with high-definition images.1 The reason for this failure with improved visualization with augmented details in high-definition images may be in fact due to interpretation of a 3D environment on a 2D screen. Nonetheless, there has not been widespread use of 3D monitor technology. Reasons are the lack of clear evidence for an Received for publication October 22, 2014; accepted March 28, 2015. From the Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA. Presented as a poster at the 2013 Annual SAGES Meeting in Baltimore, MD. The authors declare no conflicts of interest. Reprints: Kyle G. Cologne, MD, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033 (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
METHODS First-year and second-year medical students without laparoscopic experience (novices) were selected during their skills laboratory rotation to participate in this study. The study was approved by the University of Southern California Institutional Review Board. The protocol included the evaluation of the performance of a variety of tasks. Inanimate models were used to assess the transfer of objects on a peg-board (according to the standardized FLS skills task) (Fig. 1) as well as laparoscopic suturing as the second task. Participants were instructed to repeat the task using the 2D and the 3D camera systems with the standard laparoscopic instruments. For the 2D system, a Storz camera system and optic was used (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), as well as a standard HD monitor, whereas for the 3D system the 3DHD system from Viking Systems (Viking Systems Inc., Westborough, MA) was used. Time and error rates were calculated and scored. An error was defined as either a missed attempt or the drop of an object, or the failure to complete the task. Further, a survey was performed on experienced laparoscopic surgeons regarding the overall impression of the technology’s impact on performance, skills acquisition, training, and teaching. Statistical analysis was performed using a paired t test for all time variables, and independent t test for error rates using SPSS software (SPSS Inc., Chicago, IL). A cutoff of 0.05 was used to determine significance.
Volume 25, Number 4, August 2015
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321
Surg Laparosc Endosc Percutan Tech
Cologne et al
FIGURE 1. Laparoscopic transfer of objects on PEG board (FLS exercise).
RESULTS There were 29 first-year and second-year medical students who participated in the study. All students finished the tasks of transferring objects on the PEG board as well as the suturing skills exercise. In the PEG transfer laparoscopic skill exercise there was a 45.5% decrease in the time to complete the task among novice providers when using 3D (mean 207 s with 2D vs. 113 s with 3D, P < 0.001). The average error rate was reduced to 50% (2D, 4 errors vs. 3D, 2 errors) and the mean drop rate was reduced from 1 to 0 (P = 0.8). Similar decrease in time for the complex task of laparoscopic suturing was seen with 46.5% (mean 403 s with 2D vs. 220 s with 3D, P < 0.001. The survey of expert laparoscopic surgeons that used the 3D technology in a trial phase (n = 12 surgeons) reported after an average of 5 to 10 procedures an improved accuracy and performance. Eighty-five percent felt 3D was “Better than high-definition laparoscopy” and 57% felt 3D visualization “Improved accuracy and performance.” Fifty-seven percent based their experience on 5 to 10 procedures with the 3D device. Fifty-seven percent perceived an improved accuracy and performance of procedures using the 3D, though 43% would choose this technology over 2D given the choice for any particular procedure, with the same number stating it was more advantageous for more complex surgical tasks (suturing, vessel ligation). When compared with robot technology, 28% prefer the 3D technology over the robot. Fourteen percent prefer the robot due to increased degrees of freedom, and 28% prefer the robot due to both increased degree of freedom and surgeon camera control. Twentyeight percent do not use robotic technology regularly. Comments on the technology included: “I have found it incrementally helpful even for an experienced surgeon. Trainees are more precise compared to 2D”; “Gives a good image and would probably help with resident training”; “It provides a better picture, but not sure it increases my effectiveness”; “When functioning properly, my impression of the technology is positive. The struggle to have the equipment in place and functioning properly make it somewhat cumbersome at this point. With dedication to its use and consistency, I would consider it to be beneficial.”
DISCUSSION Three-dimensional laparoscopy appears to be a promising technology for teaching novice providers, and our results show advantages in skills acquiring for novices in laparoscopic
Volume 25, Number 4, August 2015
surgery. Previous authors have shown similar results, with a subsequent improvement in later 2D performance (ie, shortened learning curve),2–5 although no study has been adequately powered to definitively show this improvement. The impact of the research regarding 3D technology might overcome the reduced exposure of current residents to the operating room and patients due to the limited work hours since the introduction of the 80-hour work week. Further, the reduction of the intern hours to maximum of 16 hours will further reduce exposure of the novice students and residents to laparoscopic surgery. This has translated into a decrease in operative caseload.6 The positive effects seen in the laboratory with a nearly 50% reduction in time performing the same tasks is encouraging that with more skills labs including 3D technology, as well as 3D camera sets for the laparoscopic procedures such as cholecystectomy and appendectomy might decrease the learning curve. The available evidence suggests that 3D visualization (mostly through the use of a robotic platform) enhances surgical skill, decreases error rates, and improves the ability to perform complex tasks among trainees.7,8 What remains unclear is whether this effect is due to the robot itself, or merely the enhanced visualization provided by a 3D camera in this medium. No study has been conducted to date to assess the impact of this difference. Our study suggests that 3D platform alone provides many of the advantages in learning these complex operative skills. A number of studies have been used to evaluate procedural tasks.9 Storz et al3 published a study of medical students and expert surgeons in 2D versus 3D. In complex tasks, experienced surgeons were no faster in a 3D environment, but they gained overall precision with 3D visualization. Novices, or student laparoscopists, improved the time by 28% to 31% for most tasks and also decreased error rates. This study was performed using 20 medical students and 10 laparoscopic surgeons doing a series of tasks 1 time. Their results are similar to ours, though we demonstrated a greater improvement with 3D. Stefanidis et al10 looked at robotic assistance in performing complex suturing tasks among novices. Thirty-four students were randomized to perform suturing for a Nissen fundoplications on a porcine model with premarked suture points after a brief instructional session. Those assigned to perform the suturing task using the robot performed faster and committed fewer errors. It is unclear from the study how much of this effect is due to the robot and how much is from 3D visualization, as the standard laparoscopy arm did not have access to either tool to enhance performance. Interestingly, robotics eliminated the early learning curve for novices. Chandra et al11 published a study evaluating 20 novices and 9 experts on a series of 10 tasks using both the robot and standard laparoscopy. These were scored using pathlengths, smoothness, and time to complete the tasks. Novices that used the robotic environment first performed each task with increased speed, decreased pathlength, and improved smoothness. Again, it is unclear how much of this improved effect is due to the robot versus the 3D visualization. The total time was no different for experts between the 2 environments, but pathlength was decreased in the robotic group. Our data seem to suggest that similar improvements in time can be accomplished with 3D alone, without the use of robot technology. Kong et al4 performed a comparison of 21 novices and 6 experts using 2 tasks in both environments by alternating environments on 4 different days (3D first on day 1, 2D first on the subsequent day). The novice group experienced
322 | www.surgical-laparoscopy.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 4, August 2015
decreased errors but no difference in time to complete the tasks. In addition, there was increased use of the nondominant hand (as measured by EMG analysis). Although there were no statistical performance improvements, 80% of the expert group preferred the 3D environment to 2D—an effect we saw as well in our survey results. Votanopoulos et al12 published a study comparing 3D versus 2D on 6 laparoscopic tasks. Three-dimensional imaging allowed novice participants to make less errors and reduce the time to complete the tasks. This effect was more pronounced on the more complex tasks of rope passing (simulating running the bowel) and suturing. Experienced participants (third-year and fifth-year residents) showed no difference in errors or time to complete the tasks between the environments. The study implied that teaching laparoscopic skills may be facilitated by a 3D environment. Interestingly, those that performed the tasks in a 3D environment first were significantly better in 2D during their subsequent testing session (as compared with those that experienced the 2D environment first and 3D second), further suggesting that the 3D environment may play a role in faster acquisition of visuospatial skills in a minimally invasive environment. It is interesting that this effect may not be as great once the technical skills are mastered. The future direction of this research will be to evaluate the learning curve for certain procedures using 3D technology. For example, it is known that it takes Z50 cases for surgeons that already have a basic laparoscopic skills set to learn complex laparoscopic procedures such as a laparoscopic colectomy13 with the 2D standard or high-definition cameras. How much that can be decreased with advanced 3D visualization remains to be determined, but the preliminary data on performance of complex tasks are encouraging.
CONCLUSIONS Our results indicate that 3D significantly improved visualization and ability to perform complex tasks in the skills laboratory setting. It is likely that 3D technology is very effective at shortening the learning curve to train surgeons in advanced laparoscopic skills—a very important factor in the era of work-hour restrictions.
Copyright
r
Three-dimensional Laparoscopy
REFERENCES 1. Feng C, Rozenblit JW, Hamilton AJ. A computerized assessment to compare the impact of standard, stereoscopic, and high-definition laparoscopic monitor displays on surgical technique. Surg Endosc. 2010;24:2743–2748. 2. Van Sickle KR, Ritter EM, Baghai M, et al. Prospective, randomized, double-blind trial of curriculum-based training for intracorporeal suturing and knot tying. J Am Coll Surg. 2008;207:560–568. 3. Storz P, Buess GF, Kunert W, et al. 3D HD versus 2D HD surgical task efficiency in standardized phantom tasks. Surg Endosc. 2012;26:1454–1460. 4. Kong SH, Oh BM, Yoon H, et al. Comparison of two- and three-dimensional camera systems in laparoscopic performance: a novel 3D system with one camera. Surg Endosc. 2010;24:1132–1143. 5. Taffinder N, Smith SGT, Huber J, et al. The effect of a secondgeneration 3D endoscope on the laparoscopic precision of novices and experienced surgeons. Surg Endosc. 1999;13: 1087–1092. 6. Schwartz SI, Galante J, Kaji I, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multiinstitutional study. JAMA Surg. 2013;148:829–833. 7. Barbash GI, Glied SA. New technology and health care costs—the case of robot-assisted surgery. N Engl J Med. 2010; 363:701–704. 8. Smith R, Day A, Rockall T, et al. Advanced stereotactic projection technology significantly improves novice performance of minimally invasive surgical skills. Surg Endosc. 2012;26:1522–1527. 9. van Hove PD, Tuijthof GJ, Verdaasdonk EG, et al. Objective assessment of technical surgical skills. Br J Surg. 2010;97: 972–987. 10. Stefanidis D, Wang F, Korndorffer JR Jr, et al. Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surg Endosc. 2010;24:277–282. 11. Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery. 2010;147:830–839. 12. Votanopoulos K, Brunicardi FC, Thornby J, et al. Impact of three-dimensional vision in laparoscopic training. World J Surg. 2008;32:110–118. 13. Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg. 2005; 242:83–91.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
323
Three-dimensional Laparoscopy: Does Improved Visualization Decrease the Learning Curve Among Trainees in Advanced Procedures? Kyle G. Cologne, MD, Joerg Zehetner, MD, Loriel Liwanag, BA, Christian Cash, MD, Anthony J. Senagore, MD, and John C. Lipham, MD
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.
advantage for a 3D over a 2D system, the need to wear goggles for the surgeon as well as assistant and scrub tech to see the same image, as well as the current slightly heavier equipment for 3D, while the latest cameras are similar in handling. While the benefits of 3D visualization are obvious and touted by most of the surgeons performing robotic surgery with the DaVinci system (Intuitive Surgical Inc., Sunnyvale, CA), the expense of this system has limited more widespread use. It remains unclear whether visualization alone or increased degrees of freedom is the primary determinant of improved task performance. While other studies have shown different results of 2D versus 3D laparoscopy on surgical performance, there are very little data on novices and skills training regarding the use of 2D versus 3D systems. It remains unclear exactly what effect the use of 3D technology has on the training of a surgeon. Our aim is to evaluate the effectiveness of 3D on learning and performing advanced laparoscopic tasks in the laboratory and in more complex laparoscopic cases to see what effect (if any) 3D has on the ability to learn laparoscopic surgery and shorten the learning curve.
Key Words: advanced laparoscopy, laparoscopy, surgical training, simulation, 3-dimentional laparoscopy
(Surg Laparosc Endosc Percutan Tech 2015;25:321–323)
S
ince the introduction of laparoscopic surgery 25 years ago, residents and novice laparoscopic interested surgeons have to adapt to interpret a 3-dimensional (3D) environment on a 2-dimensional (2D) viewing screen. While picture quality has increased from standard definition to high-definition monitors in most institutions, there has been little correlation with improved laparoscopic performance measures. In fact, some studies demonstrate worse performance with high-definition images.1 The reason for this failure with improved visualization with augmented details in high-definition images may be in fact due to interpretation of a 3D environment on a 2D screen. Nonetheless, there has not been widespread use of 3D monitor technology. Reasons are the lack of clear evidence for an Received for publication October 22, 2014; accepted March 28, 2015. From the Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA. Presented as a poster at the 2013 Annual SAGES Meeting in Baltimore, MD. The authors declare no conflicts of interest. Reprints: Kyle G. Cologne, MD, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033 (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
METHODS First-year and second-year medical students without laparoscopic experience (novices) were selected during their skills laboratory rotation to participate in this study. The study was approved by the University of Southern California Institutional Review Board. The protocol included the evaluation of the performance of a variety of tasks. Inanimate models were used to assess the transfer of objects on a peg-board (according to the standardized FLS skills task) (Fig. 1) as well as laparoscopic suturing as the second task. Participants were instructed to repeat the task using the 2D and the 3D camera systems with the standard laparoscopic instruments. For the 2D system, a Storz camera system and optic was used (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), as well as a standard HD monitor, whereas for the 3D system the 3DHD system from Viking Systems (Viking Systems Inc., Westborough, MA) was used. Time and error rates were calculated and scored. An error was defined as either a missed attempt or the drop of an object, or the failure to complete the task. Further, a survey was performed on experienced laparoscopic surgeons regarding the overall impression of the technology’s impact on performance, skills acquisition, training, and teaching. Statistical analysis was performed using a paired t test for all time variables, and independent t test for error rates using SPSS software (SPSS Inc., Chicago, IL). A cutoff of 0.05 was used to determine significance.
Volume 25, Number 4, August 2015
www.surgical-laparoscopy.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
321
Surg Laparosc Endosc Percutan Tech
Cologne et al
FIGURE 1. Laparoscopic transfer of objects on PEG board (FLS exercise).
RESULTS There were 29 first-year and second-year medical students who participated in the study. All students finished the tasks of transferring objects on the PEG board as well as the suturing skills exercise. In the PEG transfer laparoscopic skill exercise there was a 45.5% decrease in the time to complete the task among novice providers when using 3D (mean 207 s with 2D vs. 113 s with 3D, P < 0.001). The average error rate was reduced to 50% (2D, 4 errors vs. 3D, 2 errors) and the mean drop rate was reduced from 1 to 0 (P = 0.8). Similar decrease in time for the complex task of laparoscopic suturing was seen with 46.5% (mean 403 s with 2D vs. 220 s with 3D, P < 0.001. The survey of expert laparoscopic surgeons that used the 3D technology in a trial phase (n = 12 surgeons) reported after an average of 5 to 10 procedures an improved accuracy and performance. Eighty-five percent felt 3D was “Better than high-definition laparoscopy” and 57% felt 3D visualization “Improved accuracy and performance.” Fifty-seven percent based their experience on 5 to 10 procedures with the 3D device. Fifty-seven percent perceived an improved accuracy and performance of procedures using the 3D, though 43% would choose this technology over 2D given the choice for any particular procedure, with the same number stating it was more advantageous for more complex surgical tasks (suturing, vessel ligation). When compared with robot technology, 28% prefer the 3D technology over the robot. Fourteen percent prefer the robot due to increased degrees of freedom, and 28% prefer the robot due to both increased degree of freedom and surgeon camera control. Twentyeight percent do not use robotic technology regularly. Comments on the technology included: “I have found it incrementally helpful even for an experienced surgeon. Trainees are more precise compared to 2D”; “Gives a good image and would probably help with resident training”; “It provides a better picture, but not sure it increases my effectiveness”; “When functioning properly, my impression of the technology is positive. The struggle to have the equipment in place and functioning properly make it somewhat cumbersome at this point. With dedication to its use and consistency, I would consider it to be beneficial.”
DISCUSSION Three-dimensional laparoscopy appears to be a promising technology for teaching novice providers, and our results show advantages in skills acquiring for novices in laparoscopic
Volume 25, Number 4, August 2015
surgery. Previous authors have shown similar results, with a subsequent improvement in later 2D performance (ie, shortened learning curve),2–5 although no study has been adequately powered to definitively show this improvement. The impact of the research regarding 3D technology might overcome the reduced exposure of current residents to the operating room and patients due to the limited work hours since the introduction of the 80-hour work week. Further, the reduction of the intern hours to maximum of 16 hours will further reduce exposure of the novice students and residents to laparoscopic surgery. This has translated into a decrease in operative caseload.6 The positive effects seen in the laboratory with a nearly 50% reduction in time performing the same tasks is encouraging that with more skills labs including 3D technology, as well as 3D camera sets for the laparoscopic procedures such as cholecystectomy and appendectomy might decrease the learning curve. The available evidence suggests that 3D visualization (mostly through the use of a robotic platform) enhances surgical skill, decreases error rates, and improves the ability to perform complex tasks among trainees.7,8 What remains unclear is whether this effect is due to the robot itself, or merely the enhanced visualization provided by a 3D camera in this medium. No study has been conducted to date to assess the impact of this difference. Our study suggests that 3D platform alone provides many of the advantages in learning these complex operative skills. A number of studies have been used to evaluate procedural tasks.9 Storz et al3 published a study of medical students and expert surgeons in 2D versus 3D. In complex tasks, experienced surgeons were no faster in a 3D environment, but they gained overall precision with 3D visualization. Novices, or student laparoscopists, improved the time by 28% to 31% for most tasks and also decreased error rates. This study was performed using 20 medical students and 10 laparoscopic surgeons doing a series of tasks 1 time. Their results are similar to ours, though we demonstrated a greater improvement with 3D. Stefanidis et al10 looked at robotic assistance in performing complex suturing tasks among novices. Thirty-four students were randomized to perform suturing for a Nissen fundoplications on a porcine model with premarked suture points after a brief instructional session. Those assigned to perform the suturing task using the robot performed faster and committed fewer errors. It is unclear from the study how much of this effect is due to the robot and how much is from 3D visualization, as the standard laparoscopy arm did not have access to either tool to enhance performance. Interestingly, robotics eliminated the early learning curve for novices. Chandra et al11 published a study evaluating 20 novices and 9 experts on a series of 10 tasks using both the robot and standard laparoscopy. These were scored using pathlengths, smoothness, and time to complete the tasks. Novices that used the robotic environment first performed each task with increased speed, decreased pathlength, and improved smoothness. Again, it is unclear how much of this improved effect is due to the robot versus the 3D visualization. The total time was no different for experts between the 2 environments, but pathlength was decreased in the robotic group. Our data seem to suggest that similar improvements in time can be accomplished with 3D alone, without the use of robot technology. Kong et al4 performed a comparison of 21 novices and 6 experts using 2 tasks in both environments by alternating environments on 4 different days (3D first on day 1, 2D first on the subsequent day). The novice group experienced
322 | www.surgical-laparoscopy.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 4, August 2015
decreased errors but no difference in time to complete the tasks. In addition, there was increased use of the nondominant hand (as measured by EMG analysis). Although there were no statistical performance improvements, 80% of the expert group preferred the 3D environment to 2D—an effect we saw as well in our survey results. Votanopoulos et al12 published a study comparing 3D versus 2D on 6 laparoscopic tasks. Three-dimensional imaging allowed novice participants to make less errors and reduce the time to complete the tasks. This effect was more pronounced on the more complex tasks of rope passing (simulating running the bowel) and suturing. Experienced participants (third-year and fifth-year residents) showed no difference in errors or time to complete the tasks between the environments. The study implied that teaching laparoscopic skills may be facilitated by a 3D environment. Interestingly, those that performed the tasks in a 3D environment first were significantly better in 2D during their subsequent testing session (as compared with those that experienced the 2D environment first and 3D second), further suggesting that the 3D environment may play a role in faster acquisition of visuospatial skills in a minimally invasive environment. It is interesting that this effect may not be as great once the technical skills are mastered. The future direction of this research will be to evaluate the learning curve for certain procedures using 3D technology. For example, it is known that it takes Z50 cases for surgeons that already have a basic laparoscopic skills set to learn complex laparoscopic procedures such as a laparoscopic colectomy13 with the 2D standard or high-definition cameras. How much that can be decreased with advanced 3D visualization remains to be determined, but the preliminary data on performance of complex tasks are encouraging.
CONCLUSIONS Our results indicate that 3D significantly improved visualization and ability to perform complex tasks in the skills laboratory setting. It is likely that 3D technology is very effective at shortening the learning curve to train surgeons in advanced laparoscopic skills—a very important factor in the era of work-hour restrictions.
Copyright
r
Three-dimensional Laparoscopy
REFERENCES 1. Feng C, Rozenblit JW, Hamilton AJ. A computerized assessment to compare the impact of standard, stereoscopic, and high-definition laparoscopic monitor displays on surgical technique. Surg Endosc. 2010;24:2743–2748. 2. Van Sickle KR, Ritter EM, Baghai M, et al. Prospective, randomized, double-blind trial of curriculum-based training for intracorporeal suturing and knot tying. J Am Coll Surg. 2008;207:560–568. 3. Storz P, Buess GF, Kunert W, et al. 3D HD versus 2D HD surgical task efficiency in standardized phantom tasks. Surg Endosc. 2012;26:1454–1460. 4. Kong SH, Oh BM, Yoon H, et al. Comparison of two- and three-dimensional camera systems in laparoscopic performance: a novel 3D system with one camera. Surg Endosc. 2010;24:1132–1143. 5. Taffinder N, Smith SGT, Huber J, et al. The effect of a secondgeneration 3D endoscope on the laparoscopic precision of novices and experienced surgeons. Surg Endosc. 1999;13: 1087–1092. 6. Schwartz SI, Galante J, Kaji I, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multiinstitutional study. JAMA Surg. 2013;148:829–833. 7. Barbash GI, Glied SA. New technology and health care costs—the case of robot-assisted surgery. N Engl J Med. 2010; 363:701–704. 8. Smith R, Day A, Rockall T, et al. Advanced stereotactic projection technology significantly improves novice performance of minimally invasive surgical skills. Surg Endosc. 2012;26:1522–1527. 9. van Hove PD, Tuijthof GJ, Verdaasdonk EG, et al. Objective assessment of technical surgical skills. Br J Surg. 2010;97: 972–987. 10. Stefanidis D, Wang F, Korndorffer JR Jr, et al. Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surg Endosc. 2010;24:277–282. 11. Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery. 2010;147:830–839. 12. Votanopoulos K, Brunicardi FC, Thornby J, et al. Impact of three-dimensional vision in laparoscopic training. World J Surg. 2008;32:110–118. 13. Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg. 2005; 242:83–91.
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323
