3D Technology in Laparoscopy

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The 3D laparoscopy – new technology on trial

Priv.-Doz. Dr. med. Peter Grimminger, Senior Consultant Head Upper GI Surgery, Minimally Invasive Surgery and Robotics, University Medical Center of the Johannes Gutenberg University Mainz

Introduction

The Departement of General-, Visceral and Transplant Surgery of the University Medical Center Mainz as well as the former working place of Dr. Grimminger at the General, Visceral and Tumor Surgery of the University of Cologne, offers the full range of general and visceral surgery. It also provides transplant surgery (kidney, pancreas and liver), surgery for morbid obesity and pediatric surgery. Proctology and several consultation clinics complete the spectrum. As a supra-maximal care hospital, our clinic is able to provide adequate interdisciplinary treatment to even the most severely injured patients around the clock.
The treatment of tumors along the entire digestive tract and in the endocrine glands is one of our specialties. The center has an international reputation as a center of excellence for the treatment of the esophagus and the stomach.
Patients are cared for by a medical team consisting of a director, 8 senior physicians, 20 specialists and assistant physicians.
Treatment takes place within an interdisciplinary framework – both bedside and at joint meetings. The patient is always the most important person and an individualized therapy tailored to their needs and based on the latest scientific knowledge is always the basis of the treatment. We contribute to expanding this knowledge with the clinic’s own research. We transmit this knowledge to medical and non-medical professionals in the teaching provided by the clinic.

Potential uses

The potential uses of EinsteinVision® 3D are essentially the same as the current (2D) laparoscopy. Image resolution and image display enable the use of EinsteinVision® 3D in all operations that were previously performed in 2D. However, the lower level of detail from the enlargement of the EinsteinVision® 3D requires an initial adjustment. This can be particularly difficult at the start, particularly for surgeons who have less experience of laparoscopies. In this regard, a zoom option would be desirable and certainly technically feasible in the future. [Editor’s note: The idea was taken up by Aesculap and implemented in the form of an electronic zoom]
You also have to accept a change of perspective from a 30° camera angle with the EinsteinVision® 3D, as a 30° angle is not possible with the 3D camera system. However, the camera can be rotated 180°. You get used to wearing the 3D glasses and using a single, but large, 3D monitor with no problem. The monitors permanently installed in the operating theater are, at least in our clinic, not compatible with 3D and can therefore only show the image in two dimensions. However, even this did not have a disruptive effect.
As the cost of using EinsteinVision® 3D does not differ from the other 2D laparoscopic systems, we have successfully used EinsteinVision® 3D for almost all the operations carried out at our clinic, from laparoscopic appendectomies to thoracoscopic esophagectomies.

Uses and advantages for users

After a short adaptation phase, handling the EinsteinVision® 3D is very easy. The special sharpness of the image on the large monitor is very impressive and advantageous. Thanks to the 3-dimensional imaging of even the smallest anatomical structure and deep into the site, it is possible to dissect the anatomical structures precisely and exactly and to insert and knot fine sutures intracorporeally. In our experience, in particular for laparoscopic gastrolysis (mobilization of the stomach in the context of esophageal resection in esophageal cancer) operations, which we perform very frequently at our clinic, the delicate dissection of the lymphadenectomy along the celiac trunk, the common hepatic artery and the lienal artery and the dissection of the vascular arc on the large curvature side was extremely useful thanks to the 3-dimensional imaging and the very high image resolution. As a result, a systematic and complete lymphadenectomy can be performed very safely in this area. In other operations as well where precision is very important when performing the dissection because the surrounding structures can be damaged very easily, using the EinsteinVision® 3D again provides significant advantages. This expands the indication for 3D laparoscopic operations for corresponding conditions.

Figure 1: Intrathoracic site for the enucleation of a large esophageal leiomyoma

As an example, the intraoperative site of a patient with a leiomyoma of the upper thoracic esophagus measuring 8x6x2 cm that was removed using EinsteinVision® 3D is shown (see Figure 1). During this dissection maximum caution is required due to the fine adhesions of the leiomyoma to the esophageal mucosa and the resulting danger of a perforation, as well as the narrow topographical relationship with the pars membranacea of the trachea, the vagus nerve and the thoracic duct.
In diseases such as achalasia, the 3D camera is also a big advantage for the laparoscopic dissection of the esophageal mucosa during a myotomy. Thanks to the excellent image, the operation is, in our experience, also made significantly less tiring and stressful for the surgeon.

Uses and advantages for patients

EinsteinVision® 3D naturally benefits patients undergoing laparoscopy and thoracoscopy due to the increased safety of the operation. Firstly, thanks to the technical superiority of 3D imaging during delicate dissection of fragile and sensitive structures, there are technical options that previously could maybe only be attained using open surgical techniques and magnifying glasses. In addition, patient safety is further increased by the ability to spatially control the dissections and actions precisely. In particular, in tumor surgery, EinsteinVision® 3D makes a safe resection of the primary tumor and the lymphatic drainage area along the vessels possible.

Benefits for the clinic

Using EinsteinVision® 3D has resulted in a well-rounded concept for the clinic. Thanks to the 3D laparoscopy and thoracoscopy, today our clinic can offer state of the art minimally invasive surgery. Procurement costs are an acceptable strain on the budget because the operating costs remain the same. Using sterile protective film over the camera and camera cable means that the camera does not have to be sterilized and that it is not necessary to purchase several cameras. There is still no statistical evidence of the reduction in postoperative complications as a result of using EinsteinVision® 3D and so this decrease is still speculative.

Advantages for training and advanced training

The visualization of anatomy and the pathological findings in situ is a unique experience for students in training as well as for medical technicians in advanced training. The surgical and anatomical relationship is easier to understand and can be grasped quicker by students with 3D operations. Using EinsteinVision® 3D is particularly advantageous for inexperienced physicians or physicians who are less able to deduce the three-dimensional (= real) situation from a 2D image.

Conclusion

In summary, we can report a lot of positive experiences and only a few negative aspects with regard to the use of EinsteinVision® 3D. Only the camera movement limitation from the change of perspective and the slightly lower picture detail are disadvantages, otherwise the 3D video provides considerable advantages for laparoscopy and thoracoscopy. After a short adaptation phase, particularly if you have been using 2D systems for several years, operating with the EinsteinVision® 3D represents a new era in which the safety and precision of operations has been significantly increased. EinsteinVision® 3D is, in our opinion, the future of laparoscopic and thoracoscopic surgery.

Priv.-Doz. Dr. med. Peter Grimminger
Head of General Surgery
University Medical Center of the Johannes Gutenberg University Mainz
Langenbeckstraße 1
55131 Mainz
Germany