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Background
Optimizing a living kidney donation program is important to guarantee a high grade of acceptance among potential donors. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative to the open anterior approach (AA) technique. Problems associated to the learning curve could hinder a transition. 3D display technique seem...
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Background:
Since its introduction in 1995, laparoscopic living donor nephrectomy (LLDN) has been a standard procedure in many transplantation centers worldwide. In 2011, LLDN was performed for the first time in Indonesia and became a standard procedure at our institution. The aim of this study is to evaluate the first 250 cases of LLDN at our ins...
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Citations
... The surgeons had performed at least 30 laparoscopic tumor nephrectomies before and assisted various LDNs; to guarantee a maximum of safety, younger LDN surgeons were always assisted by experienced ones [19]. Of note, this is the largest cohort of pure LDNs in Germany and the technique has not changed throughout the period [20,21]. Overall, the right and left LDNs did not have different complication rates, but recipients of right grafts had more postoperative complications. ...
Objectives:
Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques.
Methods:
Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up.
Results:
160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, p < 0.001) and worse scintigraphic function (44 vs. 51%, p < 0.001). RLDNs were shorter (201 vs. 220 min, p = 0.032) with longer warm ischemia time (165 vs. 140 s, p < 0.001), but left grafts were transplanted faster (160 vs. 171 min, p = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, p = 0.020). At a follow-up of 45 (range 6-79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, p = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, p = 0.747) differed.
Conclusions:
Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.
... 11 A clinical relevant benefit of the 3D technique seems to apply to more complex laparoscopic procedures like pancreas, liver, upper GI surgery or living kidney donation. [16][17][18][19] Experienced surgeons benefit from 3D versus 2D technique as shown by Smith et al: 20 experienced surgeons showed a 62% and 35% reduction of errors and time in a laparoscopic skill parkour. 20 Our data support these, although we saw a stronger effect on time reduction than on mistake rate in experienced surgeons. ...
Objective:
To evaluate if "state-of-the-art" 3D- versus 4K-display techniques could influence surgical performance.
Background:
High quality minimally invasive surgery is challenging. Therefore excellent vision is crucial. 3D display technique (3D) and 2D-4K technique (4K) are designed to facilitate surgical performance, either due to spatial resolution (3D) or due to very high resolution (4K).
Methods:
In randomized cross-over trial the surgical performance of medical students (MS), non-board certified surgeons (NBC), and board certified surgeons (BC) was compared using 3D versus 4K display technique at a minimally invasive training Parkour.
Results:
One hundred twenty-eight participants were included (February 2018 through October 2019, 49 MS, 39 NBC, 40 BC). The overall Parkour time (s) 3D versus 4K was 712.5 s ± 17.5 s versus 999.5 s ± 25.1 s (P < 0.001) for all levels of experience. It was (3D vs 4K) for MS (30 tasks) 555.4 s ± 28.9 s versus 858.7 s ± 41.6 s, (P < 0.0001), for NBC (42 tasks) 935.9 s ± 31.5 s versus 1274.1 s ± 45.1 s (P =< 0.001) and for BC (42 task) 646.3 s ± 30.9 s versus 865.7 s ± 43.7 s (P < 0.001). The overall number of mistakes was (3D vs 4K) 10.0 ± 0.5 versus 13.3 ± 0.7 (P < 0.001), for MS 8.9 ± 0.9 versus 13.1 ± 1.1 (P < 0.001), for NBC 12.45 ± 1.0 versus 16.7 ± 1.2 (P < 0.001) and for BC 8.8 ± 1.0 versus 10.0 ± 1.2 (P = 0.18). MS, BC, and NBC showed shorter performance time in 100% of the task with 3D (significantly in 6/7 tasks). For number of mistakes the effect was less pronounced for more experienced surgeons. The National Aeronautics and Space Administration-task load index was lower with 3D.
Conclusion:
3D laparoscopic display technique optimizes surgical performance compared to the 4K technique. Surgeons benefit from the improved visualization regardless of their individual surgical expertise.
... In parallel, steep learning curves have also been reported for both minimally invasive retroperitoneoscopic and laparoscopic donor nephrectomies (43). 3-D vision which is not only exclusively restricted to robotic assisted operations, but also broadly available for laparoscopic procedures in general seem to reduce operation time and warm ischemia times when compared to 2-D techniques (44). ...
Background:
Robotic assisted nephrectomy for living donation (RANLD) is a rapid emerging surgical technique competing for supremacy with totally laparoscopic and laparoscopic hand assisted techniques. Opinions about the safety of specific techniques of vascular closure in minimally invasive living kidney donation are heterogeneous and may be different for laparoscopic and robotic assisted surgical techniques.
Methods:
We retrospectively analyzed perioperative and short-term outcomes of our first (n=40) RANLD performed with the da Vinci Si surgical platform. Vascular closure of renal vessels was performed by either double clipping or a combination of clips and non-transfixing suture ligatures.
Results:
RANLD almost quintupled in our center for the observed time period. A total of n=21 (52.5%) left and n=19 (47.5%) right kidneys were procured. Renal vessel sealing with two locking clips was performed in 18 cases (45%) Both, clips and non-transfixing ligatures were used in 22 cases (55%). Mean donor age was 53.075±11.68 years (range, 28-70). The average total operative time was 150.75±27.30 min. Right donor nephrectomy (139±22 min) was performed significantly faster than left (160.95±27.93 min, P=0.01). Warm ischemia time was similar for both vascular sealing techniques and did not differ between left and right nephrectomies. No conversion was necessary. Clavien-Dindo Grade ≤IIIb complications occurred in (n=5) 12.5%. Grade IV and V complications did not develop. In particular no hemorrhage occurred using multiple locking clips or suture ligatures for renal vascular closure. Mortality was 0%. Thirteen kidneys (32.5%) were transplanted across the AB0 barrier.
Conclusions:
RANLD is an emerging minimally invasive surgical technique which facilitates excellent perioperative and short-term outcomes also when using multiple locking clips or suture ligatures for renal vascular closure.
... In parallel, steep learning curves have also been reported for both minimally invasive retroperitoneoscopic and laparoscopic donor nephrectomies (43). 3-D vision which is not only exclusively restricted to robotic assisted operations, but also broadly available for laparoscopic procedures in general seem to reduce operation time and warm ischemia times when compared to 2-D techniques (44). ...
... We included 18 primary studies, reporting data about operative time, from nine countries across three continents [3,26,[101][102][103][104][105][106][107][108][109][110][111][112][113][114][115][116] (Fig. 1). All but one study was published after 2013 suggesting a relatively limited variability of modern 3D systems were used. ...
... The literature search identified 1653 hits. Seven studies met inclusion criteria [26, 103-106, 132, 133] with four RCTs [26,[104][105][106]. A total of 460 patients were included: 224 in 3D and 236 2D. ...
... The urological procedures included 122 donor nephrectomies, 121 radical prostatectomies, 93 partial nephrectomies, 54 simple nephrectomies, 40 pyeloplasties, 21 radical nephrectomies, six radical cystectomies and three other laparoscopic surgeries. The operative time was significantly shorter in two of the four RCTs [104,105], but in meta-analysis a statistically significant was seen (MD − 25.6 min, , I 2 88%, p = 0.02). Blood loss was significantly lower in two of the three RCTs reporting it [26,104]. ...
Background
The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.
Methods
Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.
Results
9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29–1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60–0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35–0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.
Conclusion
We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).
... Transthoracic e s o p h a g e a l s u r g e r y i s a m o n g t h e m o s t c o m p l e x minimally invasive surgical procedures, and especially the reconstruction phase with gastric interposition and esophagogastric anastomosis is currently a highly debated part of the surgical procedure (2). One possibility to diminish the complexity of a minimally invasive procedure is the use of hand-assisted or hybrid approaches (3,4). Another more recent approach is the division of complex procedures into different modules and to perform a step-by-step approach to a complex procedure (5). ...
Background:
The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery.
Methods:
A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy.
Results:
A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case.
Conclusions:
The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.
... The learning curve and performance, especially in complex surgical procedures, e.g. vascular preparation during retroperitoneoscopic donor nephrectomy, could be optimized and simplified [9]. The recent European Association for Endoscopic Surgery (EAES) consensus statement recommended the use of 3D vision to reduce operative time [7]. ...
... Depending on the different factors (e.g. structured teaching programs, talent of the surgeon, kind of operation, equipment), 30-100 procedures could be necessary to adopt a complex minimally invasive operation [3,4,9]. It seems possible, that an optimal display system could also optimize this teaching and learning process. ...
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.
... The learning curve and performance especially in complex surgical procedures, e.g. vascular preparation during retroperitoneoscopic donor nephrectomy could be optimized and simpli ed 9 . The recent EAES consensus statement recommended the use of 3D-vision to reduce operative time 7 . ...
Background Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual tasks. The reduction from real life 3D- to virtual two-dimensional (2D) sight is a major challenge in minimal invasive surgery (MIS). 3D-display technique has shown to reduce operation time, mistakes, and to improve the learning curve. Therefore it seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics 4K-display technique was recently introduced to MIS. Due to its high resolution and zoom-effect surgeons should benefit from it. Aim of this study is to evaluate if “state-of-the-art” 3D- versus 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 (2 arms) to perform different tasks in a minimal invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (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 7 tasks (novices 5 tasks), which will be repeated 3 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 additional 5% for a non-parametric approach) with a power of 80% at two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled. Discussion Complex surgical procedures are performed in minimal invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance. Trial Registration This trial is registered at clinicaltrials.gov (trial number: NCT 03445429, registered February 7, 2018, http://www.clinicaltrials.gov)
... The learning curve and performance especially in complex surgical procedures, e.g. vascular preparation during retroperitoneoscopic donor nephrectomy could be optimized and simpli ed 9 . The recent EAES consensus statement recommended the use of 3D-vision to reduce operative time 7 . ...
Background Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual tasks. The reduction from real life 3D- to virtual two-dimensional (2D) sight is a major challenge in minimal invasive surgery (MIS). 3D-display technique has shown to reduce operation time, mistakes, and to improve the learning curve. Therefore it seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics 4K-display technique was recently introduced to MIS. Due to its high resolution and zoom-effect surgeons should benefit from it. Aim of this study is to evaluate if “state-of-the-art” 3D- versus 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 (2 arms) to perform different tasks in a minimal invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (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 7 tasks (novices 5 tasks), which will be repeated 3 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. A sample-size of 36 per stratum is required to detect a standardized effect of 1.0 (including additional 5% for a non-parametric approach) with a power of 80% at two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled. Discussion Complex surgical procedures are performed in minimal invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance. Trial Registration This trial is registered at clinicaltrials.gov (trial number: NCT 03445429, registered February 7, 2018, http://www.clinicaltrials.gov)
... The learning curve and performance especially in complex surgical procedures, e.g. vascular preparation during retroperitoneoscopic donor nephrectomy could be optimized and simpli ed 9 . The recent EAES consensus statement recommended the use of 3D-vision to reduce operative time 7 . ...
Background: Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual tasks. The reduction from real life 3D- to virtual two-dimensional (2D) sight is a major challenge in minimal invasive surgery (MIS). 3D-display technique has shown to reduce operation time, mistakes, and improve the learning curve. Therefore it seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics 4K display technique was introduced to MIS recently. Due to its high resolution and zoom-effect surgeons should benefit from it. Aim of this study is to evaluate if “state-of-the-art” 3D- versus 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 (2 arms) to perform different tasks in a minimal-invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (NASA task load index) and the learning curve. Unexperienced novices (medial students), non-board certified and board-certified abdominal surgeons participate in the trial (i.e. level of experience, 3 strata). The parkour consists of 7 tasks (novices 5 tasks), which will be repeated 3 times. The 1st run of the parkour will be performed with the randomized display system the 2nd with the other one. After each run metal stress load is measured. After completion of the parkour all participant are evaluated by an ophthalmologist for visual acuity and stereoscopic vision with five tests. A sample-size of 34 per stratum is required to detect a standardized effect of 0.5 with a power of 80% at two-sided type I error of 5%. Thus, altogether 102 subjects need to be enrolled.
Discussion: Complex surgical procedures are performed in minimal invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance.
Trial Registration: This trial is registered at clinicaltrials.gov (trial number: NCT03445429, registered February 7, 2018, http://www.clinicaltrials.gov)
Keywords: Minimal invasive surgery, laparoscopic, 3D, 4K, surgical performance, learning curve, surgical training
