Applicability and Effectiveness of Laparoscopic Procedures in Pediatrics

Introduction

For the past 20 years, laparoscopic technique progressively diffused, which changed radically surgical practice for patients. Laparoscopy evolved to the standard treatment approach for many congenital and acquired diseases, even in infants and newborns. ¹ “Open technique” in newborns and infants continues to be safer and easier, because minimally invasive surgery (MIS) still misses adequate instrumentation. Therefore, MIS in pediatrics, particularly in oncology, has been debated and sometimes confined to the role of a diagnostic tool.^2,3 Conventional laparoscopic disadvantages such as bidimensional view, lack of depth perception, increased hand-eye coordination skills, and learning-curve length, sometimes exceed advantages such as improved aesthetic results, less postoperative complications, and shorter hospital stays. ⁴ In pediatrics, three-dimensional (3D) technology is yet not diffused and few in vivo studies were performed for the past 10 years. This trend is mainly because the majority of pediatric surgeons are satisfied and used to two-dimensional (2D) imaging. On the contrary, the use of robotic technology in the pediatric population is increasingly used for a large number of surgical procedures,^5–7 whereas the 3D camera is still scarcely implemented. Stereoscopic vision and tremor filter are the two main reasons for this development, but its disadvantages should not be underestimated.

We evaluated applicability and effectiveness of 3D compared with 2D endosurgery, in the treatment of pediatric congenital and acquired conditions using surgeons' and assistants' evaluation.

Materials and Methods

In this prospective comparative study, we collected information on 62 planned laparoscopic procedures in the Pediatric Surgery Division of the Fondazione Policlinico Universitario A. Gemelli IRCCS Hospital in Rome between May 2016 and April 2018. Informed consent was obtained before the intervention. Patients underwent conventional 2D or 3D laparoscopy based on availability of the optics during scheduled intervention.

Results

Table 1 summarizes intervention types for both groups.

The results of the questionnaire (Table 2), comparing 3D versus 2D procedures from a surgeon perspective, showed that “Technical aspects” of 3D imaging were statistically significant superior (P = .0000). The assistant reported statistically significant improved spatial orientation (P = .0088), depth perception (P = .000), and tissue maneuvers (P = .000). About the aspects related to “Vision of the Surgeon,” the surgeon noted statistically significant decreased visual fatigue (P = .0000) and improved visual adaptation (P = .0048). No aspect of this category resulted as statistical significant in the assistants' evaluation. Regarding physical complaints, the surgeon reported statistically significant diminished fatigue (P = .0010). Instead, assistants reported less nausea (P = .0123) and vertigo (P = .0154).

Discussion

Our comparison of 2D versus 3D laparoscopic procedures showed that 3D optics allowed a better visualization of internal organ anatomy with an improved spatial orientation. Improved depth perception facilitated tactile feedback and complex endosurgical tasks, such as suturing and knotting. Furthermore, in small spaces enhanced visualization and a superior hand-eye coordination reduced manipulation and trauma to tissues. Better visualization affected positively physical complaints of the surgeon usually reported during 2D procedures.

Taffinder et al. ⁹ highlighted second-generation 3D laparoscopy advantages in adults already in 1999, and several studies were subsequently published analyzing the efficacy and safety of 3D laparoscopy.^10,11 In fact, the stereoscopic vision accelerates the learning curve (especially for medium and high skills) and reduces significantly surgery.^12,13

However, 3D laparoscopy is still restrictedly used in infants and children. ¹⁴ Since its inception, laparoscopic procedures in pediatrics lag behind the adult counterpart, related to absent suitable devices. However, the results of the unique partnership between pediatric minimally invasive surgeons and industry have spawned a new generation of MIS instrumentation fostering neonatal MIS surgery.^15,16 The development of pediatric devices is an ongoing process. Based on our practical experience, we propose a modification of the 10 mm 3D camera employed. In particular, the length of the camera should be reduced because the dimensions of its flexible head are uncomfortable in pediatric surgery due to limited space available in the operating field.

First trials to adapt 3D technology to the pediatric setting were published in 2015 when Feng et al. evaluated the effectiveness of 3D laparoscopic procedures compared with 2D procedures with an experimental study on rabbit cadavers representing a restricted surgical field. ¹⁷ Shorter surgical duration, learning curve, fewer errors, and better hemodynamic response of the surgeon (i.e., absence of eyestrain, headache, dizziness, and nausea) demonstrated superiority of 3D compared with 2D technology. The authors concluded that 3D vision facilitates minimally invasive interventions in infants. Advantages of the 3D technology have been underlined in two additional experimental studies performed with pediatric simulation boxes^8,18 demonstrating a shorter learning curve and a lower error rate. Advantages were likely correlated to depth perception and absence of physical symptoms in expert laparoscopists and trainers.

In 2016, Kozlov et al. ¹⁹ published the first in vivo comparative study between 3D and 2D optics in small babies. In the procedures in which intracorporeal suturing was used, 3D laparoscopy enabled a shorter surgery duration; depth perception improved 3D laparoscopy user-friendliness for the surgeon when compared with traditional laparoscopy. ¹⁹ Moreover, the 10 mm 3D laparoscopic cameras are sometimes considered too large especially for neonates and infants, compared with the 5 mm 2D optics, but as Kozlov et al. ¹⁹ sustained the umbilical scar of infants and neonates is elastic and flexible representing a perfect “invisible door” for instruments into the abdominal cavity.

Nowadays, the use of 3D technology in pediatrics is still scarce due to the wide use of the robotic technology, as shown by the numerous publications. The stereoscopic vision and the tremor filter are two main advantages introduced by the robotic technology, but its disadvantages should not be underestimated. The disadvantages related to robot-assisted laparoscopy include the huge dimensions of the robotic trocar and the loss of tactile feedback; furthermore, no clinical differences have been evidenced between patients operated with the robot-assisted technique compared with those operated with standard laparoscopy. ⁵ In 2015, Park et al. ²⁰ published a comparative study between robot-assisted 3D and 2D laparoscopic surgeries. Surgeons with different experience were enrolled: both the number of errors and the time to complete a suture were compared between the three technologies. Nonlaparoscopic surgeons were the ones who benefitted most from robotic technology, because laparoscopic surgeons were able to use all three surgical techniques without significant advantages from the robot-assisted laparoscopy. ²⁰

Certainly, more studies are needed to compare the use of 3D and robotic technology in pediatrics.

Conclusion

The results of this prospective study, which included both diagnostic and therapeutic procedures of medium and high complexity, confirm data reported in literature. The use of 3D laparoscopy in the pediatric population is still under debate. We showed that maneuvering tissue is more precise affecting positively safety aspects during 3D procedures. As already evidenced in general surgery, 3D technology could play a significant role in pediatric surgery in the future potentially surpassing classic 2D MIS. Considering the easier operative performance, 3D laparoscopy will likely become a valid alternative to robotic surgery, which will continue to have its main indications in some surgical procedures with static fields and in “cavity” surgery. Moreover, in the current hospital “culture” in which economic aspects are correlated to medical choices, costs associated with new technologies should be considered. We propose to compare 3D laparoscopy with robotic technology in pediatric surgery considering also economic aspects.