Comparison of Short-Term Outcomes Using Three-Dimensional and Two-Dimensional Laparoscopic Gastrectomy for Gastric Cancer

Abstract

Introduction:

This study investigated the oncological and technical advantages of three-dimensional (3D) versus two-dimensional (2D) laparoscopic gastric cancer surgery.

Materials and Methods:

This study included 68 gastric cancer patients who had undergone laparoscopic distal gastrectomy at Korea University Ansan Hospital (3D group, n = 34; 2D group, n = 34). The surgical outcomes and duration of each phase were compared between the groups.

Results:

The total operative time with 3D laparoscopy was significantly shorter than with 2D laparoscopy (227.8 ± 39.0 versus 249.6 ± 45.3 minutes; P = .037). There were no significant differences between the groups in the number of gauze pads used, time to first postoperative flatus, and number of harvested lymph nodes (2.0 [1.0–2.0] versus 2.0 [1.0–2.0]; P = .692; 4.0 [4.0–4.0] versus 4.0 [4.0–4.0] days; P = .196; 40.8 ± 16.6 versus 44.0 ± 15.7; P = .412, respectively). The time from omentectomy to right gastric artery ligation and the duration of the reconstruction phase were shorter with 3D than with 2D laparoscopy (62.6 ± 14.5 versus 71.9 ± 18.8 minutes; P = .027; 32.3 ± 7.6 versus 47.7 ± 16.8 minutes; P < .001).

Conclusion:

In a procedure requiring spatial perception, the operative time was shortened by introducing 3D laparoscopy. Despite the anticipation of a better view for lymph node dissection, the 3D image showed no advantage. Further study may be required by novice surgeons.

Introduction

Since the first report of laparoscopic gastrectomy,¹ the minimally invasive technique has been widely used in gastric cancer surgery, with reduced surgical trauma, hospital stay, and postoperative pain.^2–4 This trend was accelerated by technical advances in laparoscopic surgery, stapling devices, vessel sealing devices, and high-definition (HD) cameras. Despite the improvement in image definition, two-dimensional (2D) cameras have inherent limitations, with loss of depth perception and visual misperception resulting from a lack of stereoscopic vision. To overcome these limitations, expert surgeons reconstruct three-dimensional (3D) images in the brain using existing information such as object interposition, relative motion of the scope, familiar anatomy, and size of anatomical structures.⁵

However, it might take a lot of time and effort to overcome these limitations with 2D cameras. Therefore, a 3D scope was developed for laparoscopic surgery; this device provides a true 3D surgical field, enabling proper laparoscopic surgery with depth perception to provide information about surrounding tissues, guide the dissection plane, and identify the tips of instruments.⁶ The 3D technology makes it easy to insert the stapler into the intestinal lumen and perform laparoscopic suturing.

In their early form, 3D cameras were associated with blurred vision, difficulty in focusing, headaches, fatigue, and dizziness.⁷ These limitations have been overcome with technologic development and camera operator experience; however, low resolution compared to that with 2D laparoscopy is still a technical limitation.

Several studies have evaluated the short-term outcomes of 3D laparoscopic gastrectomy compared with those with 2D procedures in gastric cancer, but differences in resolution and scope flexibility between the two groups were not described.^8–10 This study investigated the oncological and technical advantages of 3D versus 2D laparoscopy in gastric cancer surgery using scopes with the same resolution and flexibility with regard to operative time and duration of procedure phases and the extent of lymphadenectomy.

Materials and Methods

Study design and patients

This retrospective study included gastric cancer patients who had undergone laparoscopic distal gastrectomy at Korea University Ansan Hospital between March 2016 and June 2017. A single surgeon with experience in more than 500 laparoscopic gastrectomies for gastric cancer participated in this study. The study compared 34 patients who had undergone laparoscopic distal gastrectomy with a 3D/HD/flexible system (Olympus Corporation, Tokyo, Japan) with the last 34 patients to undergo laparoscopic distal gastrectomy with a 2D/HD/flexible system (Olympus). The use of a 3D or 2D system was determined by availability.

Study objectives

The primary objective of this study was to examine operative time. Operation time was divided into three phases. Lymph node dissection (LND) phase 1 was defined as the duration from omentectomy to right gastric artery ligation. LND phase 2 was defined as the duration from right gastric artery ligation to stomach resection. LND phase 2 estimated the duration of suprapancreatic LND, including lymph node (LN) station numbers 5, 6, 7, 8a, and 9 around the common hepatic artery and celiac axis. The reconstruction phase was defined as the duration required for intestinal anastomosis. The secondary objectives were short-term outcomes, including the number of harvested LNs, intraoperative blood loss, postoperative complications, and postoperative recovery time. Intraoperative blood loss was determined according to the number of surgical gauze pads used during the operation. We evaluated the degree of lymphadenectomy according to the incidence of more than D1+ LND, involving LN station numbers 8p, 11p, and 12a.

Surgical procedures

Laparoscopic distal gastrectomy procedures were carried out in all cases as follows. The patient was placed with both legs separated under general anesthesia. The operator sat on the right side of the patient, and the first assistant was positioned on the left side. The scope assistant was positioned between the patient's legs. A 12-mm trocar was inserted through a transumbilical incision using an open method. After the pneumoperitoneum was created, a 2D or 3D flexible scope was inserted through this umbilical port. Under the guidance of the flexible scope, a 5-mm trocar was placed at the right subcostal margin, and a 12-mm trocar was placed at the right midclavicular line. For the first assistant, two 5-mm trocars were inserted at the left subcostal margin and left midclavicular line. The intraabdominal pressure was maintained at a constant 15 mmHg.

Lymphadenectomy for curative distal gastrectomy was accomplished based on the criteria of the Japanese Gastric Cancer Treatment Guidelines 2014 (ver. 4).¹¹ We performed D1+ or D2 lymphadenectomy. After the completion of lymphadenectomy, Billroth II gastrojejunostomy was performed for the recovery of gastrointestinal continuity. A Braun jejunojejunostomy was also performed to reduce bile reflux into the remnant stomach. All anastomoses were performed with laparoscopic linear staplers (Endo GIA^®; Medtronic, Minneapolis, MN), and the common entry hole was closed by a laparoscopic suture technique using barbed thread.

Data collection

Patient data were collected from electronic medical records. Clinicopathologic features such as age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, operative time, time to first diet, tumor depth, number of retrieved LNs, and postoperative complications were investigated. Postoperative complications, including wound infection, leakage, and intestinal obstruction, occurring within 30 days of surgery were evaluated according to the Clavien–Dindo classification.¹²

Statistical analysis

Continuous variables are presented as mean (±standard deviation) or median (interquartile range). Statistical analyses were performed using the chi-square test for categorical variables and the Mann–Whitney U test for continuous variables. A P-value threshold of .05 was considered statistically significant. All statistical analyses were performed with R software (R Foundation for Statistical Computing, Vienna, Austria; http://cran.r-project.org/).

Ethics statement

The Institutional Review Board of the Korea University Medical Center Ansan Hospital (K2018-2250-001) approved the present study. All procedures followed were in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.

Results

Short-term surgical outcomes

A total of 68 patients with equal numbers of 3D and 2D cases were included in this study. The baseline patient characteristics are shown in Table 1. Age, sex, BMI, ASA score, tumor size, and tumor depth were not significantly different between the two groups. Table 2 shows postoperative surgical outcomes. There was no significant difference between the two groups in the number of gauze pads used, time to first postoperative flatus, and the number of harvested LNs (2.0 [1.0–2.0] versus 2.0 [1.0–2.0]; P = .692; 4.0 [4.0–4.0] versus 4.0 [4.0–4.0] days; P = .196; 40.8 ± 16.6 versus 44.0 ± 15.7; P = .412).

Table 1.

Clinicopathogical Characteristics of Patients

	2D (n = 34)	3D (n = 34)	P-value
Age (years)	62.7 (12.5)	62.8 (13.2)	.977
Sex			.540
Female	10 (29.4)	11 (32.4)
Male	24 (70.6)	23 (67.6)
Body mass index (kg/m²)	25.1 (3.0)	24.3 (3.7)	.364
ASA performance status			.488
1	1 (2.9)	3 (8.8)
2	30 (88.2)	26 (76.5)
3	3 (8.8)	4 (11.8)
4	0 (0.0)	1 (2.9)
Tumor size	2.5 (1.5–3.3)	2.9 (2.0–3.7)	.304
pT stage			.213
T1	22 (64.7)	23 (67.6)
T2	5 (14.7)	8 (23.5)
T3	0 (0.0)	1 (2.9)
T4	7 (20.6)	2 (5.9)

Data shown are number (%), mean (SD), or median (IQR).

2D, two-dimensional; 3D, three-dimensional; ASA, American Society of Anesthesiologists; IQR, interquartile range; SD, standard deviation.

Table 2.

Surgical Outcomes

	2D (n = 34)	3D (n = 34)	P-value
Operation time (minutes)	249.6 (45.3)	227.8 (39.0)	.037
Number of used gauzes	2.0 (1.0–2.0)	2.0 (1.0–2.0)	.692
Time to first postoperative flatus (days)	4.0 (4.0–4.0)	4.0 (4.0–4.0)	.196
Number of harvested LNs	44.0 (15.7)	40.8 (16.6)	.412
Complications within 30 days (≥grade II)^a: yes	0 (0)	0 (0)

Data shown are number (%), mean (SD), or median (IQR).

Based on the Clavien–Dindo grading system.

2D, two-dimensional; 3D, three-dimensional; IQR, interquartile range; LN, lymph node; SD, standard deviation.

Comparison of operative duration at each step

The total operative time using 3D laparoscopy was significantly shorter than with 2D laparoscopy (227.8 ± 39.0 versus 249.6 ± 45.3 minutes; P = .037). LND phase 1 and reconstruction phase durations were shorter using 3D laparoscopy than with 2D laparoscopy (62.6 ± 14.5 versus 71.9 ± 18.8 minutes; P = .027; 32.3 ± 7.6 versus 47.7 ± 16.8 minutes; P < .001), whereas LND phase 2 showed no significant difference between the two groups (Table 3).

Table 3.

Time Per Each Phase During Operation

	2D (n = 34)	3D (n = 34)	P-value
Total operation time (minutes)	249.6 (45.3)	227.8 (39.0)	.037
Time for LND phase 1 (minutes)	71.9 (18.8)	62.6 (14.5)	.027
Time for LND phase 2 (minutes)	54.1 (13.9)	59.6 (20.4)	.203
Time for reconstruction (minutes)	47.7 (16.8)	32.3 (7.6)	<.001

Data shown are number (%), mean (SD), or median (IQR).

2D, two-dimensional; 3D, three-dimensional; IQR, interquartile range; LND, lymph node dissection; SD, standard deviation.

Discussion

The lack of depth perception, a major disadvantage of laparoscopic surgery compared with open surgery, has been overcome by the development of 3D technology. Theoretically, if all other conditions are constant (i.e., resolution, flexibility, experienced scope assistant), a 3D system should be better than a 2D system. A 3D system can provide depth perception and spatial view of anatomy. Therefore, faster, more accurate, and more precise grasping, suturing, and dissection are enabled. Moreover, a 3D system should help to accelerate the learning curve for surgical tasks and decrease operative time. However, comparative studies of 3D versus 2D have not shown a clear advantage.

A recent systematic review of 3D versus 2D with an HD scope assessed 13 randomized controlled trials.¹³ Of these, only nine showed a significant reduction in operative time. However, in most trials, subjective evaluation by the surgeon for overall satisfaction, spatial orientation, and fatigue was overwhelmingly positive in favor of the 3D procedure. The first randomized controlled trial of laparoscopic gastrectomy for gastric cancer comparing 3D versus 2D was reported in China.⁸ The authors revealed that the use of 3D did not show a reduction in operative time but had an advantage in decreasing the extent of surgery. Another study of laparoscopic total gastrectomy for gastric cancer did not show a significant difference in total operative time between 3D and 2D groups.⁹ In subgroup analysis according to each phase, however, 3D facilitated lymphadenectomy around the celiac artery.

The main reason for the lack of differences in 3D versus 2D outcomes in previous studies was that experienced laparoscopic surgeons can reconstruct 3D images in the brain using existing information.¹⁴ However, Smith et al. reported that the use of 3D systems by novice surgeons resulted in superior performance times and error reduction.¹⁵ In other studies targeting beginners, 3D showed superiority for complex tasks.^16,17

The other reason for the lack of differences in 3D versus 2D outcomes was that the resolution or flexibility of the scope was different between the two groups. In most studies, the 3D system had HD resolution and a flexible scope. In contrast, the resolution in 2D systems was full-HD or ultra-HD and the scope in the 2D system was rigid. If an inexperienced assistant manipulates a flexible scope, the disadvantages associated with the 3D scope, such as dizziness and eye fatigue, can be further increased. Moreover, high-resolution 2D systems facilitate the reconstruction of 3D images in the brain, so surgeons may not need to use a 3D system.¹⁴

In the present study, all other conditions of laparoscopic systems were the same except for 2D versus 3D vision. Three-dimensional systems only showed an advantage in the operative time. LND phase 2 did not show a significant difference between the two groups, but the 3D group showed an advantage in LND phase 1 and the reconstruction phase. Procedures for entering into the lesser sac during omentectomy or performing intestinal anastomosis by accessing the inside of the lumen are tasks that require depth perception and are easier to perform with a 3D scope. Especially for laparoscopic suturing, 3D is more beneficial for an expert surgeon than for a novice.¹⁸ The more laparoscopic experience a surgeon has, the more improved the laparoscopic suturing is by the availability of 3D vision.

In the present study, the 3D group did not show significant time reduction in LND phase 2, including suprapancreatic LN dissection. However, Kanaji et al. reported that 3D vision could facilitate lymphadenectomy around the celiac artery, because this procedure requires handling of the energy device in a tangential direction against the left gastric artery and surrounding adipose tissue.⁹ The limitation of their study was that a 30° rigid scope was used. Lymphadenectomy around the celiac axis requires a posterior field of view beyond the superior border of the pancreas, so there is a limited view with the 30° rigid scope. One of the reasons for significant time reduction with 3D is the use of a flexible system. The flexible scope can provide a complete view over the pancreas. In the present study, the same flexible scope was used for both 2D and 3D, so there was no apparent time difference in the suprapancreatic area.

Another important consideration is the cost-effectiveness. The 3D/HD/flexible system costs $177,000 USD, while the 2D/HD/flexible system costs $106,000 USD. There are no maintenance costs and no charge to patients. Although the cost of initial introduction of 3D systems is more than 1.5 times that of 2D systems, the benefits of 3D systems, including time reduction, shorter learning curve, and higher surgeon satisfaction, would overcome these cost differences.

The major limitation of this study was the retrospective design. Therefore, subjective factors such as operator satisfaction and fatigue scores could not be evaluated. Another limitation was the selection of scope systems. The choice of display system depended on availability. These limitations might lead to patient selection bias. However, although the choice of a 3D or 2D system was not randomized, the preoperative conditions between the groups were not different, so that the results of our analyses could have similar significance in a prospective setting.

In conclusion, the operative time was shortened by introducing 3D laparoscopy in a procedure requiring spatial perception. We anticipated that a 3D image could improve viewing for LND, but this system showed no advantage. Further study may be required by novice surgeons.

Footnotes

Disclosure Statement

No competing financial interests exist.

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