The Role of Three-dimensional Laparoscopy in Gynecology: Time to Revise Our Perspective?

Abstract

Minimally invasive surgery in the form of two-dimensional (2D) laparoscopy has been the gold standard for increasing number of gynecological procedures for almost three decades now. However, there are still centers in the world where conventional laparotomy is preferred by gynecologists. This is primarily due to the struggle one faces with loss of the “third dimension” or “perception of depth” in 2D laparoscopy. This makes the learning curve slower and steeper as compared to open surgery. While over the years, with practice, minimally invasive gynecologists have got accustomed to the loss of binocular vision when operating, and have learned to use monocular depth cues such as light and shade, relative size of objects, object interposition, texture gradient, and motion parallaxe,[1] it remains a challenge for few. Depth perception is the visual ability to judge the relative distance of objects and the spatial relationship of objects at different distances. As the three-dimensional (3D) world projects onto a 2D retina, this projection on its own cannot provide depth information. The brain has to combine various monocular and binocular cues given by the eyes to recover the depth, distance, and 3D shape of objects. This lead to the development of the 3D scope and technology in the early 1990s. It was presumed to overcome the main limitation of a 2D surgical field, hoping to make the hand–eye coordination easier for new surgeons. However very quickly feedback from surgeons circulated negativity amongst most centers. This included ocular fatigue, onset of headaches as well as the scopes being large and bulky leading to hand fatigue. Following the approval by the Food and Drug Administration of the Da Vinci Surgical System in 2005, there was an increasing trend toward the use of the robotic assistance. The high-definition 3D vision provided on the surgical console, along with the better ergonomics with endo–wrist movements, was considered a game changer in the field of minimally invasive surgery.[2-4] This rekindled the interest in 3D vision among many surgeons; reminding us it is a technology which has been in the market for many years; however had not percolated most institutes. Earlier models for 3D laparoscopy were limited by suboptimal image quality and had heavy active shutter glasses, but technological advancements have enabled sophisticated high-resolution systems and light polarizing glasses that are lighter and more comfortable. Today, what we use is a dual-channel optical scope which is connected to two video cameras and delivers two pictures that are displayed to the viewer on a stereoscopic display. When the surgeon wears circular, polarized 3D glasses, the two images are merged by the brain into one, and this gives the perception of depth. Over the three decades, there have been controversial publications on the first-generation 3D high-definition laparoscopic surgeries. In 1998, Hanna et al.[5] showed that there were no advantages from the use of 3D laparoscopic system. However, with the new-generation 3D high-definition systems, both inexperienced and experienced surgeons reduce their time of operation and there is no headache, dizziness, or ocular fatigue observed; some studies have even shown a significant benefit.[6-9] 3D laparoscopy appears to improve speed and reduce the number of performance errors when compared to 2D laparoscopy.[10] However, most studies to date assessed 3D laparoscopy in simulated settings, and the impact of 3D laparoscopy on clinical outcomes has yet to be examined. In today’s era, a discussion on gynecological surgery would be incomplete without considering the skills and surgical understanding required to treat endometriosis, perhaps one of the most technically challenging surgeries in gynecology.[11-14] The dense adhesions, distorted anatomy, skewed surgical planes, and the poor reproductive outcome put enormous pressure on the surgeon to do a complete and thorough job. The goal is always