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The Comparison of High Definition Versus Stereoscopic Display on Standardized Fundamental Laparoscopic Skill Procedures

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The Comparison of High Definition Versus Stereoscopic Display on Standardized Fundamental Laparoscopic Skill Procedures The Comparison Of High Definition Versus Stereoscopic Display On Standardized Fundamental Laparoscopic Skill Procedures Hannes Prescher1, David E. Biffar1, Jerzy Rozenblit2,3, Allan J. Hamilton1,2,3 1Arizona Simulation Technology and Education Center, College of Medicine, University of Arizona, Tucson, Arizona, 2Department of Surgery, University of Arizona, Tucson, Arizona, 3Department of Electrical and Computer Engineering, University of Arizona, Tucson, Arizona [email protected], [email protected], [email protected], [email protected] Keywords stereoscopy, laparoscopic surgery, monitor display for visualization [3]. This condition surgical training, FLS makes hand-eye coordination and precise manipulation of instruments challenging. Abstract To optimize the efficiency of the laparoscopic The objective of this study was to determine whether technique, efforts have been made to improve the or not a standard definition stereoscopic, 3D display quality of the video monitor display [4-7]. Several could improve trainees’ performance on a standard studies have found that three-dimensional (3D) Fundamentals of Laparoscopy (FLS) task. Thirty- monitor displays may enhance laparoscopic skills by two procedurally naïve volunteers were recruited for providing stereoscopic depth perception [8-17]. The the study. Subjects were randomized to begin the advantages of such technology have been extensively trials on either the 3D or 2D display and performed researched for robotic laparoscopic systems [5, 8, 18- 10 trials on a peg transfer task (SAGES). Subjects 20]. However, far fever studies have looked at the alternated between 3D and 2D displays for each trial. potential benefits for standard laparoscopy. While Time to completion of task, and the number of some previous studies have shown advantages of 3D dropped objects were recorded for each trial, and a endoscopes related to movement efficiency, task subjective evaluation of the subjects’ preference in completion time and error reduction, others have display monitor was collected. Mean time for peg found no significant improvement compared to transfer was significantly faster with the 3D monitor standard or high-definition 2D camera systems [21- than the 2D monitor (114.22 s. versus 133.05 s.; SE: 25]. Stereoscopic, three dimensional video monitors 3.82; P ˂ 0.0001). The number of dropped objects have improved significantly in display quality and was significantly reduced in trials using the 3D come down substantially in cost, making their monitor (3.09 versus 4.25; SE: 0.34 P = 0.035). utilization in standard laparoscopic surgery more Complaints related to the stereoscopic display feasible. monitor included teary eyes (18.75%) and dizziness We hypothesize that a standard definition, (12.5%). Nevertheless, 81.25% of subjects preferred stereoscopic 3D display might improve performance the 3D display monitor. The 3D stereoscopic monitor times of procedurally naïve medical students on a display significantly improves performance of standard Fundamentals of Laparoscopic Surgery laparoscopic surgery skills on a standardized FLS peg (FLS) peg transfer task compared to a high-definition transfer task. 2D display. 1. INTRODUCTION 2. MATERIALS AND METHODS Performing laparoscopy in a two-dimensional We conducted a randomized, crossover study to vision system without stereoscopic depth perception evaluate the difference in efficacy between a can be challenging for the operator and can require stereoscopic 3D and high-definition 2D monitor substantial training and experience to overcome [1, display. 2]. The loss of depth perception is a product of the indirect way of viewing the anatomy that is 2.1 Study Design necessitated by the laparoscopic technique. Given the Standard laparoscopic box trainers were used to misalignment of the visual axis from the simulate the surgical working space. For the high- manipulation of laparoscopic instruments, the definition (HD) 2D system, we used a Karl Storz surgeon relies almost exclusively on the video Endoscopy HD camera, a 24-inch 1080p HD liquid- crystal display (LCD) monitor, a 0° telescope, and a 346 standard light source. For the 3D system, we used a requirements. All participants volunteered to prototype Karl Storz stereovision camera, a Sony 24- participate after completing an informed consent. A inch LCD monitor and a pair of 3D goggles. Trocar total of 32 procedurally naïve participants (12 male, sites for insertion of the laparoscopic instruments and 20 females) were recruited to the study. The endoscopes were fixed and the same Maryland participants consisted of both medical students (MS; graspers were used for both stations. We aligned both n = 6) and non-medical students (NMS; n = 26) with monitors to the same height and adjusted the no previous laparoscopic surgery training. Because endoscopes and cameras to standardize the size of the the study was designed to evaluate the impact of the viewing space on the 2D and 3D monitors [21]. monitor display system on laparoscopic skill, any previous training was considered a bias to the study. 2.2 Laparoscopic Task The MS included first- and second-year medical Participants performed the Fundamentals of students from the University of Arizona, College of Laparoscopic Surgery (FLS) peg transfer task Medicine. The NMS consisted of undergraduate (SAGES). The task includes 3 skills that require students from the University of Arizona. substantial depth perception, ambidexterity and hand- eye coordination: (1) lifting a triangular object with Table 1 Subjects Characteristics the non-dominant hand, (2) transferring the object Group A Group B mid-air to the dominant hand, and (3) placing the (3D First) (2D First) object on a corresponding peg on the other side of a (n = 15) (n = 17) pegboard. Once all 6 objects are transferred, the Male Female Male Female process is reversed. The task is complete when all Medical 2 0 2 2 objects are returned to their original position. Students The pegs were color-coded to standardize the Non- 4 9 4 9 motion path of each participant. If the participant Medical dropped the object within the field of view, the Students participant was required to pick it up with the same grasper and continue the task. If the object fell Participants were randomized to begin the outside the field of view, the research assistant placed experiment with either the 2D or 3D display and the object into the out-of-field dish for the participant performed 10 trials of the peg transfer task, to continue the task. (Figure 1) alternating between 2D and 3D displays for each In-field drops and out-of- field-drops were trial. Each participant was provided with a video treated equally and counted as one error respectively. demonstration of the task and instructions on how to Total time and the number of drops were recorded for use the laparoscopic instruments. To reduce the each trial. learning curve effect, practice was not permitted prior to the collection of data. Performances were supervised and timed. 2.4 Questionnaire Participants were asked to complete a questionnaire concerning their experience with the 1b stereoscopic imaging system following completion of 1c the trials. We asked them to rate their level of comfort with the 3D vision and to identify any complaints related to it. Finally, we asked participants to identify their preference of the 1a imaging systems, 2D or 3D. Figure 1 Peg transfer pegboard under 2D monitor: 2.5 Statistical Analysis 1a. out of field dish, 1b. color coded pegs, 1c. A linear mixed-effect model using SAS® Proc triangular objects Mixed was conducted to examine the main effect of monitor condition (2D, 3D), presentation order (2D vs. 3D presented first), and trial (trials 1-10) on time 2.3 Participants consumed to complete the task. In each of the This study was performed under the supervision models, the independent variables were treated as of the Institutional Review Board of the University of class variables, with person as the random effect. A Arizona and in compliance with its regulations and repeated measures general linear model was 347 conducted on the number of drops in each condition Table 2 Mean performance times (seconds) and (2D, 3D) with presentation order (2D first, 3D first) number of dropped objects by monitor type as the between group variable. We used a P value of Monitor Mean Std P-value less than 0.05 to define statistical significance. error Performance 3. RESULTS time 2D 133.47 3.82 <0.0001 3.1 Time to task completion 3D 114.22 3.82 The mean time to complete the peg transfer task Dropped was significantly faster with the 3D monitor than the objects 2D monitor (P < 0.0001, Figure 1). Presentation 2D 4.25 0.34 0.035 order was not found to be statistically significant with 3D 3.09 0.34 respect to average time (P = 0.73). Beginning the trials with 3D versus 2D did not impact the average Table 3 Improvements in mean time between time of the ensuing 3D or 2D trial times respectively. subsequent trials by monitor condition 200 Trials 2D 3D 1 – 2 28 % 19.3% 2 – 3 5.6 % 8.7 % 150 3 – 4 3.9 % 11.2 % 4 – 5 10.4 % 1.1 % 100 3.3 Questionnaire Time (seconds) Time Of the 32 subjects, 75% rated the comfort level 50 of the 3D glasses as either high or very high. Table 4 summarizes the complaints reported by subjects related to the stereoscopic display monitor. 0 1 2 3 4 5 The 3D display monitor was preferred over 2D by Trial on Monitor Condition 81.25% of the participants. One subject reported no preference between the two monitors. 2D 3D Table 4 Complaints with the 3D Monitor (n=32) Figure 1 Mean time to complete ten trials of the peg Complaint n % transfer task. Dizziness 4 12.50 Teary Eyes 6 18.75 3.2 Dropped object errors Headache 2 6.25 Overall, there was a significant difference Eye Pain 4 12.50 between the number of dropped objects in the two Out of Focus 4 12.50 monitor conditions (P = 0.035), with fewer drops None 15 46.88 occurring with the 3D monitor than the 2D monitor.
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