3-D内窥镜外科手术是否来您附近的或剧院？

2010年8月6日

Samar Fakhri, MD
教授

One of the most exciting aspects of attending scientific meetings is to explore new products and technologies presented during the program sessions or showcased by the exhibitors. At the recentCombined Otolaryngology Society Meetings(COSM) in Las Vegas, three-dimensional endoscopic technology generated interest among the audience and stood out among a medley of innovations that combine biochemical, physical and information sciences. Meant to enhance surgical performance and overcome limitations of current technology, this is the long-awaited answer to the lack of depth perception of conventional two-dimensional endoscopy.

There were two presentations on the utility of 3-dimensional stereoscopic vision during endoscopic sinonasal surgery. The first study compared outcomes of traditional 2-dimensional endoscopic pituitary surgery in 36 patients to a 3-dimensional endoscopic system in 27 patients.1There was no difference between the 2 groups in blood loss, operative time, rate of CSF leak, and postoperative endocrine complications.

在the second study, a high-definition 2-D endoscopic system was used on 7 patients undergoing sinonasal and skull base surgery.2The 3-D endoscopic system was then incorporated at key portions of the procedure. The authors reported that 3-D endoscopy enhanced depth perception and endoscopic orientation, and resulted in additional intervention including tumor resection or removal of remnant partitions in 43% of patients. There were no complications but there was inability to visualize a type III frontal cell and loss of orientation due to over-magnification during an ASB reconstruction.

We are witnessing an explosive growth in the surgical applications of information science. In the field of Rhinology, the introduction of the telescope to the modern practice of surgery is a perfect example of how the information age has enabled an unequivocal paradigm shift in the surgical management of sinonasal disease. Advances in imaging protocols, surgical navigation, computer-aided surgery, virtual endoscopy and robotics are reshaping the face of modern day surgery and forcing surgeons to engage in constant re-evaluation of the way they practice surgery. More importantly, technological advances have enhanced the quality of care delivered to individual patients.

内窥镜鼻窦手术中最大的挑战之一是基于二维显示监视器提供的反馈，在三维空间中产生运动。即使使用高清视频内窥镜检查，依靠单眼线索也可能会限制外科医生执行准确有效的操纵达到手术目标的能力。在传统的2D腹腔镜检查过程中跟踪经验丰富的内窥镜外科医生的运动显示出有趣的模式。最初，外科医生将水平和垂直轴对齐，将仪器带到目标的前面，但随后缓慢地将其移动，直到与目标接触。显然，这会导致“ Z滞后”或较慢的深度定位。尽管在二维视觉条件下工作的局限性可以通过实践最小化，但研究表明，与直觉相比，在二维内窥镜条件下，经验丰富的内镜医生在二维内镜条件下的表现不佳。在一项研究, experienced laparoscopic surgeons made 47% more movements, took 56% longer and overshot the target 35% deeper than with direct vision.3当然，新手内窥镜医生的情况会更糟。在同一项研究中，引入3D内镜系统将外科医生的内窥镜“障碍”减半，以测量所有客观参数。

At movie theatres, the advantages of 3-D are evident in movies like头像。观看詹姆斯·卡梅隆（James Cameron）在3D中的最新大片的经历是如此壮观，这真是一个奇迹，我们仍然打扰看传统的2D电影。去年，我在使用3D内窥镜进行尸体鼻窦和颅底解剖后得出了类似的结论。使用3D技术的理由，该技术为外科医生提供了近似直接视觉的手术领域的空间图。对于我的头骨基础神经外科同事，3D体验受到改变的改变，这将有助于神经外科医生采用内窥镜技术。从我的角度来看，我可以证明它提供了增强的深度感知和独特的手术体验。但是，与我已经使用的高清2-D内窥镜相比，这项新技术是否会导致鼻窦手术中的外科手术表现出色。

采用新技术需要仔细评估其优点，限制和成本。已经克服了3D望远镜特性的初始限制，直径较小（4.0mm）和倾斜范围现在可用。作为外科医生，我可能会采用降低手术风险并改善患者预后的技术。虽然增强的视觉信息应该导致更有效，更安全的程序似乎是本能的，但确实很难将手术性能的改善与更好的患者结局相关联。关于3D内窥镜检查对患者护理的影响，在COMM提出的两项研究得出了不同的结论。具体而言，第一项研究没有显示出2-D和3D内镜垂体手术之间的患者结局和手术风险的任何差异。来自其他手术学科的研究表明，该技术的有效性及其对患者的好处有类似的分歧。

Considering this environment of health care reform and cost containment, it is likely that hospitals will evaluate novel and expensive technology based on a stringent evidence-based acquisition process. This technology remains prohibitively expensive and needs to prove itself before it hits the big time.

参考

  • 1Kari E, Oyesiku N, Dadashev V, Wise S. Comparison of traditional two-dimensional endoscopic pituitary surgery with new three-dimensional endoscopic technology. Presented at the 2010 American Rhinologic Society COSM meeting, Las Vegas, April 29, 2010.
  • 2Manes RP，Brewer J，Barnett S，Batra PS。内窥镜鼻窦和颅底手术期间新型三维立体视觉系统的效用。2010年4月29日在拉斯维加斯举行的2010年美国伦敦学会COSM会议上发表。
  • 3Taffinder N，Smith SG，Huber J，Russell RC，DarziA。第二代3D内窥镜对新手和经验丰富的外科医生的腹腔镜精度的影响。外科手术1999年11月,13(11):1087 - 92。
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