The advantages of minimal access surgery are well known and laparoscopy as a treatment modality is well accepted in the paediatric age group. In 1995, Farello et al performed the first laparoscopic choledochal cyst excision with hepaticojejunostomy (HJ) in a 6-year-old girl [1]. Since then, laparoscopic approaches for management of CDC have gained widespread popularity, even though they are technically-demanding procedures.
The greatest challenge while working with a 2D system is the hand-eye coordination within a 3D field observed on a 2D display. Moreover, the bilio-enteric anastomosis requires advanced laparoscopic suturing skills. The many aberrations of the anatomy including the vasculature at the porta, along with the difficult surgical planes from recurrent episodes of inflammation, add to the challenge. 3D laparoscopy and subsequently Robotic surgery was developed as an advancement in order to overcome challenges of absent depth perception of 2D laparoscopy. Use of 3D vision, especially in complex reconstructive procedures provides the advantage of improvement in hand coordination and depth perception; thus, making dissection precise and almost bloodless.
Additional training is not required for 3D laparoscopy (over 2D laparoscopy) apart from adaptation to operating with 3D glasses. 3D vision on account of stereopsis simulating the human eye, benefits by shortening the laparoscopic learning curve. Studies have shown that the learning curve is shorter even in trainee and fellows in 3D laparoscopy as compared to conventional laparoscopy [2]. We began laparoscopic management of choledochal cyst in 2014. Initial few cases were operated by 2 D laparoscopy. We faced a lot of difficulties with vision, blood loss and suturing in the narrow cavity. 3D laparoscopy was started in our institute in 2016. Initially we started using the system for extirpetive procedures like appendicectomy, cholecystectomy and nephroureterectomy so as to get accustomed to the system. In 2017, the first CDC procedure was performed. We found that the 3D system made the dissection precise reducing the blood loss significant enough that none of the patients required blood transfusion. The suturing became much easier and less cumbersome than with conventional 2D system. Thereafter, we have only used the 3D system for management of CDC.
The first case in our series lasted for 540 mins and 5 ports were used. With time, the number and the size of the ports have gradually reduced. The number of ports reduced from 5 to 3, size of ports reduced from 5mm to 3 mm to 3mm direct instruments. Currently the operative time is approximately 230 mins with a total of 3 incisions which includes a 10mm camera port, one 3mm port and a 3mm direct instrument. Initially orals were allowed only after day 5 as for any intraabdominal anastomosis. With increasing experience and as a step towards incorporating the ERAS guidelines [3], currently, orals are started early after return of bowel function (within 48 hours in the last case). The aim is to start orals within 24 hours and discharge by day 3 in future.
In a study by Zhasun et al comparing use of 3D vs 2D laparoscopy in CDC, there was statistically significant shorter operative time and lesser blood loss in the 3D laparoscopy group (P < .001) [4]. This was attributed to better depth perception and clearer vision aiding the dissection and identification of vascular structures with the 3D laparoscope. Way et al highlighted, the most common reason for bile duct injuries in conventional laparoscopy was visual misperception (97 %) [5]. The enhancements of 3D on visual depth perception can improve the quality of laparoscopic surgery as well as patient safety.
In 2006, first robotic CDC excision with HJ was done by Woo et al [6]. Nazki et al in 2019 summarised the published literature on robotic assisted choledochal cyst and published their series on Robotic management of CDC with HD [7]. They highlighted robotic system provides 3D high-definition vision and x 10 magnification which makes the vision clearer and dissection more precise. This also makes the horizontal anastomosis of HD easy. However, they also highlighted that the learning curve is steep even in the good volume centres. Also, that higher per patient cost is a prominent concern and will remain so until the equipment costs come down.
The comparison between 2D laparoscopy, 3D laparoscopy and robotics is tabulated as follows.
Comparison between conventional 2D laparoscopy, 3D laparoscopy and robotics:
|
Conventional Laparoscopy
|
3D laparoscopy
|
Robotic
|
View of the surgical site
|
++
|
+++
|
+++
|
Minimisation of the surgical trauma
|
+
|
+++
|
+++
|
Ease of learning of the methodology
|
+ +
|
++
|
+
|
Cost savings
|
+++
|
++
|
+
|
+ =least preferred, +++ = most preferred
Not all cases of choledochal cyst are traditionally considered amenable to laparoscopic approach. Pancreatitis, cholangitis, perforation, previous history of a biliary procedure done are considered in exclusion criteria by some on account of anticipated difficult surgery in already technically challenging procedure [8-9]. We found it feasible to use 3D laparoscopy with relative ease even in the management of such challenging cases. 6 patients in our series as mentioned below were successfully completed laparoscopically without need for conversions.
- Post ERCP +/- stenting (ERCP - n=2, ERCP with stenting n=1)
- Previously operated for open procedure outside (n=1)
- Biliary ascites with choledochal cyst (n=1)
- Past history of Pancreatitis (n=1)
3D vision thus helps to broaden the indications of laparoscopic surgery even in challenging and anticipated difficult surgeries.
Another advantage of 3D laparoscopy is that it is relatively more feasible in younger age group as against a robotic procedure as there are no size constraints in using conventional instruments. 5 patients in our series were younger than 2 years. Zhasun [4] et al used 3D laparoscopy for the treatment of patients with CDC in patients younger than 12 months. They reported no increase in the occurrence of complications in this group of patients. They inferred that 3D laparoscopy can provide better depth perception and clearer vision, in the small abdominal space making it feasible even in smaller children. We find the advantages of 3D system to be a great asset to performing this surgery with greater ease and safety. The minimal blood loss significant enough leading to the requirements of blood transfusions to be zero in the series makes 3D laparoscopy our preferred approach in advanced, complicated laparoscopic cases like CDC.
3D laparoscopy as ‘bridging the gap’ asset: Binocular depth perception, magnified view and improved hand eye coordination with 3D system leads to more accurate and swift dissection and aids in intra-corporeal suturing and knotting. Additionally, no specialized instruments are needed for the same. 3D High-Definition laparoscopy system thus offers the vision advantage of robotic surgery at a significantly lower cost with use of conventional laparoscopic equipment like 3 mm instruments.
Limitations of 3D laparoscopy:
10 mm incision is essential for the camera port placement. However, taking the incision within the umbilical crease gives good cosmetic outcome. (Figure 2 and 3). Headache, nausea and eye strain from 3D laparoscopy have been reported, although these are not consistently demonstrated across different studies [10]. No headache, vision disturbances or any other symptoms were reported by the surgeons in our study.