4K ultra HD technology reduces operative time and intraoperative blood loss in colorectal laparoscopic surgery

Introduction

Laparoscopic surgery provides several intra- and post-operative advantages such as improved cosmesis, less post-operative pain and faster recovery compared to open surgery¹. The development of new technologies has allowed laparoscopic surgery to become faster and safer. In particular, the quality of digital imaging has played a key role in the development of such procedures². The association between quality of vision and surgical outcome is very tight. Improving the image quality allows the sharpness of laparoscopic surgery to be fully expressed. The clear view of the anatomical landmarks can improve the accuracy of dissection, permitting dissection of the lymphatic and nervous structures, which represent a crucial aspect of colorectal surgery³. Furthermore, the improved visualization of vascular structures and the better definition of adipose tissues may avoid intraoperative bleeding and reduce operative time, resulting in reduced surgical stress for the patient and potentially decreased complication rate⁴.

Recently, several new imaging technologies, such as three-dimensional (3D)/high-definition (HD) stereovision and high-resolution two-dimensional (2D)/4K monitors have been made available to laparoscopic surgeons⁵. However, it is still unclear to what extent these technologies can actually improve surgical performance⁶.

Nowadays, HD systems are routinely used in laparoscopic surgery, while 4K ultra HD monitors are mainly available within specialized, high-volume laparoscopic centers^7,8. The higher resolution of 4K ultra HD video could upgrade the surgical performance by improving depth perception, dissection precision, and bleeding control, but no study has yet provided a good evidence to sustain this finding. For this reason, we designed the present study to compare surgical intraoperative and post-operative parameters in patients operated on for colorectal cancer either with 4K ultra HD technology or a standard HD vision.

Methods

Results

There were no statistically significant differences in terms of baseline characteristics between groups⁹. Table 1 describes patient characteristics.

In 2017, a total of 28 LHRs, 38 LLHs and 28 LRARs were performed, while there were 30 LRHs, 44 LLHs and 23 LRARs in 2018. The overall complication rate according to CD classification was 21.2% (20/94) in 2017 and 17.5% (17/97) in 2018 (p>0.05). The rate of major complications (CD ≥ 3) was 6.3% (6/94) in 2017 vs 4.1% (4/97) in 2018 (p>0.05). In particular, there were no statistically significant differences in anastomotic leak rate, post-operative bleeding rate, mortality rate and readmission rate between groups. Mean surgical time was statistically significantly shorter with 4K ultra HD technology than HD technology (p < 0.05). Intraoperative blood loss was statistically significantly reduced in patients operated on in 2018 (p < 0.05) (Table 2).

Figure 1A shows the ileocolic vein and the inferior mesenteric vein dissected during a right hemicolectomy with complete mesocolic excision. Figure 1B shows the middle colic vein isolated during the same procedure performed with 4K ultra HD technology. Figure 1C shows the Gerota fascia and the inferior mesenteric artery isolated during a left hemicolectomy with HD technology. Figure 1D shows the hypogastric plexus at the origin of the inferior mesenteric artery spared during anterior rectal resection with 4K ultra HD technology.

Figure 1.

A) Ileocolic vein and inferior mesenteric vein (HD technology). B) Middle colic vein (4K ultra HD technology). C) Gerota’s fascia and inferior mesenteric artery (HD technology). D) Hypogastric plexus at the origin of the inferior mesenteric artery (4K ultra HD technology). Images were obtained retrospectively from the video electronic library of our institution, which contains records of all minimally invasive procedures of patients who gave consent for publication of the images for educational or research purposes.

Discussion

The main finding of our study is the statistically significant reduction in surgical time with the 4K ultra HD technology compared to normal HD technology. Intraoperative blood loss was also statistically significantly reduced in patients operated on with 4K ultra HD technology.

4K ultra HD monitors were introduced in our surgical department in January 2018, replacing full HD technology for major colorectal laparoscopic procedures. Accurate visualization of the anatomical structures is crucial during laparoscopic procedures. Recognizing the vascular structures, their divisions and their course within the mesocolic fat tissue is of fundamental importance in oncological surgery¹². Lymph node visualization along the course of the vessels and the ability to remove them without encountering troublesome bleeding allow a more precise dissection¹³.

Cutting edge technologies like 4K ultra HD allow the surgeon to be even more minimally invasive. Abderlahman et al. reported on the importance of the quality of 4K ultra HD images in reducing mistakes in structure identification¹. Moreover, during left sided colorectal laparoscopic procedures, a precise visualization of the autonomic nerves is related to a better preservation of the genitourinary function. Especially for LRARs, both preservation of the autonomic nerves and avoiding injury to the mesorectum are essential for functional outcomes¹⁴.

The results we reported show how, following the introduction of a 4K technology, operating time for the same operations performed by the same surgeons decreased significantly. This may lead to lower operating room costs, as well as to the clinical benefits of a reduction in the peri-operative stress that patients are subjected to due to the duration of surgery and use of anesthesia¹⁵. The significant reduction of intraoperative blood loss in the two groups could be related to the improved capability in recognizing vascular structures that 4K ultra HD permits.

Although it was not scientifically investigated in the present work, the subjective impressions of the operating surgeons are important when a new technology is introduced. All participating surgeons subjectively reported a much more detailed image with the 4K ultra HD technology. They all depicted a clearer understanding of the anatomical structures and of the surgical planes. In LRARs above all, the advantages of the 4K ultra HD view have been particularly enhanced, given the complexity of the anatomical field^16,17. All operators reported ending procedures with less eye fatigue using 4K technology, although this could not be measured. The eye fatigue was reported to be minimal during the procedures performed in 2018. This finding is important when related to the fact that in almost all cases, the surgeon has to perform three or four procedures in the same day. Moreover, the 4K ultra HD technology could help in reducing the inevitable eye fatigue that aging brings¹⁸.

This study has several biases, beside its retrospective nature. The estimation of the validity of a technology cannot be entrusted only to the operative time required and instead consists of much more complex analysis. However, the reduction in surgical time is a reliable assessment of the technological improvement reached. The subjective reports of the intraoperative perception of the operating surgeons were not structured in intelligible questionnaires. Further efforts should be made to produce a specific tool to investigate the quality of the devices used in mini-invasive surgery.

Conclusions

4K ultra HD technology applied to colorectal oncologic laparoscopic procedures is safe and effective in reducing surgical time and minimizing intraoperative blood loss compared to normal HD technology.

Data availability

Consent

Written informed consent for publication of the patients’ data and clinical images was obtained from each patient involved.