Comparison of two- and three-dimensional endoscopic visualization for fetal myelomeningocele repair: a pilot study using a fetoscopic surgical simulator

Abstract

Introduction The objective of this study was to evaluate the utility of three-dimensional (3D) versus conventional two-dimensional (2D) endoscopy for fetal myelomeningocele repair using a low-fidelity fetoscopic surgical simulator. Methods A low-fidelity fetoscopic box trainer was developed for surgical simulation of myelomeningocele repair. Participants with varying surgical experience were recruited and completed three essential tasks (cutting skin, dural patch placement, and suturing skin) using both 2D and 3D endoscopic visualization. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion was measured for each task, and each participant subsequently completed the NASA Load Index test and a questionnaire evaluating their experience. Results Sixteen participants completed the study tasks using both 2D and 3D endoscopes in the simulator. While the mean performance time across all tasks was shorter with 3D versus 2D endoscopy (cutting skin, 47 vs. 54 seconds; dural patch placement, 38 vs. 52 seconds; and suturing skin, 424 vs. 499 seconds), the results did not reach statistical significance. When comparing times to completion of each of the three tasks between levels of expertise, participants in the expert category were faster when suturing skin on the 2D modality ( P = 0.047). Under 3D visualization, experts were faster at cutting the skin ( P = 0.008). When comparing experiences using the NASA-TLX test, participants felt that their performance was better using 3D over the 2D system ( P = 0.045). Overall, 13 of 16 (81.3%) participants preferred 3D over 2D visualization. Conclusions Three-dimensional endoscopes could potentially be used in the near future for relative improvement in visualization and possibly performance during complex fetoscopic procedures such as prenatal repair of myelomeningocele defects. Further studies utilizing 3D scopes for other related procedures may potentially support clinical implementation of this technology in fetal surgery and also prove to be a useful tool in surgical training.