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Background: This study was performed to introduce a new wireless endoscopic system. Research and development were based on fifth-generation transmission technology. Eye symptoms and visual discomfort induced by the novel endoscopic system were com- pared with those induced by the conventional endoscopic system before and during laparoscopic pelvic surgery. Materials and methods: Twenty surgeons successfully conducted laparoscopic pelvic surgeries using a conventional endoscopic system and a wireless endoscopic system. Subjective and objective data were measured to evaluate visual discomfort before and 2 hours after surgery. Results: In the conventional endoscopic and wireless endoscopic system groups, no significant differences were found in the presurgical or postsurgical questionnaires. In both groups, tear film breakup times significantly decreased after surgery. However, after comparing the 2 groups, no statistically significant difference was found. Conclusions: Compared with the conventional endoscopic system, the novel wireless endoscopic system does not cause additional visual discomfort for experienced surgeons. Keywords: Wireless endoscope; Endoscopic system; 5G; Dry eyes; Visual discomfort 1. Introduction In the present study, a wireless high-definition endoscopic surgery system was proposed for the first time (P1080; DVL Electron Co, Laparoscopic surgery has been used in clinical practice for decades Hefei, China). Compared with the traditional endoscopic surgery sys- as a minimally invasive surgery that benefits patients in terms of tem, the proposed system possesses the advantages of high-definition operative complications, recovery time, pain, and cosmesis. Tradi- imaging, wireless connection, high-speed wireless transmission, small tional laparoscopy requires various wired connections, bulky cam- volume, low cost, easy portability, and more. Prior research has shown eras, and laterally positioned optic fibers. These problems hinder that the latency of telesurgery can affect surgery completion time but is  the performance of surgeons and result in various discomforts, es- within tolerable limits and does not affect operations. However, latency [1,2] pecially if the surgery is considerably long. Furthermore, tradi- can cause adverse phenomena (such as fatigue, stress, shorter working [10–12] tional means can potentially contaminate the operation area, memory, dizziness, and nausea) and should not be ignored. As lap- which is a potential safety hazard and highly costly to health eco- aroscopic pelvic surgery requires a longer operation time, the high re- nomics. With the development of transmission technology, wire- quirement for the surgical field of view may have a greater visual impact. less surgery has become possible. Since the 1980s, the National In- We compared the occurrence of visual discomfort between surgeons stitutes of Health has been funding the development of cordless during conventional and wireless laparoscopic surgeries to determine [3–8] energy-based technology. The new 5G wireless networks have whether the wireless endoscopic system causes visual discomfort. The a faster (100 times faster than 4G networks) and more stable data comparison was performed by testing subjective questionnaires and transmission, reducing latency to 1–2ms—much lower than the re- objective physiological indicators in laparoscopic pelvic surgeries. action time of the human brain (approximately 40 ms). Such speed and stability are revolutionary for the progress of surgical technol-  ogy and have even allowed for remote surgery to be achieved. 2. Materials and methods The proposed wireless endoscopic system consists of a light-emitting di- *Corresponding Author: Chaozhao Liang, Jixi Rd 218, Shushan District, Hefei, 230022, ode light source, camera, battery, handheld part, and a wireless trans- China. E-mail address: Liang_chaozhao@ahmu.edu.cn (C. Liang). Supplemental digital contents are available for this article. mission module (Fig. 1). A Trans-Flash card slot was built in the hand- Current Urology, (2023) 17, 2, 77–81 held part, facilitating convenient video saving for the operator. Video Received August 5, 2022; Accepted December 29, 2022. signals are sampled by the camera and wirelessly sent to the radiofre- http://dx.doi.org/10.1097/CU9.0000000000000182 quency receiver via radiofrequency waves, which are connected to a Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. This is high-definition monitor through a high-definition multimedia interface. an open-access article distributed under the terms of the Creative Commons Simultaneously, data can be wirelessly transmitted to a computer and Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it smartphone. is permissible to download and share the work provided it is properly cited. The The present study was a cross-sectional study in which visual dis- work cannot be changed in any way or used commercially without permission from the journal. comfort before and after laparoscopic pelvic surgeries was recorded 77 Xu et al. Volume 17 Issue 2 2023 www.currurol.org Figure 1. Wireless endoscopic system diagram 254 190 mm (96 96 DPI). by 20 surgeons, with the surgeons having over 3 years of experience in using 30-degree lenses, and the monitors were obtained from the regularly performing laparoscopic pelvic surgeries. All subjects had a same manufacturer using the same parameters (Deming Technology habitual or corrected visual acuity of at least 6/6 in each eye. None Co, Ltd, Shenzhen, China). of the subjects had strabismus or any ocular disease, and all subjects Statistical analysis was performed using the SPSS Statistics soft- had normal stereopsis and no eye irritation before the tests. This study ware (IBM-SPSS Corp, Armonk, NY). Symptom scores were not was approved by the medical ethics committee of the First Affiliated normally distributed (calculated using the Kolmogorov-Smirnov Hospital of Anhui Medical University. test). Nonparametric statistical tests (Wilcoxon two-sample tests) Twenty surgeons were asked to perform laparoscopic pelvic were used, and the data are presented as the median (interquartile surgeries (laparoscopic radical prostatectomy or laparoscopic range). The raw visual function data followed a normal distribu- radical cystectomy) using the conventional endoscopic system on tion, and a one-way analysis of variance (least significant difference the first day and the wireless endoscopic system the next week (Fig. 2). To eliminate the effects of surgical fatigue, all the surgeries performed were the first surgeries in the surgical schedule for each operator. To evaluate visual discomfort before surgery and 2 hours after surgery, operation times less than 2 hours were excluded. Sub- jective and objective data were used in this study. The questionnaire  was revised based on previous research, which included ques- tions on blurred vision, difficulty in refocusing from one distance to another, irritated or burning eyes, dry eyes, eyestrain, headache, tired eyes, sensitivity to bright lights, and eye discomfort. General scores (ranging from 0 to 10) for the symptoms were evaluated by the study participants and calculated by subtracting the scores be- fore surgery from those after surgery (Supplemental Table 1, http:// links.lww.com/CURRUROL/A32). The objective test indicators in- cluded fusion range, accommodative convergence/accommodation (AC/A) ratio, film breakup time (BUT), and critical flicker frequency (CFF). The fusion range and AC/A ratio were measured using a synoptophore (TSJ-IV-A; Photoelectric Instrument Co, Ltd, Changchun, China). The fusion range reflects the function of fus- ing 2 slightly different images (parallax) generated by each eye. The AC/A ratio refers to accommodative convergence changes (in prism diopters) in response to the stimulus to accommodation (in diopters). Visual fatigue and blurred vision can lead to changes in certain param- eters. Visual fatigue can lead to dry eyes and shorten the BUT indica- tors. Breakup times were measured using a slit lamp corneal micro- scope (YZ5FI; 66 Vision Tech, Inc, Suzhou, China). Representing the critical value for human eyes to distinguish external stimuli, CFF objectively reflects the visual condition of the subjects and is exten- sively used in the detection of visual fatigue. Critical flicker frequency was measured using a BD-II-118 scintillator (Hongde Industrial Co, Ltd, Shandong, China). In this study, the same ambient light was present in each operat- ing room and the distance between the monitor and the operator was kept at 1.5 m to eliminate the influence of external environmen- Figure 2. Wireless endoscopic system operation diagram. tal factors and screen parameters. All surgeries were performed 78 Xu et al. Volume 17 Issue 2 2023 www.currurol.org Table 1 Results of questionnaires in conventional endoscopic system and wireless endoscopic system groups. Symptoms Conventional, Median (IQR) Wireless, Median (IQR) Zp Blurred vision 2 (1.75) 2 (2) 0.34 0.73 Difficulty in refocusing from one distance to another 1 (2) 1 (2) 0.17 0.87 Irritated or burning eyes 0.5 (1) 0 (1) 1.46 0.14 Dry eyes 3 (1.75) 3 (2) 0.27 0.79 Eyestrain 2.5 (1) 3 (2) 0.65 0.52 Headache 0(2) 0(0) 0.95 0.35 Tired eyes 3 (3.5) 1 (2) 1.74 0.08 Sensitivity to bright lights 0 (0) 0 (0) 0.38 0.71 Discomfort in eyes 2 (2.75) 1.5 (2.75) 1.35 0.18 The symptoms were scored from 0 (none) to 10 (very severe), with a score of 5 representing a moderate response. IQR = interquartile range. method) was used to perform multiple comparisons. The signifi- any visual discomfort (Table 1). The previously mentioned results cance level was set at p <0.05. are consistent with a previous study by the present authors on lapa-  roscopic surgery, which revealed that psychological pressure and highly concentrated attention during laparoscopic surgery did not 3. Results seem to have increased the subjective visual discomfort of surgeons. Such results could be attributed to the rich experience of surgeons in In both the conventional endoscopic system and wireless endo- laparoscopic surgery and significant hand-eye coordination, which scopic system groups, the users exhibited slight visual symptoms were likely beneficial for quickly adapting to the new equipment. of discomfort (Table 1). Major discomfort included dry and The vision parameters were examined to comprehensively de- tired eyes, but the symptoms were tolerable. Minimally intense termine whether the visual functions had changed, as shown in discomfort was experienced, such as sensitivity to bright lights, Table 2. A decrease in fusion range (fusional amplitude) can cause tearing, and headaches. After comparing the scores between a vergence-accommodation conflict, leading to visual fatigue. A pro- the 2 groups using Wilcoxon two-sample tests, no significant spective observational study of 60 subjects reported that with pro- differences were found. longed use of certain devices (smartphones, computers, lap- For further objective verification, the visual function data were tops, and others), fusion range values dropped less than 30 de- tested, as shown in Table 2. In the conventional endoscopic system grees, and patients complained of symptoms such as eye pain,  and wireless endoscopic system groups, there were significant dif- blurry vision, and frontal headache. However, computer vision ferences in the decline of BUT 2 hours after laparoscopic surgery syndrome remains underdiagnosed. Another study revealed that ( p = 0.01, p = 0.00, respectively). However, no statistically signifi- smartphone and tablet use resulted in changes in the lag and ampli-  cant difference was found ( p = 0.35) between them. No significant tude of accommodation, which influenced the AC/A ratio. Such differences were found in the fusion range, AC/A, or CFF before changes can lead to symptoms such as blurred vision, near vision, [17,18] and after surgery between the 2 groups. sore eyes, and tired eyes. Critical fusion frequency is an effec-  tive indicator for evaluating visual function. A decline in CFF cor- responds to subjective ocular discomfort, such as pain in or around [20–22] 4. Discussion the eyes and eyes feeling heavy and itchy, and has an obvious  time accumulation effect. In the present study, as shown in Table After analyzing the surgeons’ questionnaire scores, no significant 2, there were no significant decreases in the AC/A ratio or CFF in ei- differences were found in any of the outcome variables between ther group before or after the fusion range was tested. In addition, the conventional and wireless groups. In both groups, the mean there were no statistically significant differences in the values be- scores were significantly low, and many surgeons did not experience tween the 2 groups. Notably, the AC/A ratio was measured at the lower end of or below the historically cited range of 3 to 5:1 but  was normal because of different methods. In addition, handheld devices or computers differ from laparoscopic monitors in terms of Table 2 patterns of use, viewing position and distance, screen size, and lumi- Changes in visual functional parameters after surgery in the conventional and nance. Compared with watching at a short range, the work distance wireless endoscopic system groups. in the present study was longer at 1.5 m, and eye movements were 1 2 3 relatively infrequent. Of the patients, 51.4% reported visual fatigue Parameter Before Conventional Wireless p p p  and dry eye syndrome and 71.3% with dry eye syndrome. Lon- Fusion range, degree 25.75 ± 2.86 24.25 ± 2.57 24.55 ± 2.63 0.08 0.16 0.73 ger hours of computer use in visual display terminal workers with AC/A 2.58 ± 0.67 2.40 ± 0.59 2.37 ± 0.61 0.36 0.28 0.87  dry eye are associated with reduced tear film BUT. In this study, BUT, s 23.00 ± 5.13 19.45 ± 4.16 18.15 ± 3.53 0.01 0.00 0.35 tear film BUTs significantly decreased ( p =0.01, p = 0.00, respec- CFF, Hz 29.94 ± 5.29 28.72 ± 4.61 28.87 ± 4.79 0.44 0.49 0.93 tively) after surgery in both the conventional endoscopic system p : comparison between before and after conventional laparoscopic pelvic surgery. group and wireless endoscopic system group. During the surger- p : comparison between before and after wireless laparoscopic pelvic surgery. ies, the monitor was viewed in horizontal gaze. In addition, the p : comparison between the conventional and wireless groups after laparoscopic pelvic surgery. palpebral aperture was wider than that for conventional reading AC/A = accommodative convergence/accommodation ratio; BUT = tear film breakup time; CFF = critical flicker frequency. tasks, which are usually performed in downward gaze, with a larger 79 Xu et al. Volume 17 Issue 2 2023 www.currurol.org [26,27] ocular surface area exposed to the effects of tear film evaporation. HX, DN: Acquired the data;  Simultaneously, humidity, air conditioning, and intensity of illu- HX, CY: Analyzed and interpreted the data and wrote the manuscript; mination in the operating room were interference factors. In com- All authors have read and approved the final manuscript. paring the 2 groups, there were no statistically significant differences in tear film BUT changes ( p = 0.35), indicating that the wireless en- References doscopic system did not cause additional dry eye symptoms.  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Current Urology – Wolters Kluwer Health
Published: Jun 23, 2023
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