Pulmonary Arterial Anatomical Patterns: a Classification Scheme Based on Lobectomy and 3D-CTBA

PURPOSE

 Preoperative evaluation of pulmonary vascular and tracheal routes and variations is of great importance to the surgeon. Three-dimensional computed tomography bronchography and angiography (3D-CTBA) has evolved in recent years with the optimization of 3D reconstruction techniques and artificial intelligence. We aim to apply CT angiography and Exoview 3D reconstruction technology to assess patients' pulmonary arterial tree and its anatomical variants and to try to summarize a set of anatomical typing of the pulmonary arterial tree that is relatively easy and conducive to promoting teaching based on surgical habits of lobectomy.

METHODS

 A total of 358 patients hospitalized in the Department of Thoracic Surgery of the First Affiliated Hospital of Soochow University between July 2020 and August 2021 were included in this study. We carefully analyzed the site of emanation, alignment, and number of branches of the pulmonary artery according to a uniform classification method in conjunction with the two-dimensional CT images and transformed them into 3D reconstruction models.

RESULTS

 Different types of pulmonary artery were observed in 358 cases. We evaluated the complete pulmonary artery tree and counted the number and frequency of major arteries of the pulmonary based on the surgical habits of anatomical lobectomy.

CONCLUSION

 The 3D-CTBA technique enables us to adequately assess the anatomy of the pulmonary arteries. Moreover, we provide a practical classification scheme of pulmonary arterial anatomical patterns based on lobectomy and 3D-CTBA. Our data can be used by clinicians in the teaching of pulmonary artery anatomy and the preoperative preparation for anatomical lobectomy.

Harnessing 3D-CT Simulation and Planning for Enhanced Precision Surgery: A Review of Applications and Advancements in Lung Cancer Treatment

The clinical application of three-dimensional computed tomography (3D-CT) technology has rapidly expanded in the last decade and has been applied to lung cancer surgery. Two consecutive reports of large-scale prospective clinical trials from Japan and the United States have brought a paradigm shift in lung cancer surgery and may have led to a rapid increase in sublobar lung resections. Sublobar resection, especially segmentectomy, requires a more precise understanding of the anatomy than lobectomy, and preoperative 3D simulation and intraoperative navigation support it. The latest 3D simulation software packages are user-friendly. Therefore, in this narrative review, we focus on recent attempts to apply 3D imaging technologies, particularly in the sublobar resection of the lung, and review respective research and outcomes. Improvements in CT accuracy and the use of 3D technology have advanced lung segmental anatomy. Clinical applications have enabled the safe execution of complex sublobar resection through a minimally invasive approach, such as video-assisted thoracoscopic surgery and robotic surgery. However, currently, many facilities still render 3D images on two-dimensional monitors for usage. In the future, it will be challenging to further spread and advance intraoperative navigation through the application of 3D output technologies such as extended reality.

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review

Background

Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery.

Methods

The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery.

Results

Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes.

Discussion

Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.

Adoption of Robotic Core Technology in Minimally Invasive Lung Segmentectomy: Review

A recent randomized trial demonstrated the survival superiority of lung segmentectomy over lobectomy in patients with early stage, small-sized lung cancer. Hence, there is a pressing need for thoracic surgeons to gain familiarity with lung segmentectomy. However, lung segmentectomy, especially via minimally invasive surgery, is a technically challenging thoracic surgical procedure. The robotic surgery platform helps surgeons to improve their operative performance based on its core technological features: improved dexterity, precision, and visualization. Herein, we have discussed the key issues related to robotic lung segmentectomy, explicitly focusing on the technical features of complex segmentectomy under difficult conditions. We have also introduced our preferred surgical strategy for robotic lung segmentectomy with specific maneuvers.

A localization-independent approach for invisible and impalpable ground-glass opacity nodules detection in an in vitro lung specimen: two case reports

A growing number of ground-glass opacity (GGO) nodules are screened out in lungs. Small GGOs are frequently neither visible nor palpable, thus undetectable during operation. Various nodule localization techniques have been developed to facilitate the intraoperative detection of GGO nodules; however, general localization techniques are infeasible or inappropriate in some cases. The detection of small GGO is a great challenge, even within a surgical specimen in the absence of preoperative localization. A localization-independent approach for GGO detection is urgently needed. Herein, we report two cases with invisible and impalpable small GGO which were not appropriate for preoperative localization. The lesions were anatomically resected under the guidance of three-dimensional (3D) reconstruction and got an adequate margin distance. A vessel (artery, vein, or bronchus) which had advanced into or immediately adjacent to the nodule was assigned as a reference vessel. By dissecting and tracing the reference vessel from proximal to distal, the GGO lesions were successfully detected in the surgical specimens, to the eventual obtainment of an accurate pathological diagnosis. Via the two case reports, we introduced an easily handled approach, namely dissecting and tracing a reference vessel, for GGO detection. The novel approach was first described. Combined with precise anatomical segmentectomy guided by 3D reconstruction, it provides an alternative scheme for GGO resection with no need for preoperative localization.

The application of virtual segmentectomy based on three-dimensional computed tomography and angiography in thoracoscopic segmentectomy for children and infants

OBJECTIVES

The purpose of this retrospective study was to evaluate the efficacy of anatomic thoracoscopic pulmonary segmentectomy performed based on three-dimensional computed tomography bronchography and angiography (3D-CTBA) in children and infants.

METHODS

Totally, 22 patients received thoracoscopic segmentectomy from October 2019 to February 2020. The procedures were performed virtual segmentectomy based on 3D-CTBA. The preoperative planning depended on the 3D-CTBA result.

RESULTS

All of the 22 cases ( 1 left S1, 1 right S3, 1 left S1 + 2, 1 left S1 + 2 + 3, 1 left S4 + 5, 1 right S6, 1 right S10, 1 left S10, 2 right S9 + 10, 3 left S9 + 10, 1 right S7 + 8 + 9 + 10, 8 left S7 + 8 + 9 + 10) were received thoracoscopic segmentectomy successfully. The mean procedure length was 76.6 ± 17.2 min, and the intraoperative blood loss was 16.5 ± 2.8 ml. The mean duration of chest tube insertion was 3.2 ± 0.7 days, and the mean hospital stay was 8.2 ± 2.8 days. Postoperative complications included infection (n = 1), atelectasis (n = 1), hydropneumothorax (n = 1) and pneumothorax (n = 1). No recurrence or mortality was observed during the short-term follow-up period of 3 months.

CONCLUSIONS

Based on the 3D-CTBA technique, the specific pulmonary segments invaded by the lesions and the relationship between the corresponding pulmonary vessels and bronchi can be acknowledged before the operation, which is of positive significance for the resection of complex pulmonary segments and good preoperative surgical planning. It's worth popularizing in the pediatric population.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.

The Surgeon and the Smartphone - is the Association Really Smart?

The aim of this literature review is to encompass the importance of integrating smartphones in the life of a surgeon especially in the era of the COVID-19 pandemic. With the progression of technology, telesurgery, remote pre and postoperative care, smartphone-assisted intraoperative navigation and transcontinental education can be made a reality. Nonetheless, rates of nosocomial infections have been raised and the increased use of a smartphone can compound this issue. Similarly, there is a greater potential for operator distraction, medical equipment interference and increased radiation exposure for the user. All the above create a new set of problems for the surgeon. We hereby attempt a review of the advantages and harmful effects from the usage of smartphones.

Identification of the intersegmental plane during thoracoscopic segmentectomy: state of the art

During thoracoscopic segmentectomy, where direct palpation of the tumour is not always possible, achieving adequate margins from the cancer is of crucial importance. It is thus mandatory to accurately identify the intersegmental plane (ISP). Indeed, inadequate determination and division of the ISP can lead to unsatisfactory oncological results. Our systematic review focused on the effectiveness of the different techniques for identifying the ISP, highlighting the fact that a 1-size-fits-all method is not feasible. Based on the published evidence, 6 main methods were reported, each with its pros and cons: inflation-deflation technique, selective resected segmental inflation, systemic injection of indocyanine green, injection of endobronchial dye, 3-dimensional simulation using multidetector computed tomography and virtual-assisted lung mapping. In conclusion, ISP demarcation is mandatory to achieve a high rate of success of thoracoscopic segmentectomy, and it is very helpful in surgical planning, especially when preoperative multidetector computed tomography and 3-dimensional reconstructions are routinely performed.

Reliability of diagnosing acute ischemic cerebrovascular on magnetic resonance imaging disorders using iPads

PURPOSE

The use of tablet terminals has been explored in various medical settings; however, caution should be exercised when performing image diagnosis using this technology. The present study examined the characteristics of an iPad Air™ monitor and assessed radiographic image interpretations to verify the reliability of the telediagnosis of acute cerebral infarction based on magnetic resonance imaging (MRI) using a tablet terminal.

MATERIALS AND METHODS

The luminance of the iPad Air™ was measured using a UA-10 analyzer, and radiographic image interpretation experiments were performed in 100 patients who underwent MRI within 6 h of symptom onset. Ten physicians viewed the images on the iPad Air™ and a medical monitor, with an interval of 2 months between each interpretation.

RESULTS

When the iPad Air™ screen was pure white, the contour lines revealed nonuniform luminance distribution. In the reading experiment, the areas under the curve of the medical monitor and the iPad Air™ were 0.9311 and 0.9431, respectively. No significant difference was observed between the medical monitor and the iPad Air™ (p = 0.113).

CONCLUSION

The results of the observer performance studies for detecting acute ischemic cerebrovascular disorders on an iPad Air™ were found to be similar to those on a medical monitor.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

Impact of personalized three-dimensional -3D- printed pelvicalyceal system models on patient information in percutaneous nephrolithotripsy surgery: a pilot study

Objective

To investigate the impact of personalized three dimensional (3D) printed pelvicalyceal system models on patient information before percutaneous nephrolithotripsy surgery.

Material and Methods

Patients with unilateral complex renal stones with indicatation of percutaneous nephrolithotripsy surgery were selected. Usable data of patients were obtained from CT scans as Digital Imaging and Communications in Medicine (DICOM) format. Mimics software version 16.0 (Materialise, Belgium) was used for segmentation and extraction of pelvicalyceal systems. DICOM format were converted to Stereolithography file format. Finally, fused deposition modeling was used to create plasticine 3D models of pelvicalyceal systems. A questionnaire was designed for patients to assess personalized 3D models effect on patient’s understanding their conditions before percutaneous nephrolithotripsy surgery (PCNL). The day before surgery, each patient was seen by a urologist to deliver information about surgery. Questionnaire forms were asked to patients complete before and after presentation of 3D models and the results of the questions were compared.

Results

Five patient’s anatomically accurate models of the human renal collecting system were successfully generated. After the 3D printed model presentation, patients demonstrated an improvement in their understanding of basic kidney anatomy by 60% (p=0.017), kidney stone position by 50% (p=0.02), the planned surgical procedure by 60% (p=0.017), and understanding the complications related to the surgery by 64% (p=0.015). In addition, overall satisfaction of conservation improvement was 50% (p=0.02).

Conclusion

Generating kidney models of PCSs using 3D printing technology is feasible, and understandings of the disease and the surgical procedure from patients were well appreciated with this novel technology.

Three-dimensional virtual bronchoscopy using a tablet computer to guide real-time transbronchial needle aspiration

Objectives

We proposed a new virtual bronchoscopy tool to improve the accuracy of traditional transbronchial needle aspiration for mediastinal staging.

Methods

Chest-computed tomographic images (1 mm thickness) were reconstructed with Osirix software to produce a virtual bronchoscopic simulation. The target adenopathy was identified by measuring its distance from the carina on multiplanar reconstruction images. The static images were uploaded in iMovie Software, which produced a virtual bronchoscopic movie from the images; the movie was then transferred to a tablet computer to provide real-time guidance during a biopsy. To test the validity of our tool, we divided all consecutive patients undergoing transbronchial needle aspiration retrospectively in two groups based on whether the biopsy was guided by virtual bronchoscopy (virtual bronchoscopy group) or not (traditional group). The intergroup diagnostic yields were statistically compared.

Results

Our analysis included 53 patients in the traditional and 53 in the virtual bronchoscopy group. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the traditional group were 66.6%, 100%, 100%, 10.53% and 67.92%, respectively, and for the virtual bronchoscopy group were 84.31%, 100%, 100%, 20% and 84.91%, respectively. The sensitivity ( P  = 0.011) and diagnostic accuracy ( P  = 0.011) of sampling the paratracheal station were better for the virtual bronchoscopy group than for the traditional group; no significant differences were found for the subcarinal lymph node.

Conclusions

Our tool is simple, economic and available in all centres. It guided in real time the needle insertion, thereby improving the accuracy of traditional transbronchial needle aspiration, especially when target lesions are located in a difficult site like the paratracheal station.

Tablet terminals: a useful tool to explain in vitro fertilization treatment

Background

Explanations that involve medical care treatment take time. This also applies to explanations of in vitro fertilization (IVF) in the field of infertility treatment. This is because the cause of infertility differs from couple to couple, and because the explanations must begin with the mechanism of pregnancy. Recently, explanations facilitated by tablet terminals have been used in the field of medicine. In the present study, the efficacy and problems of explanations facilitated by tablet terminals were evaluated and compared with the explanations of IVF facilitated by paper-based pamphlets.

Methods

A total of 249 couples were asked to read a paper-based pamphlet explaining IVF treatment, while 252 couples were asked to view an explanation on a tablet terminal. The patients then answered a seven-item questionnaire. The answers to the questionnaire were based on a three-point scale, and statistical analysis was performed with the Mann-Whitney U test.

Results

Patients responded that the explanation facilitated by the tablet terminal was significantly easier to understand for all seven questionnaire items (p <0.05).

The answer ‘I did not understand’ was selected for the items related to ‘The treatment fees’ (4.8% of answers) and ‘Things to take note of, such as consultation times’ (6.7% of answers).

Conclusion

While patients generally did not understand the mechanism of pregnancy, explanations of IVF treatment facilitated by a tablet terminal were found to be more effective than paper-based explanations, although there is room for improvement.

Planning video-assisted thoracic surgery segmentectomy using three dimensional computed tomography angiography and bronchography with a virtual safety margin

In segmentectomy using video-assisted thoracic surgery (VATS), surgeons view the operative field on a 2-dimensional video monitor. The lack of ability to palpate organs directly frequently leads to difficulties in evaluating anatomic relations. Three-dimensional computed tomography angiography and bronchography (3D-CTAB) using a virtual 3D safety margin enables thoracic surgeons to recognize the distance and positional relation between the primary tumor and intersegmental veins. It also helps with surgical planning, allowing the surgeon to secure an adequate safety margin around the primary tumor. We report two patients with double primary lung cancer who underwent segmentectomy based on preoperative simulation 3D-CTAB with a virtual 3D safety margin.

Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy

Thoracoscopic pulmonary segmentectomy is technically meticulous due to the complicated anatomical variations of segmental bronchus and vessels. Currently three dimensional-computed tomography angiography (3D-CTA) could only meet the simple requirements of segmentectomy. Our center developed a software for reconstruction, "deepinsight", which could effectively solve some key technical problems. Preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) could reveal the anatomical structures and improve the accuracy of operation. Preoperative simulation on the three-dimensional image is helpful for surgery planning, which includes nodule location, identification of the targeted vessels, bronchus and surgical margin, revealing of anatomical variations, and planning of surgical approach. With the assistance of 3D navigation, during the surgical procedure all the targeted structures could be divided accurately, the intersegmental veins could be preserved, the targeted parenchyma could be en bloc removed, and the surgical margin could be ensured. Our center has developed a method to separate pulmonary segments from the lobe based on cone-shaped principle, and we named it "Cone-shaped Segmentectomy". This technique covers precise identification and dissection of segmental bronchus, vessels and intersegmental demarcation, which ultimately achieve a completely anatomical segmentectomy.

New simple image overlay system using a tablet PC for pinpoint identification of the appropriate site for anastomosis in peripheral arterial reconstruction

PURPOSE

To evaluate the accuracy and utility of a new image overlay system using a tablet PC for patients undergoing peripheral arterial reconstruction.

METHODS

Eleven limbs treated with distal bypass surgery were studied. Three-dimensional images obtained by processing a preoperative contrast-enhanced computed tomography scan were superimposed onto the back-camera images of a tablet PC. We used this system to pinpoint a planned distal anastomotic site preoperatively and to make a precise incision directly above it during surgery. We used a branch artery near the distal anastomotic site as a reference point and the accuracy of the system was validated by comparing its results with the intraoperative findings. The precision of the system was also compared with that of a preoperative ultrasonographic examination.

RESULTS

Both the image overlay system and ultrasonography (US) accurately identified the target branch artery in all except one limb. In that limb, which had a very small reference branch artery, preoperative US wrongly identified another branch, whereas the image overlay system located the target branch with an error of 10 mm.

CONCLUSIONS

Our image overlay system was easy to use and allowed us to precisely identify a target artery preoperatively. Therefore, this system could be helpful for pinpointing the most accurate incision site during surgery.

How to Conduct Multimethod Field Studies in the Operating Room: The iPad Combined With a Survey App as a Valid and Reliable Data Collection Tool

Background

Tablet computers such as the Apple iPad are progressively replacing traditional paper-and-pencil-based data collection. We combined the iPad with the ready-to-use survey software, iSurvey (from Harvestyourdata), to create a straightforward tool for data collection during the Anesthesia Pre-Induction Checklist (APIC) study, a hospital-wide multimethod intervention study involving observation of team performance and team member surveys in the operating room (OR).

Objective

We aimed to provide an analysis of the factors that led to the use of the iPad- and iSurvey-based tool for data collection, illustrate our experiences with the use of this data collection tool, and report the results of an expert survey about user experience with this tool.

Methods

We used an iPad- and iSurvey-based tool to observe anesthesia inductions conducted by 205 teams (N=557 team members) in the OR. In Phase 1, expert raters used the iPad- and iSurvey-based tool to rate team performance during anesthesia inductions, and anesthesia team members were asked to indicate their perceptions after the inductions. In Phase 2, we surveyed the expert raters about their perceptions regarding the use of the iPad- and iSurvey-based tool to observe, rate, and survey teams in the ORs.

Results

The results of Phase 1 showed that training data collectors on the iPad- and iSurvey-based data collection tool was effortless and there were no serious problems during data collection, upload, download, and export. Interrater agreement of the combined data collection tool was found to be very high for the team observations (median Fleiss’ kappa=0.88, 95% CI 0.78-1.00). The results of the follow-up expert rater survey (Phase 2) showed that the raters did not prefer a paper-and-pencil-based data collection method they had used during other earlier studies over the iPad- and iSurvey-based tool (median response 1, IQR 1-1; 1=do not agree, 2=somewhat disagree, 3=neutral, 4=somewhat agree, 5=fully agree). They found the iPad (median 5, IQR 4.5-5) and iSurvey (median 4, IQR 4-5) to be working flawlessly and easy to use (median 5, IQR 4-5). Expert ratings also showed that the anesthesia team members (ie, the surveyed doctors and nurses) who used the iPad- and iSurvey-based tool in the OR liked it (median 4, IQR 3-4.5).

Conclusions

The combination of the iPad and iSurvey provides an efficient and unobtrusive method to observe teams in their natural environment in the OR and to survey team members immediately after completing their task (ie, anesthesia induction). The expert raters positively evaluated the use of the device and user perceptions. Considering these comprehensive results, we can recommend the use of the iPad- and iSurvey-based tool for studying team performance and team member perceptions in the OR.

Binocular stereo-navigation for three-dimensional thoracoscopic lung resection

Background

This study investigated the efficacy of binocular stereo-navigation during three-dimensional (3-D) thoracoscopic sublobar resection (TSLR).

Methods

From July 2001, the authors’ department began to use a virtual 3-D pulmonary model on a personal computer (PC) for preoperative simulation before thoracoscopic lung resection and for intraoperative navigation during operation. From 120 of 1-mm thin-sliced high-resolution computed tomography (HRCT)-scan images of tumor and hilum, homemade software CTTRY allowed sugeons to mark pulmonary arteries, veins, bronchi, and tumor on the HRCT images manually. The location and thickness of pulmonary vessels and bronchi were rendered as diverse size cylinders. With the resulting numerical data, a 3-D image was reconstructed by Metasequoia shareware. Subsequently, the data of reconstructed 3-D images were converted to Autodesk data, which appeared on a stereoscopic-vision display. Surgeons wearing 3-D polarized glasses performed 3-D TSLR.

Results

The patients consisted of 5 men and 5 women, ranging in age from 65 to 84 years. The clinical diagnoses were a primary lung cancer in 6 cases and a solitary metastatic lung tumor in 4 cases. Eight single segmentectomies, one bi-segmentectomy, and one bi-subsegmentectomy were performed. Hilar lymphadenectomy with mediastinal lymph node sampling has been performed in 6 primary lung cancers, but four patients with metastatic lung tumors were performed without lymphadenectomy. The operation time and estimated blood loss ranged from 125 to 333 min and from 5 to 187 g, respectively. There were no intraoperative complications and no conversion to open thoracotomy and lobectomy. Postoperative courses of eight patients were uneventful, and another two patients had a prolonged lung air leak. The drainage duration and hospital stay ranged from 2 to 13 days and from 8 to 19 days, respectively. The tumor histology of primary lung cancer showed 5 adenocarcinoma and 1 squamous cell carcinoma. All primary lung cancers were at stage IA. The organs having metastatic pulmonary tumors were kidney, bladder, breast, and rectum. No patients had macroscopically positive surgical margins.

Conclusions

Binocular stereo-navigation was able to identify the bronchovascular structures accurately and suitable to perform TSLR with a sufficient margin for small pulmonary tumors.

Comparative efficacy of new interfaces for intra-procedural imaging review: the Microsoft Kinect, Hillcrest Labs Loop Pointer, and the Apple iPad

We adapted and evaluated the Microsoft Kinect (touchless interface), Hillcrest Labs Loop Pointer (gyroscopic mouse), and the Apple iPad (multi-touch tablet) for intra-procedural imaging review efficacy in a simulation using MIM Software DICOM viewers. Using each device, 29 radiologists executed five basic interactions to complete the overall task of measuring an 8.1-cm hepatic lesion: scroll, window, zoom, pan, and measure. For each interaction, participants assessed the devices on a 3-point subjective scale (3 = highest usability score). The five individual scores were summed to calculate a subjective composite usability score (max 15 points). Overall task time to completion was recorded. Each user also assessed each device for its potential to jeopardize a sterile field. The composite usability scores were as follows: Kinect 9.9 (out of 15.0; SD = 2.8), Loop Pointer 12.9 (SD = 13.5), and iPad 13.5 (SD = 1.8). Mean task completion times were as follows: Kinect 156.7 s (SD = 86.5), Loop Pointer 51.5 s (SD = 30.6), and iPad 41.1 s (SD = 25.3). The mean hepatic lesion measurements were as follows: Kinect was 7.3 cm (SD = 0.9), Loop Pointer 7.8 cm (SD = 1.1), and iPad 8.2 cm (SD = 1.2). The mean deviations from true hepatic lesion measurement were as follows: Kinect 1.0 cm and for both the Loop Pointer and iPad, 0.9 cm (SD = 0.7). The Kinect had the least and iPad had the most subjective concern for compromising the sterile field. A new intra-operative imaging review interface may be near. Most surveyed foresee these devices as useful in procedures, and most do not anticipate problems with a sterile field. An ideal device would combine iPad's usability and accuracy with the Kinect's touchless aspect.

Is the iPad suitable for image display at American Board of Radiology examinations?

OBJECTIVE

The study aimed to determine the acceptability of the iPad 3 as a display option for American Board of Radiology (ABR) examinations.

SUBJECTS AND METHODS

A set of 20 cases for each of nine specialties examined by the ABR was prepared. Each comprised between one and seven images and case information and had been used in previous ABR Initial Certification examinations. Examining radiologists (n = 119) at the ABR oral Initial Certification examinations reviewed sets from one or more specialties on both a 2 MP LED monitor and on the iPad 3 and rated the visibility of the salient image features for each case. The Wilcoxon signed rank test was performed to compare ratings. In addition, a thematic analysis of participants' opinions was undertaken.

RESULTS

When all specialties were pooled, the iPad 3 ratings were significantly higher than the monitor ratings (p = 0.0217). The breast, gastrointestinal, genitourinary, and nuclear medicine specialties also returned significantly higher ratings for the visibility of relevant image features for the iPad 3. Monitor ratings were significantly higher for the vascular and interventional specialty, although no images were rated unacceptably poor on the iPad in this specialty.

CONCLUSION

The relevant image features were rated more visible on the iPad 3 than on the monitors overall. The iPad 3 was well accepted by a large majority of examiners and can be considered adequate for image display for examination in most or all specialties.

A novel 3-dimensional image analysis system for case-specific kidney anatomy and surgical simulation to facilitate clampless partial nephrectomy

OBJECTIVE

To report our initial experience with the novel 3-dimensional (3D) image analysis system Synapse Vincent in clampless partial nephrectomy (PN), describing its advantages with regard to short-term surgical outcomes and its usefulness as an informed consent tool.

METHODS

Twenty-six patients with renal cell carcinoma underwent clampless PN navigated with the aid of case-specific 3D anatomic video images of the kidney, after surgical simulation using the same video system. Baseline characteristics were reviewed, and short-term surgical outcomes were recorded. Of the 26, 6 had imperative indications, and 22 were treated with a minimally invasive approach. Before tumor excision, the renal hilar vessels were meticulously dissected, and definite tumor feeders were selectively ligated. Before patients consented to PN, the surgical procedure and perioperative risks were explained to each patient using case-specific 3D video images; subsequently, surgeons asked patients whether the 3D images had helped them understand PN more clearly than 2D images would have.

RESULTS

All operations were successfully completed without clamping, with negative surgical margins. No patients required blood transfusions. During PN, the surgeons confirmed the accuracy of the reconstructed 3D images and surgical simulations in all cases. All patients answered that the 3D images had helped them understand their disease status and surgical risks.

CONCLUSION

This is the first report on the Synapse Vincent 3D image analysis system for kidney surgery. Its 3D images and surgical simulation helped not only surgeons in their performance of clampless PN but also patients in their understanding of the operation.

Medical iPad use in the cardiac catheterization and echo laboratories

The present study aims to describe a dedicated cardiac imaging application on a tablet and to assess the accuracy and reproducibility of this novel application for measurement on angiography and echocardiography data sets. Tablet devices have recently been used in radiological image interpretation and enable transfer of images. It allows the clinician to look up clinical information, search the Internet and communicate with colleagues and family. The study group consisted of 30 patients who had both echocardiographic and angiographic examinations. For each patient, a few measurements (i.e. length, area and angle) were performed using the iPad, and compared to the McKesson workstation, which is routinely used in the hospital. In order to show the equivalence between these two methods, a linear regression was fitted and the distribution of differences between measurements was examined. In addition, the variability of the measurements was compared between two different reviewers (inter-observer test) and between the measurements of the same reviewer at two different time settings (intra-observer test) by calculating the intraclass correlation coefficient (ICC). In all comparisons, the linear regression showed high correlation coefficient (r > 0.9), and the distribution of differences was around zero, implying that the two methods lead to equivalent results. The absolute mean difference between the two different observers demonstrated high agreement between the two observers' repeated measurements. The same conclusions can be deduced from the same observer's repeated measurements. The ICC indicates the resemblance between the two sets, and could be considered almost perfect (ICC > 0.968 for all cases). The newly developed cardiology iPad application offers the opportunity to accurately present the cardiac procedure in a visual, clear and professional manner.

New technique for lung segmentectomy using indocyanine green injection

One of the most difficult aspects of complete segmentectomy of the lung is the identification of the intersegmental plane. Instead of a conventional residual segment inflation method, we have developed a new technique for detecting intersegmental planes using indocyanine green medium. The technique is simple and consists of (1) ligation of the segmental vein to prevent loss of the indocyanine green and (2) injection of indocyanine green through the segmental bronchus. These two steps result in easy identification of intersegmental planes by a change of color not only of the surface but also of the parenchyma of the lung. This technique can be indicated for atypical segmentectomy.

Resident iPad use: has it really changed the game?

PURPOSE

The purpose of this study was to assess residents' usage patterns and opinions of the iPad as a tool for radiology education and clinical practice at an academic medical center.

METHODS

All 38 radiology residents in our radiology program (postgraduate years 2 to 5) were provided with iPad 2 tablets and subscriptions to e-Anatomy and STATdx. After 6 months of device use, residents were surveyed to assess their opinions regarding the technology as a tool for education and clinical practice.

RESULTS

A total of 36 residents (95%) completed the survey. Eighty-six percent reported daily iPad use. Radiology-specific applications, particularly e-Anatomy, were used weekly or daily by 88% of respondents. Most preferred to read journal articles on the iPad (70%), but the number of respondents preferring to read textbooks on the iPad (48.5%) compared with the traditional bound form (48.5%) was evenly divided. Residents were also divided on the clinical utility of the iPad. Most had not used the iPad to view radiologic examinations (75%). Fewer than half (47%) used their iPads during readout. Finally, only 12% had used the iPad to edit dictated reports.

CONCLUSIONS

The iPad has generated excitement within the radiology community, particularly among resident educators, who are increasingly recognizing the unique needs of "millennial learners." This study showed that the majority of residents at the authors' institution have incorporated the iPad as an educational tool and use it as a learning aid. Incorporation of the iPad into clinical workflow has been less pronounced.

Three dimensional computed tomography lung modeling is useful in simulation and navigation of lung cancer surgery

The number of minimally invasive operations, such as video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy, has enormously increased in recent years. These operations require extreme knowledge of the anatomy of pulmonary vessels and bronchi in each patient, and surgeons must carefully dissect the branches of pulmonary vessels during operation. Thus, foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The development of multi-detector computed tomography (MDCT) has promoted three dimensional (3D) images of lung structures. It is possible to see the vascular and bronchial structures from the view of the operator; therefore, it is employed for preoperative simulation as well as navigation during operation. Due to advances in software, even small vessels can be accurately imaged, which is useful in performing segmentectomy. Surgical simulation and navigation systems based on high quality 3D lung modeling, including vascular and bronchial structures, can be used routinely to enhance the safety operation, education of junior staff, as well as providing a greater sense of security to the operators.

The iPad as a mobile device for CT display and interpretation: diagnostic accuracy for identification of pulmonary embolism

Recent software developments enable interactive, real-time axial, 2D and 3D CT display on an iPad by cloud computing from a server for remote rendering. The purpose of this study was to compare radiologists' interpretative performance on the iPad to interpretation on the conventional picture archive and communication system (PACS). Fifty de-identified contrast-enhanced CT exams performed for suspected pulmonary embolism were compiled as an educational tool to prepare our residents for night call. Two junior radiology attendings blindly interpreted the cases twice, one reader used the PACS first, and the other interpreted on the iPad first. After an interval of at least 2 weeks, the cases were reinterpreted in different order using the other display technique. Sensitivity, specificity, and accuracy for identification of pulmonary embolism were compared for each interpretation method. Pulmonary embolism was present in 25 patients, ranging from main pulmonary artery to subsegmental thrombi. Both readers interpreted 98 % of cases correctly regardless of display platform. There was no significant difference in sensitivity (98 vs 100 %, p = 1.0), specificity (98 vs 96 %, p = 1.0), or accuracy (98 vs 98 %, p = 1.0) for interpretation with the iPad vs the PACS, respectively. CT interpretation on an iPad enabled accurate identification of pulmonary embolism, equivalent to display on the PACS. This mobile device has the potential to expand radiologists' availability for consultation and expedite emergency patient management.