Augmented Reality Navigation for Stereoscopic Laparoscopic Anatomical Hepatectomy of Primary Liver Cancer: Preliminary Experience

More than meets the eye: Augmented reality in surgical oncology

BACKGROUND AND OBJECTIVES

In the field of surgical oncology, there has been a desire for innovative techniques to improve tumor visualization, resection, and patient outcomes. Augmented reality (AR) technology superimposes digital content onto the real-world environment, enhancing the user's experience by blending digital and physical elements. A thorough examination of AR technology in surgical oncology has yet to be performed.

METHODS

A scoping review of intraoperative AR in surgical oncology was conducted according to the guidelines and recommendations of The Preferred Reporting Items for Systematic Review and Meta-analyzes Extension for Scoping Reviews (PRISMA-ScR) framework. All original articles examining the use of intraoperative AR during surgical management of cancer were included. Exclusion criteria included virtual reality applications only, preoperative use only, fluorescence, AR not specific to surgical oncology, and study design (reviews, commentaries, abstracts).

RESULTS

A total of 2735 articles were identified of which 83 were included. Most studies (52) were performed on animals or phantom models, while the remaining included patients. A total of 1112 intraoperative AR surgical cases were performed across the studies. The most common anatomic site was brain (20 articles), followed by liver (16), renal (9), and head and neck (8). AR was most often used for intraoperative navigation or anatomic visualization of tumors or critical structures but was also used to identify osteotomy or craniotomy planes.

CONCLUSIONS

AR technology has been applied across the field of surgical oncology to aid in localization and resection of tumors.

Smart Operating Room in Digestive Surgery: A Narrative Review

The introduction of new technologies in current digestive surgical practice is progressively reshaping the operating room, defining the fourth surgical revolution. The implementation of black boxes and control towers aims at streamlining workflow and reducing surgical error by early identification and analysis, while augmented reality and artificial intelligence augment surgeons' perceptual and technical skills by superimposing three-dimensional models to real-time surgical images. Moreover, the operating room architecture is transitioning toward an integrated digital environment to improve efficiency and, ultimately, patients' outcomes. This narrative review describes the most recent evidence regarding the role of these technologies in transforming the current digestive surgical practice, underlining their potential benefits and drawbacks in terms of efficiency and patients' outcomes, as an attempt to foresee the digestive surgical practice of tomorrow.

Laparoscopic left hemihepatectomy using augmented reality navigation plus ICG fluorescence imaging for hepatolithiasis: a retrospective single-arm cohort study (with video)

BACKGROUND

Laparoscopic left hemihepatectomy (LLH) has been shown to be an effective and safe method for treating hepatolithiasis primarily affecting the left hemiliver. However, this procedure still presents challenges. Due to pathological changes in intrahepatic duct stones, safely dissecting the hilar vessels and determining precise resection boundaries remains difficult, even with fluorescent imaging. Our team proposed a new method of augmented reality navigation (ARN) combined with Indocyanine green (ICG) fluorescence imaging for LLH in hepatolithiasis cases. This study aimed to investigate the feasibility of this combined approach in the procedure.

METHODS

Between May 2021 and September 2023, 16 patients with hepatolithiasis who underwent LLH were included. All patients underwent preoperative 3D evaluation and were then guided using ARN and ICG fluorescence imaging during the procedure. Perioperative and short-term postoperative outcomes were assessed to evaluate the safety and efficacy of the method.

RESULTS

All 16 patients successfully underwent LLH. The mean operation time was 380.31 ± 92.17 min, with a mean estimated blood loss of 116.25 ± 64.49 ml. ARN successfully aided in guiding hilar vessel dissection in all patients. ICG fluorescence imaging successfully identified liver resection boundaries in 11 patients (68.8%). In the remaining 5 patients (31.3%) where fluorescence imaging failed, virtual liver segment projection (VLSP) successfully identified their resection boundaries. No major complications occurred in any patients. Immediate stone residual rate, stone recurrence rate, and stone extraction rate through the T-tube sinus tract were 12.5%, 6.3%, and 6.3%, respectively.

CONCLUSION

The combination of ARN and ICG fluorescence imaging enhances the safety and precision of LLH for hepatolithiasis. Moreover, ARN may serve as a safe and effective tool for identifying precise resection boundaries in cases where ICG fluorescence imaging fails.

Application of Laennec extrathecal blockade combined with indocyanine green fluorescence imaging in laparoscopic anatomic hepatectomy

OBJECTIVE

To investigate the safety and application value of combining Laennec extracapsular occlusion with ICG fluorescence imaging in laparoscopic anatomic hepatectomy.

METHODS

Complete laparoscopic dissection was performed outside the Laennec sheath, blocking Glisson's pedicle of the corresponding liver segment or lobe. An appropriate amount of indocyanine green (ICG) dye was intravenously injected, and the boundary line between the pre-cut liver segment and liver lobe was identified using fluorescence laparoscopy. Complete resection of the liver segment or lobe was performed based on anatomical markers. Clinical data, including operation time, intraoperative blood loss, postoperative hospital stay, and postoperative complications, were collected.

RESULTS

A total of 14 cases were included in the study, including seven cases of primary liver cancer, three cases of metastatic liver cancer, three cases of intrahepatic bile duct calculi, and one case of hepatic hemangioma. All 14 patients underwent anatomic hepatectomy under fluorescent laparoscopy, with four cases involving the right liver, seven cases involving the left liver, two cases involving the right anterior lobe, and one case involving the right posterior lobe.

CONCLUSION

Combining laparoscopic follow-up of the Laennec membrane with Glisson outer sheath block and intraoperative ICG fluorescence imaging provides real-time guidance for locating the resection boundaries during anatomic hepatectomy. This approach helps in controlling intraoperative bleeding, reducing operation time, and ensuring high safety. It holds significant value in clinical application.

Current Trends in Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Surgical management, including hepatic resection, liver transplantation, and ablation, offers the greatest potential for a curative approach. This review aims to discuss recent advancements in HCC surgery and identify unresolved issues in the field. Treatment selection relies on the BCLC staging system, with surgical therapies primarily recommended for early-stage disease. Recent studies have shown that patients previously considered unresectable, such as those with portal vein tumor thrombus and uncomplicated portal hypertension, may benefit from hepatic resection. Minimally invasive surgery and improved visualization techniques are also explored, alongside new techniques for optimizing future liver remnant, ex vivo resection, and advancements in hemorrhage control. Liver transplantation criteria, particularly the long-standing Milan criteria, are critically examined. Alternative criteria proposed and tested in specific regions are presented. In the context of organ shortage, bridging therapy plays a critical role in preventing tumor progression and maintaining patients eligible for transplantation. Lastly, we explore emerging ablation modalities, comparing them with the current standard, radiofrequency ablation. In conclusion, this comprehensive review provides insights into recent trends and future prospects in the surgical management of HCC, highlighting areas that require further investigation.

Augmented reality-assisted navigation system contributes to better intraoperative and short-time outcomes of laparoscopic pancreaticoduodenectomy: a retrospective cohort study

BACKGROUND

Augmented reality (AR)-assisted navigation system are currently good techniques for hepatectomy; however, its application and efficacy for laparoscopic pancreatoduodenectomy have not been reported. This study sought to focus on and evaluate the advantages of laparoscopic pancreatoduodenectomy guided by the AR-assisted navigation system in intraoperative and short-time outcomes.

METHODS

Eighty-two patients who underwent laparoscopic pancreatoduodenectomy from January 2018 to May 2022 were enrolled and divided into the AR and non-AR groups. Clinical baseline features, operation time, intraoperative blood loss, blood transfusion rate, perioperative complications, and mortality were analyzed.

RESULTS

AR-guided laparoscopic pancreaticoduodenectomy was performed in the AR group ( n =41), whereas laparoscopic pancreatoduodenectomy was carried out routinely in the non-AR group ( n =41). There was no significant difference in baseline data between the two groups ( P >0.05); Although the operation time of the AR group was longer than that of the non-AR group (420.15±94.38 vs. 348.98±76.15, P <0.001), the AR group had a less intraoperative blood loss (219.51±167.03 vs. 312.20±195.51, P =0.023), lower blood transfusion rate (24.4 vs. 65.9%, P <0.001), lower occurrence rates of postoperative pancreatic fistula (12.2 vs. 46.3%, P =0.002) and bile leakage (0 vs. 14.6%, P =0.026), and shorter postoperative hospital stay (11.29±2.78 vs. 20.04±11.22, P <0.001) compared with the non-AR group.

CONCLUSION

AR-guided laparoscopic pancreatoduodenectomy has significant advantages in identifying important vascular structures, minimizing intraoperative damage, and reducing postoperative complications, suggesting that it is a safe, feasible method with a bright future in the clinical setting.

Perioperative and Disease-Free Survival Outcomes after Hepatectomy for Centrally Located Hepatocellular Carcinoma Guided by Augmented Reality and Indocyanine Green Fluorescence Imaging: A Single-Center Experience

BACKGROUND

Laparoscopic hepatectomy for centrally located hepatocellular carcinoma is challenging to perform. Augmented reality navigation (ARN) and fluorescence imaging are currently safe and reproducible techniques for hepatectomy, but the efficacy results for centrally located hepatocellular carcinoma have not been reported. This study aimed to evaluate the efficacy of an ARN system combined with fluorescence imaging (ARN-FI) in laparoscopic hepatectomy for centrally located hepatocellular carcinoma.

STUDY DESIGN

This was a post hoc analysis of an original nonrandomized clinical trial that was designed to evaluate the feasibility and efficacy of ARN-FI for laparoscopic liver resection. A total of 76 patients were consecutively enrolled from June 2018 to June 2021, of which 42 underwent laparoscopic hepatectomy using ARN-FI (ARN-FI group), and the other 34 who did not use ARN-FI guidance (non-ARN-FI group). Perioperative outcomes and disease-free survival were compared between the 2 groups.

RESULTS

Compared with the non-ARN-FI group, the ARN-FI group had less intraoperative blood loss (median 275 vs 300 mL, p = 0.013), lower intraoperative transfusion rate (14.3% vs 64.7%, p < 0.01), shorter postoperative hospital stay (median 8 vs 9 days, p = 0.005), and lower postoperative complication rate (35.7% vs 61.8%, p = 0.024). There was no death in the perioperative period and follow-up period. There was no significant difference in overall disease-free survival between the 2 groups (p = 0.16).

CONCLUSIONS

The ARN system and fluorescence imaging may be of value in improving the success rate of surgery, reducing postoperative complications, accelerating postoperative recovery, and shortening postoperative hospital stay.

Basic Experiments Toward Mixed Reality Dynamic Navigation for Laparoscopic Surgery

Laparoscopic surgery is a minimally invasive procedure that is performed by viewing endoscopic camera images. However, the limited field of view of endoscopic cameras makes laparoscopic surgery difficult. To provide more visual information during laparoscopic surgeries, augmented reality (AR) surgical navigation systems have been developed to visualize the positional relationship between the surgical field and organs based on preoperative medical images of a patient. However, since earlier studies used preoperative medical images, the navigation became inaccurate as the surgery progressed because the organs were displaced and deformed during surgery. To solve this problem, we propose a mixed reality (MR) surgery navigation system in which surgical instruments are tracked by a motion capture (Mocap) system; we also evaluated the contact between the instruments and organs and simulated and visualized the deformation of the organ caused by the contact. This paper describes a method for the numerical calculation of the deformation of a soft body. Then, the basic technology of MR and projection mapping is presented for MR surgical navigation. The accuracy of the simulated and visualized deformations is evaluated through basic experiments using a soft rectangular cuboid object.

Effect of rapid rehabilitation nursing on inflammation and liver function after laparoscopic radical resection of primary liver cancer

OBJECTIVE

To explore the effect of rapid rehabilitation nursing on inflammation and liver function in patients with primary liver cancer (PLC) after laparoscopic radical resection.

METHODS

A total of 124 PLC patients who underwent laparoscopic radical surgery in the Zhuji People's Hospital of Zhejiang Province from April 2019 to July 2021 were enrolled in this retrospective study. Among them, 65 patients who received rapid rehabilitation nursing were assigned into the observation group (OG), and the other 59 with routine nursing were considered to be the control group (CG). The pain before operation (T0), 3 days after operation (T1) and 7 days after operation (T2) was evaluated by visual analogue scale (VAS). The perioperative related indexes and nursing satisfaction were compared. The levels of liver function indexes alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and inflammatory factors C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured before operation, 1 day and 7 days after operation. Finally, the incidence of postoperative complications was counted, the 6-month survival rate of both groups of patients was compared.

RESULTS

There was no obvious difference in VAS scores between the two groups at T0 (P>0.050), but the VAS scores at T1 and T2 in the OG were lower than those in the CG (P<0.001). There was no marked difference in the total operation time. Compared with the CG, the time to first exhaust, catheter indwelling and hospitalization in the OG were shorter (P<0.001) and the nursing satisfaction rate was higher (P<0.05). There was no obvious difference in ALT, AST and TBIL on the 1st day after operation (P>0.05); however, on the 7th day after operation, ALT and AST were lower while TBIL was higher in the OG (all P<0.05). There was no marked difference in CRP, IL-6 and TNF-α between the two groups on postoperative day 1 (P>0.05), but the levels were lower in the OG than those in the CG on postoperative day 7 (all P<0.05), and the total incidence of adverse reactions in the OG was lower (P<0.05). There was no statistical difference in the postoperative survival rate between both groups of patients (P>0.05). Age, number of lesions, tumor size, Child-Pugh grade, AST, TBIL, CRP, IL-6, TNF-α were associated with the survival rate of patients.

CONCLUSION

Rapid rehabilitation nursing can effectively reduce adverse reactions after laparoscopic radical resection of PLC. Thus, it has a high application value in future clinical treatment.

Influence of Three-Dimensional Visual Reconstruction Technology Combined with Virtual Surgical Planning of CTA Images on Precise Resection of Liver Cancer in Hepatobiliary Surgery

Hepatobiliary malignancies, such as hepatocellular carcinoma (HCC) and biliary tract cancers, namely, gallbladder carcinoma and cholangiocarcinoma, are linked to a high rate of morbidity and mortality, depending on the phase of the disease. The intricate hepatobiliary anatomy and the need for accurate peroperative management, especially in patients with advanced liver disease, make these tumors difficult to treat. Surgical resection is a notable therapy for hepatobiliary cancers. Unnecessary or excessive liver excision influences patient rehabilitation, normal liver function, and postoperative complications. Hepatobiliary operations must therefore include accurate liver removal. The present advancements in imaging technology are aimed at improving the diagnostic efficacy of liver injury even more. Three-dimensional visual reconstruction is becoming more important in the diagnosis as well as treatment of a variety of disorders. In this paper, we proposed a novel three-dimensional visual reconstruction technology using enhanced nonuniform rational basis spline (ENURBS) combined with virtual surgical planning of Computed Tomography Angiography (CTA) images for precise liver cancer resection. The purpose of this project is to rebuild 2D CTA scan images of liver cancer into a 3D reconstructed model for efficient visualization and diagnosis of liver cancer and to prepare an effective preoperative surgical plan for precise liver excision based on a 3D recreated liver model. This method's performance is compared to that of 2D planning in terms of accuracy and time taken to complete the plan. It is concluded that our proposed technique outperforms the planning technique based on 2D images.

Clinical efficacy and safety of 3D vascular reconstruction combined with 3D navigation in laparoscopic hepatectomy: systematic review and meta-analysis

Background

Meta-analysis was used to compare the difference between 3D reconstruction technology and 2D computed tomography (CT) before surgery for primary hepatic carcinoma (PHC) and to systematically evaluate the application value of 3D vascular reconstruction and 3D navigation technology in guiding precise liver resection for PHC. However, there are still many controversies in this aspect, and there are no clear conclusions on the effectiveness and safety of three-dimensional vascular reconstruction combined with three-dimensional navigation in laparoscopic hepatectomy. Therefore, it is necessary to systematically review the results of previous studies with meta method in this study to determine their clinical efficacy and complications and guide clinical treatment.

Methods

We used the Cochrane Library, PubMed, Embase, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodicals Full-Text Database (VIP), and Wanfang database to conduct an online search for data from randomized controlled trials of preoperative 3D reconstruction versus conventional CT in hepatectomy published up to October 2021. Relevant literature was selected based on the inclusion criteria, data was extracted, and quality evaluation of the included literature was carried out. I² test was used to evaluate heterogeneity among the studies, and Cochrane risk of bias 2.0 was used to evaluate the studies.

Results

A total of 16 studies were included in this study. Meta-analysis showed that there were statistically significant differences between the 3D vascular reconstruction group and conventional surgery group in operation time [mean differences (MD) =-40.10, 95% confidence interval (CI): -74.94, -5.26, P=0.02, I²=78%, Z=2.26] and intraoperative blood loss (MD =-50.40, 95% CI: -62.93, -37.86, P<0.00001, I²=9%, Z=7.88), but no statistically significant difference was found in total days in hospital (MD =-0.39, 95% CI: -1.81, 1.03, P=0.59, I²=76%, Z=0.54), and postoperative complications rate (OR =0.98, 95% CI: 0.64, 1.50, P=0.91, I²=0%, Z=0.11).

Discussion

Preoperative 3D reconstruction plays an important role in preoperative evaluation and surgical planning, which improves the operation time of PHC and reduces the intraoperative blood loss, but no effect to length of stay in hospital or complication rate comparing to conventional 2D techniques.

A 3D Image Registration Method for Laparoscopic Liver Surgery Navigation

At present, laparoscopic augmented reality (AR) navigation has been applied to minimally invasive abdominal surgery, which can help doctors to see the location of blood vessels and tumors in organs, so as to perform precise surgery operations. Image registration is the process of optimally mapping one or more images to the target image, and it is also the core of laparoscopic AR navigation. The key is how to shorten the registration time and optimize the registration accuracy. We have studied the three-dimensional (3D) image registration technology in laparoscopic liver surgery navigation and proposed a new registration method combining rough registration and fine registration. First, the adaptive fireworks algorithm (AFWA) is applied to rough registration, and then the optimized iterative closest point (ICP) algorithm is applied to fine registration. We proposed a method that is validated by the computed tomography (CT) dataset 3D-IRCADb-01. Experimental results show that our method is superior to other registration methods based on stochastic optimization algorithms in terms of registration time and accuracy.

Augmented reality navigation facilitates laparoscopic removal of foreign body in the pancreas that cause chronic complications

BACKGROUND

Foreign bodies that enter the pancreas and cause chronic complications cannot be removed by endoscopy. Surgical removal is necessary but also challenging. The development of augmented reality navigation has made it possible to accurate intraoperative navigation in laparoscopic surgery.

METHODS

A 37-year-old female had epigastric pain for 3 months and her abdominal CT showed a linear high-density shadow in her pancreas along with chronic pancreatitis. Three-dimensional models of the liver, pancreas, stomach, blood vessels, and foreign body were created based on CT images. Gastroptosis was found in the three-dimensional models, so surgical approach was adapted to open the hepatogastric ligament to reach the pancreas. After 2-3 s of video images were captured by 3D laparoscopy, a three-dimensional dense stereo-reconstruction method was used to obtain the surface model of pancreas, stomach, and blood vessels. The Globally Optimal Iterative Closest Point method was used to obtain a spatial transformation matrix between the preoperative CT image space and the intraoperative laparoscopic space. Under augmented reality navigation guidance, the position and location of the foreign body were displayed on the surface of the pancreas. Then intraoperative ultrasound was used for further verification and to quickly and easily confirm the surgical entrance. After minimal dissection and removal of the pancreatic parenchyma, the foreign body was removed completely.

RESULTS

The operation time was 60 min, the estimated blood loss was 10 ml. The foreign body was identified as a 3-cm-long fishbone. The patient recovered without complications and was discharged on the third postoperative day.

CONCLUSION

Because it enables direct visual navigation via simple operation, ARN facilitates the laparoscopic removal of foreign bodies in the pancreas with accurate and rapid positioning and minimal damage.

Intraoperative fluorescence molecular imaging accelerates the coming of precision surgery in China

Purpose

China has the largest cancer population globally. Surgery is the main choice for most solid cancer patients. Intraoperative fluorescence molecular imaging (FMI) has shown its great potential in assisting surgeons in achieving precise resection. We summarized the typical applications of intraoperative FMI and several new trends to promote the development of precision surgery.

Methods

The academic database and NIH clinical trial platform were systematically evaluated. We focused on the clinical application of intraoperative FMI in China. Special emphasis was placed on a series of typical studies with new technologies or high-level evidence. The emerging strategy of combining FMI with other modalities was also discussed.

Results

The clinical applications of clinically approved indocyanine green (ICG), methylene blue (MB), or fluorescein are on the rise in different surgical departments. Intraoperative FMI has achieved precise lesion detection, sentinel lymph node mapping, and lymphangiography for many cancers. Nerve imaging is also exploring to reduce iatrogenic injuries. Through different administration routes, these fluorescent imaging agents provided encouraging results in surgical navigation. Meanwhile, designing new cancer-specific fluorescent tracers is expected to be a promising trend to further improve the surgical outcome.

Conclusions

Intraoperative FMI is in a rapid development in China. In-depth understanding of cancer-related molecular mechanisms is necessary to achieve precision surgery. Molecular-targeted fluorescent agents and multi-modal imaging techniques might play crucial roles in the era of precision surgery.

Essential updates 2020/2021: Current topics of simulation and navigation in hepatectomy

With the development of three‐dimensional (3D) simulation software, preoperative simulation technology is almost completely established. The remaining issue is how to recognize anatomy three‐dimensionally. Extended reality is a newly developed technology with several merits for surgical application: no requirement for a sterilized display monitor, better spatial awareness, and the ability to share 3D images among all surgeons. Various technology or devices for intraoperative navigation have also been developed to support the safety and certainty of liver surgery. Consensus recommendations regarding indocyanine green fluorescence were determined in 2021. Extended reality has also been applied to intraoperative navigation, and artificial intelligence (AI) is one of the topics of real‐time navigation. AI might overcome the problem of liver deformity with automatic registration. Including the issues described above, this article focuses on recent advances in simulation and navigation in liver surgery from 2020 to 2021.

Current trends in three-dimensional visualization and real-time navigation as well as robot-assisted technologies in hepatobiliary surgery

With the continuous development of digital medicine, minimally invasive precision and safety have become the primary development trends in hepatobiliary surgery. Due to the specificity and complexity of hepatobiliary surgery, traditional preoperative imaging techniques such as computed tomography and magnetic resonance imaging cannot meet the need for identification of fine anatomical regions. Imaging-based three-dimensional (3D) reconstruction, virtual simulation of surgery and 3D printing optimize the surgical plan through preoperative assessment, improving the controllability and safety of intraoperative operations, and in difficult-to-reach areas of the posterior and superior liver, assistive robots reproduce the surgeon’s natural movements with stable cameras, reducing natural vibrations. Electromagnetic navigation in abdominal surgery solves the problem of conventional surgery still relying on direct visual observation or preoperative image assessment. We summarize and compare these recent trends in digital medical solutions for the future development and refinement of digital medicine in hepatobiliary surgery.

Hybrid Additive Fabrication of a Transparent Liver with Biosimilar Haptic Response for Preoperative Planning

Due to the complexity of liver surgery, the interest in 3D printing is constantly increasing among hepatobiliary surgeons. The aim of this study was to produce a patient-specific transparent life-sized liver model with tissue-like haptic properties by combining additive manufacturing and 3D moulding. A multistep pipeline was adopted to obtain accurate 3D printable models. Semiautomatic segmentation and registration of routine medical imaging using 3D Slicer software allowed to obtain digital objects representing the structures of interest (liver parenchyma, vasculo-biliary branching, and intrahepatic lesion). The virtual models were used as the source data for a hybrid fabrication process based on additive manufacturing using soft resins and casting of tissue-mimicking silicone-based blend into 3D moulds. The model of the haptic liver reproduced with high fidelity the vasculo-biliary branching and the relationship with the intrahepatic lesion embedded into the transparent parenchyma. It offered high-quality haptic perception and a remarkable degree of surgical and anatomical information. Our 3D transparent model with haptic properties can help surgeons understand the spatial changes of intrahepatic structures during surgical manoeuvres, optimising preoperative surgical planning.