Tumor Segmentation in Intraoperative Fluorescence Images Based on Transfer Learning and Convolutional Neural Networks

OBJECTIVE

To propose a transfer learning based method of tumor segmentation in intraoperative fluorescence images, which will assist surgeons to efficiently and accurately identify the boundary of tumors of interest.

METHODS

We employed transfer learning and deep convolutional neural networks (DCNNs) for tumor segmentation. Specifically, we first pre-trained four networks on the ImageNet dataset to extract low-level features. Subsequently, we fine-tuned these networks on two fluorescence image datasets (ABFM and DTHP) separately to enhance the segmentation performance of fluorescence images. Finally, we tested the trained models on the DTHL dataset. The performance of this approach was compared and evaluated against DCNNs trained end-to-end and the traditional level-set method.

RESULTS

The transfer learning-based UNet++ model achieved high segmentation accuracies of 82.17% on the ABFM dataset, 95.61% on the DTHP dataset, and 85.49% on the DTHL test set. For the DTHP dataset, the pre-trained Deeplab v3 + network performed exceptionally well, with a segmentation accuracy of 96.48%. Furthermore, all models achieved segmentation accuracies of over 90% when dealing with the DTHP dataset.

CONCLUSION

To the best of our knowledge, this study explores tumor segmentation on intraoperative fluorescent images for the first time. The results show that compared to traditional methods, deep learning has significant advantages in improving segmentation performance. Transfer learning enables deep learning models to perform better on small-sample fluorescence image data compared to end-to-end training. This discovery provides strong support for surgeons to obtain more reliable and accurate image segmentation results during surgery.

A System for Mixed-Reality Holographic Overlays of Real-Time Rendered 3D-Reconstructed Imaging Using a Video Pass-through Head-Mounted Display-A Pathway to Future Navigation in Chest Wall Surgery

Background: Three-dimensional reconstructions of state-of-the-art high-resolution imaging are progressively being used more for preprocedural assessment in thoracic surgery. It is a promising tool that aims to improve patient-specific treatment planning, for example, for minimally invasive or robotic-assisted lung resections. Increasingly available mixed-reality hardware based on video pass-through technology enables the projection of image data as a hologram onto the patient. We describe the novel method of real-time 3D surgical planning in a mixed-reality setting by presenting three representative cases utilizing volume rendering. Materials: A mixed-reality system was set up using a high-performance workstation running a video pass-through-based head-mounted display. Image data from computer tomography were imported and volume-rendered in real-time to be customized through live editing. The image-based hologram was projected onto the patient, highlighting the regions of interest. Results: Three oncological cases were selected to explore the potentials of the mixed-reality system. Two of them presented large tumor masses in the thoracic cavity, while a third case presented an unclear lesion of the chest wall. We aligned real-time rendered 3D holographic image data onto the patient allowing us to investigate the relationship between anatomical structures and their respective body position. Conclusions: The exploration of holographic overlay has proven to be promising in improving preprocedural surgical planning, particularly for complex oncological tasks in the thoracic surgical field. Further studies on outcome-related surgical planning and navigation should therefore be conducted. Ongoing technological progress of extended reality hardware and intelligent software features will most likely enhance applicability and the range of use in surgical fields within the near future.

Boosting Luminescence Efficiency of Near-Infrared-II Aggregation-Induced Emission Luminogens via a Mash-Up Strategy of π-Extension and Deuteration for Dual-Model Image-Guided Surgery

The simultaneous pursuit of accelerative radiative and restricted nonradiative decay is of tremendous significance to construct high-luminescence-efficiency fluorophores in the second near-infrared wavelength window (NIR-II), which is seriously hindered by the energy gap laws. Herein, a mash-up strategy of π-extension and deuteration is proposed to efficaciously ameliorate the knotty problem. By extending the π-conjugation of the aromatic fragment and introducing an isotope effect to the aggregation-induced emission luminogen (AIEgen), an improved oscillator strength (f), coupled with suppressed deformation and high-frequency oscillation in the excited state, are successively implemented. In this case, a faster rate of radiative decay (kr) and restricted nonradiative decay (knr) are simultaneously achieved. Moreover, the preeminent emissive property of AIEgen in the molecular state could be commendably inherited by the aggregates. The corresponding NIR-II emissive AIEgen-based nanoparticles display high brightness, large Stokes shift, and superior photostability simultaneously, which can be applied for image-guided cancer and sentinel lymph node (SLN) surgery. This work thus provides a rational roadmap to improve the luminescence efficiency of NIR-II fluorophores for biomedical applications.

Rapid brain MRI for image-guided ventricular catheter placement in pediatric patients: protocol and preliminary clinical outcomes

OBJECTIVE

Neuronavigation is a useful adjunct for catheter placement during neurosurgical procedures for hydrocephalus or ventricular access. MRI protocols for navigation are lengthy and require sedation for young children. CT involves ionizing radiation. In this study, the authors introduce the clinical application of a 1-minute rapid MRI sequence that does not require sedation in young children and report their preliminary clinical experience using this technique in their pediatric population.

METHODS

All patients who underwent ventricular catheter placement at a children's hospital using a rapid noncontrast MRI protocol, standard MRI, or head CT from July 2021 to August 2023 were included. Type of procedure, etiology of hydrocephalus, ventricle configuration and size, morphology of ventricles, need for adjunctive intraoperative ultrasound, duration of procedure, accuracy of catheter placement, and need for proximal revision within 90 days were retrospectively recorded and compared across imaging modalities.

RESULTS

Sixty-eight patients underwent 83 procedures: 21 underwent CT navigation, 29 standard MRI, and 33 rapid MRI. Patients who received standard MRI more often had tumor etiology, while those who underwent CT and rapid MRI had posthemorrhagic etiology (χ2 = 13.04, p = 0.042). Intraoperative ultrasound was required for 1 patient in the standard MRI group and 1 patient in the CT group. There was no difference in procedure time across groups (p = 0.831). On multivariable analysis, procedure time differed by procedure type, where external ventricular drain placement and proximal revision were faster (p < 0.001 and p < 0.028, respectively). Proximal revision due to obstruction within 90 days occurred in 3 cases (in the same patient with complex loculated hydrocephalus) in the rapid MRI group and 2 cases in the CT group.

CONCLUSIONS

Although this study was not powered for statistical inference, the authors report on the clinical use of a 1-minute rapid MRI sequence for neuronavigation in hydrocephalus or ventricular access surgery. There were no instances in which intraoperative ultrasound was required as an adjunct for procedures navigated with rapid MRI, and intraoperative time did not differ from that of standard navigation protocols.

Focal therapy with high-intensity focused ultrasound for prostate cancer: 3-year outcomes from a prospective trial

OBJECTIVE

To assess the oncological and functional outcomes of focal high-intensity focused ultrasound (HIFU) in treating localised prostate cancer (PCa), a 3-year prospective study was undertaken using periodic post-ablation saturation biopsies.

PATIENTS AND METHODS

Men with two or fewer lesions of grade group (GG) ≤3 PCa were eligible for participation. Additional criteria included a prostate-specific antigen (PSA) level of ≤15 ng/mL, clinical T1c-T2, and a life expectancy of ≥10 years. The primary endpoint was failure-free survival (FFS), defined as absence of clinically significant PCa (csPCa) in- or out-of-field on protocol-mandated saturation biopsy, no whole-gland or systemic salvage treatment, PCa metastasis, or PCa-related death. Results are reported using two distinct definitions of csPCa: (i) the presence of any GG ≥2 and (ii) any GG ≥3 or core involvement of ≥6 mm. Secondary endpoints were functional patient-reported outcome measures addressing urinary, sexual, and bowel function.

RESULTS

A total of 91 patients were included: six (7%) with GG1 and 85 (93%) with GG ≥2. In all, 83 (91%) underwent at least one follow-up biopsy. Biopsy attendance at 6, 12, and 36 months was 84%, 67%, and 51%, respectively. The FFS at these time points for any GG ≥2 PCa was 79% (95% confidence interval [CI] 80-88%), 57% (95% CI 48-69%) and 44% (95% CI 34-56%), respectively. Using the second definition, FFS were 88% (95% CI 81-95%), 70% (95% CI 61-81%) and 65% (95% CI 55-77%), respectively. The 3-year cancer-specific survival was 100%, and freedom from metastasis was 99%. Magnetic resonance imaging (MRI) (negative predictive value of up to 89%, 95% CI 84-93%) and relative decrease of PSA values (P = 0.4) performed poorly in detecting residual disease. Urinary and bowel assessment returned to baseline questionnaire scores within 3 months. In all, 17 (21%) patients reported meaningful worsening in erectile function. A significant decrease of PCa related anxiety was observed.

CONCLUSIONS

Focal HIFU treatment for localised PCa shows excellent functional outcomes with half of the patients remaining cancer-free after 3 years. Whole-gland treatment was avoided in 81%. Early follow-up biopsies are crucial to change or continue the treatment modality at the right time, while the use of MRI and PSA in detecting PCa recurrence is uncertain.

Are 3D Image Guidance Systems Ready for Use? A Comparative Analysis of 3D Image Guidance Implementations in Minimally Invasive Partial Nephrectomy

Introduction: Three-dimensional image-guided surgical (3D-IGS) systems for minimally invasive partial nephrectomy (MIPN) can potentially improve the efficiency and accuracy of intraoperative anatomical localization and tumor resection. This review seeks to analyze the current state of research regarding 3D-IGS, including the evaluation of clinical outcomes, system functionality, and qualitative insights regarding 3D-IGS's impact on surgical procedures. Methods: We have systematically reviewed the clinical literature pertaining to 3D-IGS deployed for MIPN. For inclusion, studies must produce a patient-specific 3D anatomical model from two-dimensional imaging. Data extracted from the studies include clinical results, registration (alignment of the 3D model to the surgical scene) method used, limitations, and data types reported. A subset of studies was qualitatively analyzed through an inductive coding approach to identify major themes and subthemes across the studies. Results: Twenty-five studies were included in the review. Eight (32%) studies reported clinical results that point to 3D-IGS improving multiple surgical outcomes. Manual registration was the most utilized (48%). Soft tissue deformation was the most cited limitation among the included studies. Many studies reported qualitative statements regarding surgeon accuracy improvement, but quantitative surgeon accuracy data were not reported. During the qualitative analysis, six major themes emerged across the nine applicable studies. They are as follows: 3D-IGS is necessary, 3D-IGS improved surgical outcomes, researcher/surgeon confidence in 3D-IGS system, enhanced surgeon ability/accuracy, anatomical explanation for qualitative assessment, and claims without data or reference to support. Conclusions: Currently, clinical outcomes are the main source of quantitative data available to point to 3D-IGS's efficacy. However, the literature qualitatively suggests the benefit of accurate 3D-IGS for robotic partial nephrectomy.

Stereotactic Navigation-Assisted Laparoscopic Resection of Challenging Low Pelvic Tumors: A Case Series

(1) Introduction: The laparoscopic approach to low pelvic tumors is challenging and hindered by suboptimal tumor visualization and dissection, with possible oncological failure. Stereotactic navigation provides real-time image guidance that may optimize safety, accuracy, and precision when dissecting challenging low pelvic tumors. (2) Methods: Preoperative CT images were acquired with eight skin-fixed fiducials and loaded into a navigation system. A patient tracker was mounted on the bed side. Patient-to-image paired point registration was performed, and an instrument tracker was mounted on a laparoscopic instrument and calibrated for instrument tracking. Surgical operations were performed with real-time stereotactic navigation assistance. (3) Results: Three patients underwent stereotactic navigation surgery. Fiducial registration errors were good to optimal (±1.9, ±3.4, and ±3.4 mm). Lesions were easily identified and targeted with real-time navigation. Surgeries were uneventful. Histopathology examinations identified one retro-rectal schwannoma, one lateral pelvic recurrence from rectal adenocarcinoma, and one advanced anal canal carcinoma. No navigation-related complications, readmissions, or postoperative mortalities were observed. (4) Conclusions: The application of laparoscopic stereotactic navigation surgery to complex low pelvic tumors is feasible and could impact oncological surgical quality by enabling tumor targeting and ensuring resection margins. Further wider series are needed to confirm stereotactic navigation's impact on challenging low pelvic tumors.

Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

Current Trends and Beyond Conventional Approaches: Advancements in Breast Cancer Surgery through Three-Dimensional Imaging, Virtual Reality, Augmented Reality, and the Emerging Metaverse

Breast cancer stands as the most prevalent cancer globally, necessitating comprehensive care. A multidisciplinary approach proves crucial for precise diagnosis and treatment, ultimately leading to effective disease management. While surgical interventions continue to evolve and remain integral for curative treatment, imaging assumes a fundamental role in breast cancer detection. Advanced imaging techniques not only facilitate improved diagnosis but also contribute significantly to the overall enhancement of breast cancer management. This review article aims to provide an overview of innovative technologies such as virtual reality, augmented reality, and three-dimensional imaging, utilized in the medical field to elevate the diagnosis and treatment of breast cancer. Additionally, the article delves into an emerging technology known as the metaverse, still under development. Through the analysis of impactful research and comparison of their findings, this study offers valuable insights into the advantages of each innovative technique. The goal is to provide physicians, surgeons, and radiologists with information on how to enhance breast cancer management.

Ultrasound-Guided Epigastric Hernia Repair in the Pediatric Population: One Institution's Experience and Outcomes

Introduction: Epigastric hernia repair is a common procedure performed on pediatric patients. These hernias have been demonstrated to be readily identified by ultrasound. This manuscript describes and assesses a novel technique in which ultrasound is used to identify and repair the hernias in a minimally invasive manner. Methods: A retrospective chart review evaluates all the ultrasound-guided epigastric hernia repairs done with prolene suture at one institution over 20 months. Operative details and postoperative complications were compared to patients who underwent traditional open epigastric hernia repair at the same institution during the same time frame. Results: Thirty-two pediatric patients underwent epigastric hernia repair between May 2021 and December 2022. Thirteen (41%) underwent the ultrasound-guided technique with prolene suture and using only a meniscus needle and no incision. Nineteen (59%) underwent standard open repair. There were no recurrences or postoperative complications in either group. The average operative time for the ultrasound hernia repair was 24.4 minutes, which was shorter than the average operative time of 33.6 minutes for the open repair (P = .08). In 3 ultrasound cases (23%), an additional epigastric hernia that had not been clinically apparent was identified and simultaneously repaired. Conclusions: Ultrasound-guided epigastria hernia repair is a feasible alternative to traditional open repair. It has a comparable safety and efficacy profile, has a short operative time, and has the advantages of being minimally invasive and having the ability to identify and repair concurrent epigastric hernias.

Semi-automatic standardized analysis method to objectively evaluate near-infrared fluorescent dyes in image-guided surgery

Significance

Near-infrared fluorescence imaging still lacks a standardized, objective method to evaluate fluorescent dye efficacy in oncological surgical applications. This results in difficulties in translation between preclinical to clinical studies with fluorescent dyes and in the reproduction of results between studies, which in turn hampers further clinical translation of novel fluorescent dyes.

Aim

Our aim is to develop and evaluate a semi-automatic standardized method to objectively assess fluorescent signals in resected tissue.

Approach

A standardized imaging procedure was designed and quantitative analysis methods were developed to evaluate non-targeted and tumor-targeted fluorescent dyes. The developed analysis methods included manual selection of region of interest (ROI) on white light images, automated fluorescence signal ROI selection, and automatic quantitative image analysis. The proposed analysis method was then compared with a conventional analysis method, where fluorescence signal ROIs were manually selected on fluorescence images. Dice similarity coefficients and intraclass correlation coefficients were calculated to determine the inter- and intraobserver variabilities of the ROI selections and the determined signal- and tumor-to-background ratios.

Results

The proposed non-targeted fluorescent dyes analysis method showed statistically significantly improved variabilities after application on indocyanine green specimens. For specimens with the targeted dye SGM-101, the variability of the background ROI selection was statistically significantly improved by implementing the proposed method.

Conclusion

Semi-automatic methods for standardized quantitative analysis of fluorescence images were successfully developed and showed promising results to further improve the reproducibility and standardization of clinical studies evaluating fluorescent dyes.

Accuracy of routine external ventricular drain placement following a mixed reality-guided twist-drill craniostomy

OBJECTIVE

The traditional freehand placement of an external ventricular drain (EVD) relies on empirical craniometric landmarks to guide the craniostomy and subsequent passage of the EVD catheter. The diameter and trajectory of the craniostomy physically limit the possible trajectories that can be achieved during the passage of the catheter. In this study, the authors implemented a mixed reality-guided craniostomy procedure to evaluate the benefit of an optimally drilled craniostomy to the accurate placement of the catheter.

METHODS

Optical marker-based tracking using an OptiTrack system was used to register the brain ventricular hologram and drilling guidance for craniostomy using a HoloLens 2 mixed reality headset. A patient-specific 3D-printed skull phantom embedded with intracranial camera sensors was developed to automatically calculate the EVD accuracy for evaluation. User trials consisted of one blind and one mixed reality-assisted craniostomy followed by a routine, unguided EVD catheter placement for each of two different drill bit sizes.

RESULTS

A total of 49 participants were included in the study (mean age 23.4 years, 59.2% female). The mean distance from the catheter target improved from 18.6 ± 12.5 mm to 12.7 ± 11.3 mm (p = 0.0008) using mixed reality guidance for trials with a large drill bit and from 19.3 ± 12.7 mm to 10.1 ± 8.4 mm with a small drill bit (p < 0.0001). Accuracy using mixed reality was improved using a smaller diameter drill bit compared with a larger bit (p = 0.039). Overall, the majority of the participants were positive about the helpfulness of mixed reality guidance and the overall mixed reality experience.

CONCLUSIONS

Appropriate indications and use cases for the application of mixed reality guidance to neurosurgical procedures remain an area of active inquiry. While prior studies have demonstrated the benefit of mixed reality-guided catheter placement using predrilled craniostomies, the authors demonstrate that real-time quantitative and visual feedback of a mixed reality-guided craniostomy procedure can independently improve procedural accuracy and represents an important tool for trainee education and eventual clinical implementation.

The LMIT: Light-mediated minimally-invasive theranostics in oncology

Minimally-invasive diagnosis and therapy have gradually become the trend and research hotspot of current medical applications. The integration of intraoperative diagnosis and treatment is a development important direction for real-time detection, minimally-invasive diagnosis and therapy to reduce mortality and improve the quality of life of patients, so called minimally-invasive theranostics (MIT). Light is an important theranostic tool for the treatment of cancerous tissues. Light-mediated minimally-invasive theranostics (LMIT) is a novel evolutionary technology that integrates diagnosis and therapeutics for the less invasive treatment of diseased tissues. Intelligent theranostics would promote precision surgery based on the optical characterization of cancerous tissues. Furthermore, MIT also requires the assistance of smart medical devices or robots. And, optical multimodality lay a solid foundation for intelligent MIT. In this review, we summarize the important state-of-the-arts of optical MIT or LMIT in oncology. Multimodal optical image-guided intelligent treatment is another focus. Intraoperative imaging and real-time analysis-guided optical treatment are also systemically discussed. Finally, the potential challenges and future perspectives of intelligent optical MIT are discussed.

Modern Image-Guided Surgery: A Narrative Review of Medical Image Processing and Visualization

Medical image analysis forms the basis of image-guided surgery (IGS) and many of its fundamental tasks. Driven by the growing number of medical imaging modalities, the research community of medical imaging has developed methods and achieved functionality breakthroughs. However, with the overwhelming pool of information in the literature, it has become increasingly challenging for researchers to extract context-relevant information for specific applications, especially when many widely used methods exist in a variety of versions optimized for their respective application domains. By being further equipped with sophisticated three-dimensional (3D) medical image visualization and digital reality technology, medical experts could enhance their performance capabilities in IGS by multiple folds. The goal of this narrative review is to organize the key components of IGS in the aspects of medical image processing and visualization with a new perspective and insights. The literature search was conducted using mainstream academic search engines with a combination of keywords relevant to the field up until mid-2022. This survey systemically summarizes the basic, mainstream, and state-of-the-art medical image processing methods as well as how visualization technology like augmented/mixed/virtual reality (AR/MR/VR) are enhancing performance in IGS. Further, we hope that this survey will shed some light on the future of IGS in the face of challenges and opportunities for the research directions of medical image processing and visualization.

Design and Simulate Intracranial Support to Guide Maxillo Surgery: A Study Based on Bioengineering

BACKGROUND

Intraoperative navigation allows for the creation of a real-time relationship between the anatomy imagined during diagnosis/planning and the site of surgical interest. This procedure takes place by identifying and registering trustworthy anatomical markers on planning images and using a point locator during the operation. The locator is calibrated in the workspace by placing a Dynamic Reference Frame (DRF) sensor.

OBJECTIVE

This study aims to calculate the localization accuracy of an electromagnetic locator of neuro-maxillofacial surgery, moving the standard sensor position to a different position more suitable for maxillofacial surgery.

MATERIALS AND METHODS

The upper dental arch was chosen as an alternative fixed point for the positioning of the sensor. The prototype of a bite support device was designed and generated via 3D printing. CT images of a skull phantom with 10 anatomical landmarks were acquired. The testing procedure consisted of 10 measurements for each position of the sensor: precisely 10 measurements with the sensor placed on the forehead and 10 measurements with the sensor placed on the bite support device. It also evaluated the localization error by comparing the two procedures.

RESULTS

The localization error, when the sensor was placed on the bite support device, was lower in the sphere located on the temporal bone. It was the same in the spheres located on the maxillary bone. The test analysis of the data of the new device showed that it is reliable; the tests are reproducible and can be considered as accurate as the traditional ones. In addition, the sensor mounted on this device has proven to be slightly superior in terms of accuracy and accuracy in areas such as the middle third of the face and jaw.

DISCUSSION AND CONCLUSION

The realization of the bite support device allowed the sensor to change position concerning its natural site. This procedure allows us to explore structures, such as the frontal site, which were initially difficult to approach with neuronavigation and improves the approach to midface structures, already studied with neuronavigation. The new calibration, with the position of the sensor on the support device in the same reference points sphere, highlighted the reduction in the location error. We can say that the support proposed in this study lays the foundations for a new navigation approach for patients in maxillofacial surgery, by changing the position of the sensor. It has strong points in improving the localization error for some reference points without determining disadvantages both in the calibration and in the surgical impediment.

A SPECT/NIR Fluorescence Dual-Modality Imaging Agent Composed of Drugs and Hospital Available Isotope for Preoperative Sentinel Lymph Node Mapping and Intraoperative Biopsy

Background

Sentinel lymph node (SLN) mapping-guided biopsy is crucial for cancer staging and treatment. Optical/nuclide dual-modality imaging agents for mapping SLN are ideal for preoperative planning and intraoperative biopsy, which are enabled by penetration-depth unlimited nuclide imaging and dynamic real-time optical imaging, respectively. However, commonly reported dual-modality imaging agents are composed of novel but safety-unproven materials, making their quick clinical translation challenging. Herein, we report a novel nanoparticle composed of facile hospital-available drugs and isotope for single-photon emission computed tomography (SPECT)/near-infrared (NIR) fluorescence imaging to detect SLNs.

Methods

Indocyanine green-human serum albumin (ICG-HSA) nanoparticles (NPs) were synthesized by ICG-induced HSA self-assembly and further 99mTc-labeling via a one-step, facile hospital-available method. After injecting 99mTc-ICG-HSA into the rats' forepaw pads, the rats' draining axillary lymph nodes were visualized by preoperative mapping with SPECT/CT and intraoperative biopsy with NIR fluorescence. The axillary lymph nodes of rats were identified by pathology and fluorescent staining after execution. Additionally, its toxicity testing and comparison with 99mTc-sulfur colloid imaging were also explored.

Results

The study reported a self-assembled 99mTc-ICG-HSA with a high radiochemical yield (85.6 ± 3.8%). Compared with conventional 99mTc-sulfur colloid, 99mTc-ICG-HSA NPs showed faster SLN identification, higher renal clearance, and lower hepatic retention. Furthermore, NIRF imaging allowed for the accurate visualization of the SLN and guided SLN biopsy intraoperatively. Notably, the 99mTc-ICG-HSA NPs were composed of hospital-available drugs and isotope, which are safe for acute toxicity evaluation by a certified institute.

Conclusion

The proposed 99mTc-ICG-HSA NPs are safe and capable of noninvasive SLN identification and biopsy guidance with multi-modal imaging strategies and could be a promising tool for clinically assisted SLN biopsy.

PET/NIR Fluorescence Bimodal Imaging for Targeted Tumor Detection

Cancer is one of the greatest threats to human health due to late diagnosis and incomplete resection. The bimodal probe combines positron emission tomography (PET) imaging for noninvasive whole-body scanning with intraoperative near-infrared fluorescence (NIRF) surgical guidance for preoperative tumor detection, tumor resection during surgery, and postoperative monitoring. We developed a new PET/NIRF bimodal imaging agent, [68Ga]Ga-DOTA-NPC, covalently coupled to DCDSTCY and DOTA via ethylenediamine and radiolabeled with gallium-68, and investigated it in vitro and in vivo. The probe was found to be preferential for colon cancer cells due to the organic anion-transporting polypeptide1B3 (OATP1B3). PET/NIRF imaging allowed us to confirm [68Ga]Ga-DOTA-NPC as a promising probe for tumor detection, as it provides good biosafety and high-contrast tumor accumulation. Orthotopic and subcutaneous colon tumors were successfully resected under real-time NIRF guidance. [68Ga]Ga-DOTA-NPC provides highly sensitive and unlimited tissue-penetrating PET/NIRF imaging, helping to visualize and differentiate tumors from adjacent tissue.

Application of near-infrared fluorescence imaging with indocyanine green in mediastinal surgery

Intraoperative near-infrared (NIR) fluorescence imaging has emerged in recent years and is now used in many surgical procedures. Intraoperative fluorescence imaging can guide surgeons in identifying and localizing specific structures and boundaries, which can facilitate the optimization of surgical procedures. The components of the mediastinum are complex and functionally important, making identifying and locating different structures intraoperatively challenging, and NIR fluorescence imaging has potential clinical value in mediastinal surgery. Here we review the applications of NIR fluorescence imaging technology in mediastinal surgery in recent years.

Positional accuracy during the sequence of static computer-assisted implant surgery in three alveolar ridge morphologies: An in vitro study

PURPOSE

This in vitro study aimed to assess the positional accuracy during the sequence of static computer-assisted implant surgery (sCAIS) according to the anatomical characteristics of the alveolar ridge.

MATERIAL AND METHODS

Maxillary bone models with six single tooth gaps including clinical scenarios of healed alveolar ridge (HR), single-rooted (SRS), and three-rooted socket (TRS) morphologies were used in this study. Positional deviations during implant placement procedures were evaluated after the pilot osteotomy (PD), final osteotomy (FD), and implant placement with respect to the pre-planned implant position by using a software package. ANOVA and post hoc analyses were performed.

RESULTS

A total of 90 implants were included in this study. Higher mean angular, crestal, and apical deviations were found after the PD and FD (3.5 ± 2.4°, 0.7 ± 0.3 mm, and 1.4 ± 0.8 mm versus 3.6 ±2.2°, 0.6 ± 0.3 mm, and 1.2 ± 0.6 mm) compared to IP (2.8 ± 1.6°, 0.7 ± 0.3 mm, and 1.2 ± 0.5 mm, p ≤ 0.004). Implants placed in TRS demonstrated higher mean angular, crestal, and apical deviations (4.0 ± 1.7°, 0.8 ± 0.3 mm, and 1.6 ± 0.5 mm) compared to implants placed in SRS (2.5 ± 1.2°, 0.7 ± 0.3 mm, and 1.1 ± 0.4 mm) or HR (2.0 ± 0.9°, 0.5 ± 0.3 mm, and 0.8 ± 0.4 mm, p < 0.001).

CONCLUSIONS

Positional deviations during sCAIS procedures are initiated with the first implant osteotomy and persist throughout the drilling sequence. However, deviations slightly decreased after implant placement. The alveolar ridge morphology is strongly associated with positional deviations. Higher deviations were observed in three-rooted and single-rooted sockets simulating an immediate approach compared to healed sites simulating a delayed protocol.

Exploring Deep Cervical Compartments in Head and Neck Surgical Oncology through Augmented Reality Vision: A Proof of Concept

BACKGROUND

Virtual surgical planning allows surgeons to meticulously define surgical procedures by creating a digital replica of patients' anatomy. This enables precise preoperative assessment, facilitating the selection of optimal surgical approaches and the customization of treatment plans. In neck surgery, virtual planning has been significantly underreported compared to craniofacial surgery, due to a multitude of factors, including the predominance of soft tissues, the unavailability of intraoperative navigation and the complexity of segmenting such areas. Augmented reality represents the most innovative approach to translate virtual planning for real patients, as it merges the digital world with the surgical field in real time. Surgeons can access patient-specific data directly within their field of view, through dedicated visors. In head and neck surgical oncology, augmented reality systems overlay critical anatomical information onto the surgeon's visual field. This aids in locating and preserving vital structures, such as nerves and blood vessels, during complex procedures. In this paper, the authors examine a series of patients undergoing complex neck surgical oncology procedures with prior virtual surgical planning analysis. For each patient, the surgical plan was imported in Hololens headset to allow for intraoperative augmented reality visualization. The authors discuss the results of this preliminary investigation, tracing the conceptual framework for an increasing AR implementation in complex head and neck surgical oncology procedures.

Surgical navigation for guidewire placement from intraoperative fluoroscopy in orthopaedic surgery

Objective. Surgical guidewires are commonly used in placing fixation implants to stabilize fractures. Accurate positioning of these instruments is challenged by difficulties in 3D reckoning from 2D fluoroscopy. This work aims to enhance the accuracy and reduce exposure times by providing 3D navigation for guidewire placement from as little as two fluoroscopic images.Approach. Our approach combines machine learning-based segmentation with the geometric model of the imager to determine the 3D poses of guidewires. Instrument tips are encoded as individual keypoints, and the segmentation masks are processed to estimate the trajectory. Correspondence between detections in multiple views is established using the pre-calibrated system geometry, and the corresponding features are backprojected to obtain the 3D pose. Guidewire 3D directions were computed using both an analytical and an optimization-based method. The complete approach was evaluated in cadaveric specimens with respect to potential confounding effects from the imaging geometry and radiographic scene clutter due to other instruments.Main results. The detection network identified the guidewire tips within 2.2 mm and guidewire directions within 1.1°, in 2D detector coordinates. Feature correspondence rejected false detections, particularly in images with other instruments, to achieve 83% precision and 90% recall. Estimating the 3D direction via numerical optimization showed added robustness to guidewires aligned with the gantry rotation plane. Guidewire tips and directions were localized in 3D world coordinates with a median accuracy of 1.8 mm and 2.7°, respectively.Significance. The paper reports a new method for automatic 2D detection and 3D localization of guidewires from pairs of fluoroscopic images. Localized guidewires can be virtually overlaid on the patient's pre-operative 3D scan during the intervention. Accurate pose determination for multiple guidewires from two images offers to reduce radiation dose by minimizing the need for repeated imaging and provides quantitative feedback prior to implant placement.

A novel, simple near-infrared thoracoscopic technique by a particular route for locating lung nodules

Background

The localization of pulmonary nodules prior to thoracoscopic surgery remains challenging for thoracic surgeons, especially for those nodules that are not visible or palpable on the lung surface. Our study is a simple and effective minimally invasive method using indocyanine green through a special pathway to locate pulmonary nodules and fluorescence thoracoscopic surgery.

Methods

Thoracoscopic surgery was performed for 18 undiagnosed peripheral non-solid nodules no larger than 2 cm after location. After 0.3 mg/kg indocyanine green was injected through the peripheral vein, the puncture needle was pulled out after it reached approximately 1 cm of the pulmonary parenchyma near the nodules. This was followed by transfer to the operating room. The nodule was initially localized by using a near-infrared thoracoscope to visualize indocyanine green fluorescence. Then, thoracoscopic resection was performed.

Results

Eighteen patients received this special and simple localization method, and underwent near-infrared, image-guided, video-assisted thoracoscopic surgery resection. Median computed tomography (CT) tumor size was 1.2 cm. Median depth from the pleural surface is 1.6 cm (range, 0.1-4.6 cm). The median time of CT-guided intervention was 12 min. The duration of thoracoscopic surgery was 67 min. Indocyanine green fluorescence was clearly identified in 17 of 18 patients (94.4%). The surgical margins were all negative on final pathology. The final diagnoses included 17 primary lung cancers, and 1 benign lung tumor.

Conclusions

CT-guided single puncture of indocyanine green after peripheral intravenous injection is a simple, effective, and safe method to locate the nodule. This offers surgeons the ease of localization through direct indocyanine green fluorescence imaging, and it can be used as an effective alternative to other placement methods of locating pulmonary nodules.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Assessment of Navigated Pedicle Screws From Intraoperative Imaging: A Prospective Study of Accuracy and Agreement

BACKGROUND

Intraoperative (IO) image guidance surgery using 3-dimensional fluoroscopic navigation methods, such as the O-arm system, has improved the accuracy of pedicle screw placement in instrumented spine surgery. IO and postoperative (PO) validation of the implant's correct position from radiological images is a decisive step to ensure patient safety and avoidance of complications related to implant misplacement. In this prospective single-center study, the authors investigated the accuracy and agreement of assessment of pedicle screws from IO O-arm images in comparison to PO computed tomography images. This study aimed to determine whether final evaluation of pedicle screws can safely be conducted from IO images that supersedes the PO computed tomography control.

METHODS

A prospective single-center study was carried out at the Spine Unit in the Department of Orthopedics at Umeå University Hospital between 2019 and 2021. All patients enrolled in the study underwent instrumented thoracolumbar spine surgery using navigation. Imaging data were obtained from IO and PO examinations. Four reviewers-2 attending senior spine surgeons, 1 final year resident in orthopedics, and 1 attending neuroradiologist-classified pedicle screws using the Gertzbein and Robbins classification system. Agreement and accuracy of the reviewers were studied to evaluate the assessment of pedicle screws from IO and PO images.

RESULTS

A total of 70 patients (422 screws) were included in the study. There was high accuracy among surgeons both on IO and PO images (0.96-0.97, 95% CI [0.94-0.99] and 0.97, 95% CI [0.94-0.99], respectively), and the overall agreement between all raters was 92% to 98% (95% CI [0.90, 1.00]). The discrepancy in assessment between optimal (Group 1) and suboptimal (Group 2) screws between IO and PO images was as low as 1% to 1.7%, which indicates that very few suboptimal screws are missed in the assessment of IO images.

CONCLUSIONS

The assessment of navigated pedicle screws using IO images is safe and reliable and may replace the need for further assessment using PO imaging.

LEVEL OF EVIDENCE: 3

Safety assessment of fluorescently labeled anti-EGFR Nanobodies in healthy dogs

Introduction: Surgical resection is one of the main treatment options for several types of cancer, the desired outcome being complete removal of the primary tumor and its local metastases. Any malignant tissue that remains after surgery may lead to relapsing disease, negatively impacting the patient's quality of life and overall survival. Fluorescence imaging in surgical oncology aims to facilitate full resection of solid tumors through the visualization of malignant tissue during surgery, following the administration of a fluorescent contrast agent. An important class of targeting molecules are Nanobodies® (Nbs), small antigen-binding fragments derived from camelid heavy chain only antibodies. When coupled with a fluorophore, Nbs can bind to a specific receptor and demarcate tumor margins through a fluorescence camera, improving the accuracy of surgical intervention. A widely investigated target for fluorescence-guided surgery is the epidermal growth factor receptor (EGFR), which is overexpressed in several types of tumors. Promising results with the fluorescently labeled anti-EGFR Nb 7D12-s775z in murine models motivated a project employing the compound in a pioneering study in dogs with spontaneous cancer. Methods: To determine the safety profile of the study drug, three healthy purpose-bred dogs received an intravenous injection of the tracer at 5.83, 11.66, and 19.47 mg/m2, separated by a 14-day wash-out period. Physical examination and fluorescence imaging were performed at established time points, and the animals were closely monitored between doses. Blood and urine values were analyzed pre- and 24 h post administration. Results: No adverse effects were observed, and blood and urine values stayed within the reference range. Images of the oral mucosa, acquired with a fluorescence imaging device (Fluobeam®), suggest rapid clearance, which was in accordance with previous in vivo studies. Discussion: These are the first results to indicate that 7D12-s775z is well tolerated in dogs and paves the way to conduct clinical trials in canine patients with EGFR-overexpressing spontaneous tumors.

Fluorescence-guided Two-port Robotic Gastrectomy Versus Conventional Laparoscopic Gastrectomy: A Nonrandomized Controlled Trial

Objective

To compare the number of retrieved lymph nodes between conventional laparoscopic gastrectomy (CLG) and robotic gastrectomy integrated with fluorescence guidance and a two-port system (integrated robotic gastrectomy, IRG).

Background

The benefits of robotic surgery over laparoscopic surgery for gastric cancer have not yet been established. Using built-in features of robotic system, further benefit can be provided to the patients with effective lymphadenectomy and enhanced recovery.

Methods

A nonrandomized controlled trial was performed by a single surgeon at single-center, tertiary referral hospital between January 2018 and October 2021. Overall, 140 patients scheduled to undergo minimally invasive subtotal gastrectomy for early gastric cancer were enrolled. The primary endpoint was the number of retrieved lymph nodes. Secondary endpoints were complications, hospital stay, pain score, body image, and operative cost.

Results

This study analyzed 124 patients in the per-protocol group (IRG, 64; CLG, 60). The number of retrieved lymph nodes was higher in the IRG group than those in the CLG group (IRG vs CLG; 42.1 ± 17.9 vs 35.1 ± 14.6, P = 0.019). Moreover, other surgical parameters, such as hospital stay (4.1 ± 1.0 vs 5.2 ± 1.8, P < 0.001) and body image scale (better in 4 of the 10 questions), were significantly better in the IRG than in the CLG.

Conclusions

Robotic surgical procedures integrated with fluorescence guidance and a reduced-port system yielded more retrieved lymph nodes. In addition, the IRG group showed better perioperative surgical outcomes, particularly regarding the length of hospital stay and postoperative body image.

Trial registration

NCT03396354.

Photostable Cascade-Activatable Peptide Self-Assembly on a Cancer Cell Membrane for High-Performance Identification of Human Bladder Cancer

Missed or residual tumor burden results in high risk for bladder cancer relapse. However, existing fluorescent probes cannot meet the clinical needs because of inevitable photobleaching properties. Performance can be improved by maintaining intensive and sustained fluorescence signals via resistance to intraoperative saline flushing and intrinsic fluorescent decay, providing surgeons with sufficiently clear and high-contrast surgical fields, avoiding residual tumors or missed diagnosis. This study designs and synthesizes a photostable cascade-activatable peptide, a target reaction-induced aggregation peptide (TRAP) system, which can construct polypeptide-based nanofibers in situ on the cell membrane to achieve long-term and stable imaging of bladder cancer. The probe has two parts: a target peptide (TP) targets CD44v6 to recognize bladder cancer cells, and a reaction-induced aggregation peptide (RAP) is introduced, which effectively reacts with the TP via a click reaction to enhance the hydrophobicity of the whole molecule, assembling into nanofibers and further nanonetworks. Accordingly, probe retention on the cell membrane is prolonged, and photostability is significantly improved. Finally, the TRAP system is successfully employed in the high-performance identification of human bladder cancer in ex vivo bladder tumor tissues. This cascade-activatable peptide molecular probe based on the TRAP system enables efficient and stable imaging of bladder cancer.

How Much Is Enough? A Surgical Perspective on Imaging Modalities to Estimate Function and Volume of the Future Liver Remnant before Hepatic Resection

Liver resection is the first curative option for most hepatic primary and secondary malignancies. However, post-hepatectomy liver failure (PHLF) still represents a non-negligible postoperative complication, embodying the most frequent cause of hepatic-related mortality. In the absence of a specific treatment, the most effective way to deal with PHLF is its prevention through a careful preoperative assessment of future liver remnant (FLR) volume and function. Apart from the clinical score and classical criteria to define the safe limit of resectability, new imaging modalities have shown their ability to assist surgeons in planning the best operative strategy with a precise estimation of the FLR amount. New technologies leading to liver and tumor 3D reconstruction may guide the surgeon along the best resection planes combining the least liver parenchymal sacrifice with oncological appropriateness. Integration with imaging modalities, such as hepatobiliary scintigraphy, capable of estimating total and regional liver function, may bring about a decrease in postoperative complications. Magnetic resonance imaging with hepatobiliary contrast seems to be predominant since it simultaneously integrates hepatic function and volume information along with a precise characterization of the target malignancy.

Intraoperative Imaging in Hepatopancreatobiliary Surgery

Hepatopancreatobiliary surgery belongs to one of the most complex fields of general surgery. An intricate and vital anatomy is accompanied by difficult distinctions of tumors from fibrosis and inflammation; the identification of precise tumor margins; or small, even disappearing, lesions on currently available imaging. The routine implementation of ultrasound use shifted the possibilities in the operating room, yet more precision is necessary to achieve negative resection margins. Modalities utilizing fluorescent-compatible dyes have proven their role in hepatopancreatobiliary surgery, although this is not yet a routine practice, as there are many limitations. Modalities, such as photoacoustic imaging or 3D holograms, are emerging but are mostly limited to preclinical settings. There is a need to identify and develop an ideal contrast agent capable of differentiating between malignant and benign tissue and to report on the prognostic benefits of implemented intraoperative imaging in order to navigate clinical translation. This review focuses on existing and developing imaging modalities for intraoperative use, tailored to the needs of hepatopancreatobiliary cancers. We will also cover the application of these imaging techniques to theranostics to achieve combined diagnostic and therapeutic potential.

Near-Infrared Persistent Luminescence Nanoprobe for Ultrasensitive Image-Guided Tumor Resection

Near-infrared (NIR) fluorescence imaging poses significant superiority over traditional medical imaging for tumor resection, thus having attracted widely attention. However, for tiny tumor residues, it requires relative high sensitivity to determine. Here, based on persistent luminescence nanoparticles (PLNPs), an ultrasensitive nanoprobe with extraordinary tumor imaging result is developed to guide surgical removal. Persistent luminescence (PersL) is quenched in normal tissue by the outer layer of MnO2 , and is recovered due to the degradation of MnO2 in tumor microenvironment, significantly improving the sensitivity of tumor imaging. Combined with the absence of background fluorescence in imaging of PLNPs, ultrahigh sensitivity is achieved. In orthotopic breast cancer model, the intraoperative tumor-to-normal tissue (T/NT) signal ratio of the nanoprobe is 58.8, about 9 times that of downconversion nanoparticles. The T/NT ratio of residual tumor (<2 mm) remains 12.4, considerably high to distinguish tumor tissue from normal tissue. Besides, multiple-microtumor, 4T1 liver-implanted tumor and lung metastasis models are built to prove that this ultrasensitive nanoprobe is feasible to recognize tumor residues. Notably, PersL imaging takes only 1.5 min, appropriate to be applied for intraoperative imaging. Overall, an ultrasensitive and convenient imaging for recognizing residual tumor tissue is introduced, holding promise for complete surgical removal.

The Value of Indocyanine Green Image-Guided Surgery in Patients with Primary Liver Tumors and Liver Metastases

INTRODUCTION

Successful R0 resection is crucial for the survival of patients with primary liver cancer (PLC) or liver metastases. Up to date, surgical resection lacks a sensitive, real-time intraoperative imaging modality to determine R0 resection. Real-time intraoperative visualization with near-infrared light fluorescence (NIRF) using indocyanine green (ICG) may have the potential to meet this demand. This study evaluates the value of ICG visualization in PLC and liver metastases surgery regarding R0 resection rates.

MATERIALS AND METHODS

Patients with PLC or liver metastases were included in this prospective cohort study. ICG 10 mg was administered intravenously 24 h before surgery. Real-time intraoperative NIRF visualization was created with the Spectrum^TM fluorescence imaging camera system. First, all liver segments were inspected with the fluorescence imaging system and intraoperative ultrasound for identification of the known tumor, as well as additional lesions, and were compared to preoperative MRI images. PLC, liver metastases, and additional lesions were then resected according to oncological principles. In all resected specimens, the resection margins were analyzed with the fluorescence imaging system for ICG-positive spots immediately after resection. Histology of additional detected lesions, as well as ICG fluorescence compared to histological resection margins, were assessed.

RESULTS

Of the 66 included patients, median age was 65.5 years (IQR 58.7-73.9), 27 (40.9%) were female, and 18 (27.3%) were operated on laparoscopically. Additional ICG-positive lesions were detected in 23 (35.4%) patients, of which 9 (29%) were malignant. In patients with no fluorescent signal at the resection margin, R0 rate was 93.9%, R1 rate was 6.1%, and R2 rate was 0% compared to an ICG-positive resection margin with an R0 rate of 64.3%, R1 rate of 21.4%, and R2 rate of 14.3% (p = 0.005). One- and two-year overall survival rates were 95.2% and 88.4%, respectively.

CONCLUSION

The presented study provides significant evidence that ICG NIRF guidance helps to identify R0 resection intraoperatively. This offers true potential to verify radical resection and improve patient outcomes. Furthermore, implementation of NIRF-guided imaging in liver tumor surgery allows us to detect a considerable amount of additional malignant lesions.

Accuracy assessment of dynamic navigation during implant placement: A systematic review and meta-analysis of clinical studies in the last 10 years

OBJECTIVES

To evaluate the accuracy of dynamic computer-aided implant surgery (dCAIS) and compare it with static computer-aided implant surgery (sCAIS) and freehand implant placement (FH) in partially or fully edentulous patients.

DATA

Studies that analyzed the accuracy of dynamic computer-assisted implant surgery in partially or fully edentulous patients.

SOURCES

This meta-analysis included studies published in English and Mandarin Chinese from January 2013 to February 2023 from MEDLINE/PubMed, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CNKI (China National Knowledge Infrastructure).

STUDY SELECTION

Only clinical studies were included. Accuracy was the primary outcome. Seventeen studies met the inclusion criteria. A total of 2,025 implants were analyzed. Meta-regression was conducted to compare the six different navigation systems. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) assessment was adopted as a collective grading of the evidence.

CONCLUSIONS

Dynamic navigation is a clinically reliable method for implant placement. Significantly lower angular deviation was observed for dCAIS compared to both sCAIS and FH, while significantly lower global platform and apex deviations were displayed between dCAIS and FH. Overall, dynamic navigation allowed for higher accuracy compared to both sCAIS and FH in a clinical setting; however, additional large sample RCT studies should be conducted, and patient-reported outcome measures (PROMs) reported.

CLINICAL SIGNIFICANCE

This systematic review analyzed the accuracy of dynamic computer-assisted implant surgery in partially or fully edentulous patients compared with static navigation. The results demonstrated that dynamic navigation could decrease implant placement deviations in two accuracy parameters, global apex and angular deviations.

Image-Guided Intraoperative Assessment of Surgical Margins in Oral Cavity Squamous Cell Cancer: A Diagnostic Test Accuracy Review

(1) Background: The assessment of resection margins during surgery of oral cavity squamous cell cancer (OCSCC) dramatically impacts the prognosis of the patient as well as the need for adjuvant treatment in the future. Currently there is an unmet need to improve OCSCC surgical margins which appear to be involved in around 45% cases. Intraoperative imaging techniques, magnetic resonance imaging (MRI) and intraoral ultrasound (ioUS), have emerged as promising tools in guiding surgical resection, although the number of studies available on this subject is still low. The aim of this diagnostic test accuracy (DTA) review is to investigate the accuracy of intraoperative imaging in the assessment of OCSCC margins. (2) Methods: By using the Cochrane-supported platform Review Manager version 5.4, a systematic search was performed on the online databases MEDLINE-EMBASE-CENTRAL using the keywords "oral cavity cancer, squamous cell carcinoma, tongue cancer, surgical margins, magnetic resonance imaging, intraoperative, intra-oral ultrasound". (3) Results: Ten papers were identified for full-text analysis. The negative predictive value (cutoff < 5 mm) for ioUS ranged from 0.55 to 0.91, that of MRI ranged from 0.5 to 0.91; accuracy analysis performed on four selected studies showed a sensitivity ranging from 0.07 to 0.75 and specificity ranging from 0.81 to 1. Image guidance allowed for a mean improvement in free margin resection of 35%. (4) Conclusions: IoUS shows comparable accuracy to that of ex vivo MRI for the assessment of close and involved surgical margins, and should be preferred as the more affordable and reproducible technique. Both techniques showed higher diagnostic yield if applied to early OCSCC (T1-T2 stages), and when histology is favorable.

Quantification of Indocyanine Green Fluorescence Imaging in General, Visceral and Transplant Surgery

Near-infrared (NIR) imaging with indocyanine green (ICG) has proven to be useful in general, visceral, and transplant surgery. However, most studies have performed only qualitative assessments. Therefore, a systematic overview of all studies performing quantitative indocyanine green evaluation in general, visceral, and transplant surgeries should be conducted. Free term and medical subject heading (MeSH) term searches were performed in the Medline and Cochrane databases until October 2022. The main categories of ICG quantification were esophageal surgery (24.6%), reconstructive surgery (24.6%), and colorectal surgery (21.3%). Concordantly, anastomotic leak (41%) was the main endpoint, followed by the assessment of flap perfusion (23%) and the identification of structures and organs (14.8%). Most studies examined open surgery (67.6%) or laparoscopic surgery (23.1%). The analysis was mainly carried out using manufacturer software (44.3%) and open-source software (15.6%). The most frequently analyzed parameter was intensity over time for blood flow assessment, followed by intensity alone or intensity-to-background ratios for structure and organ identification. Intraoperative ICG quantification could become more important with the increasing impact of robotic surgery and machine learning algorithms for image and video analysis.

Theoretical error analysis of spotlight-based instrument localization for retinal surgery

Retinal surgery is widely considered to be a complicated and challenging task even for specialists. Image-guided robot-assisted intervention is among the novel and promising solutions that may enhance human capabilities therein. In this paper, we demonstrate the possibility of using spotlights for 5D guidance of a microsurgical instrument. The theoretical basis of the localization for the instrument based on the projection of a single spotlight is analyzed to deduce the position and orientation of the spotlight source. The usage of multiple spotlights is also proposed to check the possibility of further improvements for the performance boundaries. The proposed method is verified within a high-fidelity simulation environment using the 3D creation suite Blender. Experimental results show that the average positioning error is 0.029 mm using a single spotlight and 0.025 mm with three spotlights, respectively, while the rotational errors are 0.124 and 0.101, which shows the application to be promising in instrument localization for retinal surgery.

Evaluation of a calibration rig for stereo laparoscopes

BACKGROUND

Accurate camera and hand-eye calibration are essential to ensure high-quality results in image-guided surgery applications. The process must also be able to be undertaken by a nonexpert user in a surgical setting.

PURPOSE

This work seeks to identify a suitable method for tracked stereo laparoscope calibration within theater.

METHODS

A custom calibration rig, to enable rapid calibration in a surgical setting, was designed. The rig was compared against freehand calibration. Stereo reprojection, stereo reconstruction, tracked stereo reprojection, and tracked stereo reconstruction error metrics were used to evaluate calibration quality.

RESULTS

Use of the calibration rig reduced mean errors: reprojection (1.47 mm [SD 0.13] vs. 3.14 mm [SD 2.11], p-value 1e-8), reconstruction (1.37 px [SD 0.10] vs. 10.10 px [SD 4.54], p-value 6e-7), and tracked reconstruction (1.38 mm [SD 0.10] vs. 12.64 mm [SD 4.34], p-value 1e-6) compared with freehand calibration. The use of a ChArUco pattern yielded slightly lower reprojection errors, while a dot grid produced lower reconstruction errors and was more robust under strong global illumination.

CONCLUSION

The use of the calibration rig results in a statistically significant decrease in calibration error metrics, versus freehand calibration, and represents the preferred approach for use in the operating theater.

Detection of Tumour-Targeted IRDye800CW Tracer with Commercially Available Laparoscopic Surgical Systems

(1) Introduction: Near-infrared fluorescence (NIRF) combined with tumour-targeted tracers, such as bevacizumab-800CW, could aid surgical decision-making. This study explored the use of IRDye800CW, conjugated to bevacizumab, with four commercially available NIRF laparoscopes optimised for indocyanine green (ICG). (2) Methods: A (lymph node) phantom was made from a calibration device for NIRF and tissue-mimicking material. Serial dilutions of bevacizumab-800CW were made and ICG functioned as a reference. System settings, working distance, and thickness of tissue-mimicking material were varied to assess visibility of the fluorescence signal and tissue penetration. Tests were performed with four laparoscopes: VISERA ELITE II, Olympus; IMAGE1 S™ 4U Rubina, KARL STORZ; ENDOCAM Logic 4K platform, Richard Wolf; da Vinci Xi, Intuitive Surgical. (3) Results: The lowest visible bevacizumab-800CW concentration ranged between 13-850 nM (8-512 times diluted stock solution) for all laparoscopes, but the tracer was not visible through 0.8 cm of tissue in all systems. In contrast, ICG was still visible at a concentration of 0.4 nM (16,384 times diluted) and through 1.6-2.4 cm of tissue. Visibility and tissue penetration generally improved with a reduced working distance and manually adjusted system settings. (4) Conclusion: Depending on the application, bevacizumab-800CW might be sufficiently visible with current laparoscopes, but optimisation would widen applicability of tumour-targeted IRDye800CW tracers.

Simultaneous, Multi-Channel, Near-Infrared Fluorescence Visualization of Mesenteric Lymph Nodes Using Indocyanine Green and Methylene Blue: A Demonstration in a Porcine Model

Near-infrared fluorescence (NIRF) image-guided surgery is a useful tool that can help reduce perioperative complications and improve tissue recognition. Indocyanine green (ICG) dye is the most frequently used in clinical studies. ICG NIRF imaging has been used for lymph node identification. However, there are still many challenges in lymph node identification by ICG. There is increasing evidence that methylene blue (MB), another clinically applicable fluorescent dye, can also be useful in the intraoperative fluorescence-guided identification of structures and tissues. We hypothesized that MB NIRF imaging could be used for lymph node identification. The aim of this study was to evaluate the feasibility of intraoperative lymph node fluorescence detection using intravenously (IV) administered MB and compare it to ICG via a camera that has two dedicated near-infrared (NIR) channels. Three pigs were used in this study. ICG (0.2 mg/kg) was administered via a peripheral venous catheter followed by immediate administration of MB (0.25 mg/kg). NIRF images were acquired as video recordings at different time points (every 10 min) over an hour using the QUEST SPECTRUM^® 3 system (Quest Medical Imaging, Middenmeer, The Netherlands), which has two dedicated NIR channels for simultaneous intraoperative fluorescence guidance. The 800 nm channel was used to capture ICG fluorescence and the 700 nm channel was used for MB. The target (lymph nodes and small bowel) and the background (vessels-free field of the mesentery) were highlighted as the regions of interest (ROIs), and corresponding fluorescence intensities (FI) from these ROIs were measured. The target-to-background ratio (TBR) was then computed as the mean FI of the target minus the mean FI of the background divided by the mean FI of the background. In all included animals, a clear identification of lymph nodes was achieved at all time points. The mean TBR of ICG in lymph nodes and small bowel was 4.57 ± 1.00 and 4.37 ± 1.70, respectively for the overall experimental time. Regarding MB, the mean TBR in lymph nodes and small bowel was 4.60 ± 0.92 and 3.27 ± 0.62, respectively. The Mann-Whitney U test of the lymph node TBR/small bowel TBR showed that the TBR ratio of MB was statistically significantly higher than ICG. The fluorescence optical imaging technology used allows for double-wavelength assessment. This feasibility study proves that lymph nodes can be discriminated using two different fluorophores (MB and ICG) with different wavelengths. The results suggest that MB has a promising potential to be used to detect lymphatic tissue during image-guided surgery. Further preclinical trials are needed before clinical translation.

Accuracy of dental implant placement using static versus dynamic computer-assisted implant surgery: An in vitro study: Accuracy of static vs. dynamic CAIS

OBJECTIVES

This in-vitro study compared the accuracy of implant placement using static versus dynamic computer-assisted implant surgery (CAIS) at two implant sites.

METHODS

Partially edentulous maxillary models were 3D-printed, and two implants (Straumann TL RN4.1 × 10mm) were inserted in FDI positions 15 and 16 per model using two CAIS approaches (10 models per approach). A three-dimensional (3D) reconstruction tool was used for implant planning, surgical guide design, and measuring implant positioning accuracy. In static CAIS, the implants were placed with 3D-printed surgical guides (n=20); in dynamic CAIS, real-time navigation was performed (n=20). Primary outcomes were defined as coronal and apical global deviation as well as angular deviations and deviation comparison between implants placed at positions 15 and 16; the secondary outcome was the bi-directional deviation in mesial-distal, buccal-palatal, and apical-coronal direction.

RESULTS

The mean±SD 3D-deviation at implant platform and apex levels for static CAIS in position 15 was 0.81±0.31mm, 1.41±0.37mm, and in position 16 was 0.67±0.31mm, 1.07±0.32mm.

PRIMARY OUTCOMES

buccal-palatal deviation is higher using static CAIS, and mesial-distal deviation is higher in dynamic CAIS. In position 15, mesial-distal deviation at the apex and the platform were lower in static approaches than in dynamic ones. In implant position 16, buccal-palatal deviation at the apex was lower in the dynamic group than with static ones.

SECONDARY OUTCOMES

for bi-directional analysis, buccal-palatal deviation at the platform (P=0.0028) and mesial-distal deviation at the apex (P=0.0056) were significantly lower in molar sites using static CAIS. Mesial-distal deviation at the apex (P=0.0246) revealed significantly lower values in position 16 following dynamic CAIS.

CONCLUSIONS

Both static and dynamic CAIS resulted in accurate implant placement. However, dynamic CAIS exhibited higher deviation in the mesial direction in an in-vitro setting. In addition, the implant site affects the accuracy of both CAIS approaches.

CLINICAL SIGNIFICANCE

Static CAIS demonstrates the highest accuracy for guided implant placement today.

Combining physics-based models with deep learning image synthesis and uncertainty in intraoperative cone-beam CT of the brain

BACKGROUND

Image-guided neurosurgery requires high localization and registration accuracy to enable effective treatment and avoid complications. However, accurate neuronavigation based on preoperative magnetic resonance (MR) or computed tomography (CT) images is challenged by brain deformation occurring during the surgical intervention.

PURPOSE

To facilitate intraoperative visualization of brain tissues and deformable registration with preoperative images, a 3D deep learning (DL) reconstruction framework (termed DL-Recon) was proposed for improved intraoperative cone-beam CT (CBCT) image quality.

METHODS

The DL-Recon framework combines physics-based models with deep learning CT synthesis and leverages uncertainty information to promote robustness to unseen features. A 3D generative adversarial network (GAN) with a conditional loss function modulated by aleatoric uncertainty was developed for CBCT-to-CT synthesis. Epistemic uncertainty of the synthesis model was estimated via Monte Carlo (MC) dropout. Using spatially varying weights derived from epistemic uncertainty, the DL-Recon image combines the synthetic CT with an artifact-corrected filtered back-projection (FBP) reconstruction. In regions of high epistemic uncertainty, DL-Recon includes greater contribution from the FBP image. Twenty paired real CT and simulated CBCT images of the head were used for network training and validation, and experiments evaluated the performance of DL-Recon on CBCT images containing simulated and real brain lesions not present in the training data. Performance among learning- and physics-based methods was quantified in terms of structural similarity (SSIM) of the resulting image to diagnostic CT and Dice similarity metric (DSC) in lesion segmentation compared to ground truth. A pilot study was conducted involving seven subjects with CBCT images acquired during neurosurgery to assess the feasibility of DL-Recon in clinical data.

RESULTS

CBCT images reconstructed via FBP with physics-based corrections exhibited the usual challenges to soft-tissue contrast resolution due to image non-uniformity, noise, and residual artifacts. GAN synthesis improved image uniformity and soft-tissue visibility but was subject to error in the shape and contrast of simulated lesions that were unseen in training. Incorporation of aleatoric uncertainty in synthesis loss improved estimation of epistemic uncertainty, with variable brain structures and unseen lesions exhibiting higher epistemic uncertainty. The DL-Recon approach mitigated synthesis errors while maintaining improvement in image quality, yielding 15%-22% increase in SSIM (image appearance compared to diagnostic CT) and up to 25% increase in DSC in lesion segmentation compared to FBP. Clear gains in visual image quality were also observed in real brain lesions and in clinical CBCT images.

CONCLUSIONS

DL-Recon leveraged uncertainty estimation to combine the strengths of DL and physics-based reconstruction and demonstrated substantial improvements in the accuracy and quality of intraoperative CBCT. The improved soft-tissue contrast resolution could facilitate visualization of brain structures and support deformable registration with preoperative images, further extending the utility of intraoperative CBCT in image-guided neurosurgery.

Ultrasound-Guided Enteropexy for Repair of Ostomy Prolapse

Background: Enterostomies provide fecal diversion for numerous conditions, but anatomical complications-prolapse, stricture, and retraction-occur in up to 25%. Given up to 76% of these complications require surgical intervention, effective minimally invasive repair techniques for their management are needed. This article describes a new technique for prolapse repair utilizing image-guided surgery for incisionless repair of ostomy prolapse. Methods: To perform the procedure, the prolapsed bowel is reduced and evaluated for feasibility for ultrasound repair. Under direct ultrasound guidance sutures are used to pexy the bowel loop to the overlying fascia. Sutures are tied with knots and sutures buried below the skin to securely tack the bowel to the abdominal wall. Results: Four patients aged 2-10 years underwent ultrasound-guided enteropexy for repair of major prolapse of an end ileostomy (2 patients), loop colostomy, and end colostomy. All patients remained free of major prolapse for 3-10 months after the procedure, 2 of whom have progressed to ostomy takedown without complications. Conclusions: Ultrasound-guided enteropexy is a noninvasive effective way to manage ostomy prolapse.

Ultrasound-guided resection for squamous cell carcinoma of the buccal mucosa: A feasibility study

BACKGROUND

Image-guided surgery could help obtain clear (≥5.0 mm) resection margins. This feasibility study investigated ultrasound-guided resection accuracy of buccal mucosa squamous cell carcinoma (BMSCC).

METHODS

MRI and ultrasound measurements of tumor thickness were compared to histology in 13 BMSCC-patients. Ultrasound measured margins (at five locations) on the specimen were compared to the corresponding histological margins.

RESULTS

Accuracy of in- and ex-vivo ultrasound (mean deviation from histology: 1.6 mm) for measuring tumor thickness was comparable to MRI (mean deviation from histology: 2.6 mm). The sensitivity to detect clear margins using ex-vivo ultrasound was low (48%). If an ex-vivo ultrasound cutoff of ≥7.5 mm would be used, the sensitivity would increase to 86%.

CONCLUSIONS

Ultrasound-guided resection of BMSCC's is feasible. In- and ex-vivo ultrasound measure tumor thickness in BMSCC accurately. We recommend ≥7.5 mm resection margins on ex-vivo ultrasound to obtain histological clear margins. Additional research is required to establish the effect of 7.5 mm ultrasound cutoff.

A Dual Function Antibody Conjugate Enabled Photoimmunotherapy Complements Fluorescence and Photoacoustic Imaging of Head and Neck Cancer Spheroids

Several molecular-targeted imaging and therapeutic agents are in clinical trials for image-guided surgery and photoimmunotherapy (PIT) of head and neck cancers. In this context, we have previously reported the development, characterization, and specificity of a dual function antibody conjugate (DFAC) for multi-modal imaging and photoimmunotherapy (PIT) of EGFR over-expressing cancer cells. The DFAC reported previously and used in the present study, comprises of an EGFR targeted antibody - Cetuximab conjugated to Benzoporphyrin derivative (BPD) for fluorescence imaging and PIT, and a Si-centered naphthalocyanine dye for photoacoustic imaging. We report here the evaluation and performance of DFAC in detecting microscopic cancer spheroids by fluorescence and photoacoustic imaging along with their treatment by PIT. We demonstrate that while fluorescence imaging can detect spheroids with volumes greater than 0.049 mm3, photoacoustic imaging-based detection was possible even for the smallest spheroids (0.01 mm3), developed in the study. When subjected to PIT, the spheroids showed a dose-dependent response with smaller spheroids (0.01 and 0.018 mm3) showing a complete response with no recurrence when treated with 100 J/cm2. Together our results demonstrate the complementary imaging and treatment capacity of DFAC. This potentially enables fluorescence imaging to assess tumor presence on a macroscopic scale followed by photoacoustic imaging for delineating tumor margins guiding surgical resection and elimination of any residual microscopic disease by PIT, in a single intra-operative setting.

Dynamic Changes in Microvascular Density Can Predict Viable and Non-Viable Areas in High-Risk Neuroblastoma

Despite aggressive treatments, the prognosis of high-risk NB remains poor. Surgical oncology needs innovative intraoperative devices to help surgeons discriminate malignant tissue from necrotic and surrounding healthy tissues. Changes within the tumor vasculature could be used intraoperatively as a diagnostic tool to guide surgical resection. Here, we retrospectively analyzed the mean vascular density (MVD) of different NB subtypes at diagnosis and after induction chemotherapy using scanned histological samples. One patient was prospectively enrolled, and an ex vivo photoacoustic imaging (PAI) scan was performed on two representative sections to assess its capacity to discriminate different tumor regions. We found that post-chemotherapy, viable areas of differentiating NBs and ganglioneuroblastomas are associated with higher MVD compared to poorly differentiated NBs. Early necrotic regions showed higher MVD than late necrotic and viable regions. Finally, calcified areas showed significantly lower MVD than any other histological component. The acquired PAI images showed a good high-resolution ex vivo 3D delineation of NB margins. Overall, these results suggest that a high-definition preclinical imaging device such as PAI could potentially be exploited to guide surgical resection by identifying different vasculature signatures.

Development of an ultrafast brain MR neuronavigation protocol for ventricular shunt placement

OBJECTIVE

Advancements in MRI technology have provided improved ways to acquire imaging data and to more seamlessly incorporate MRI into modern pediatric surgical practice. One such situation is image-guided navigation for pediatric neurosurgical procedures, including intracranial catheter placement. Image-guided surgery (IGS) requires acquisition of CT or MR images, but the former carries the risk of ionizing radiation and the latter is associated with long scan times and often requires pediatric patients to be sedated. The objective of this project was to circumvent the use of CT and standard-sequence MRI in ventricular neuronavigation by investigating the use of fast MR sequences on the basis of 3 criteria: scan duration comparable to that of CT acquisition, visualization of ventricular morphology, and image registration with surface renderings comparable to standard of care. The aim of this work was to report image development, implementation, and results of registration accuracy testing in healthy subjects.

METHODS

The authors formulated 11 candidate MR sequences on the basis of the standard IGS protocol, and various scan parameters were modified, such as k-space readout direction, partial k-space acquisition, sparse sampling of k-space (i.e., compressed sensing), in-plane spatial resolution, and slice thickness. To evaluate registration accuracy, the authors calculated target registration error (TRE). A candidate sequence was selected for further evaluation in 10 healthy subjects.

RESULTS

The authors identified a candidate imaging protocol, termed presurgical imaging with compressed sensing for time optimization (PICO). Acquisition of the PICO protocol takes 25 seconds. The authors demonstrated noninferior TRE for PICO (3.00 ± 0.19 mm) in comparison with the default MRI neuronavigation protocol (3.35 ± 0.20 mm, p = 0.20).

CONCLUSIONS

The developed and tested sequence of this work allowed accurate intraoperative image registration and provided sufficient parenchymal contrast for visualization of ventricular anatomy. Further investigations will evaluate use of the PICO protocol as a substitute for CT and conventional MRI protocols in ventricular neuronavigation.

[ICG technologies in surgical treatment of benign diseases in gynecology]

ICG (indocyanine green) angiography is a method of visualizing blood flow and tissue perfusion based on intravenous administration of ICG and assessment of vascular distribution through an infrared fluorescence camera. Since the advent of ICG as a near-infrared fluorophore, fluorescence imaging has become an important tool in many areas of surgery. Several options for ICG angiography have been recently proposed in surgical gynecology. The authors describe application of ICG including assessment of myometrial and endometrial perfusion in myomectomy or resection of adenomyosis, tissue perfusion in surgical treatment of endometriosis, blood flow in hard-to-reach places in laparoscopic procedures and reconstructive surgery. ICG was useful in laparoscopic management of some benign gynecological diseases. In particular, this technology can improve treatment of endometriosis, especially deep infiltrative endometriosis, benign neoplasms.

The primary application of indocyanine green fluorescence imaging in surgical oncology

Background

Indocyanine green (ICG) is a nontoxic, albumin-bound, liver-metabolized fluorescent iodide dye that has been widely utilized in clinical applications since the mid-1950s. However, after the 1970s, in-depth research on the fluorescence properties of ICG greatly expanded its application in the medical field.

Methods

In our mini-review, we searched the relevant literature on common oncology surgeries from PubMed, including lung cancer, breast cancer, gastric cancer, colorectal cancer, liver cancer, and pituitary tumors, using keywords such as indocyanine green, fluorescence imaging technology, and near-infrared fluorescence imaging. In addition, the application of targeted ICG photothermal technology in tumor therapy is briefly mentioned.

Results

In this mini-review, we analyzed studies on ICG fluorescence imaging in common surgical oncology and offered a thorough analysis of each form of cancer or tumor.

Conclusion

ICG has demonstrated significant potential in the detection and treatment of tumors in current clinical practice, although many applications are still in the preliminary stages, and multicenter studies are still required to more precisely define its indications, effectiveness, and safety.

Patient-specific virtual three-dimensional surgical navigation for gastric cancer surgery: A prospective study for preoperative planning and intraoperative guidance

Introduction

Abdominal computed tomography (CT) can accurately demonstrate organs and vascular structures around the stomach, and its potential role for image guidance is becoming increasingly established. However, solely using two-dimensional CT images to identify critical anatomical structures is undeniably challenging and not surgeon-friendly. To validate the feasibility of a patient-specific 3-D surgical navigation system for preoperative planning and intraoperative guidance during robotic gastric cancer surgery.

Materials and methods

A prospective single-arm open-label observational study was conducted. Thirty participants underwent robotic distal gastrectomy for gastric cancer using a virtual surgical navigation system that provides patient-specific 3-D anatomical information with a pneumoperitoneum model using preoperative CT-angiography. Turnaround time and the accuracy of detecting vascular anatomy with its variations were measured, and perioperative outcomes were compared with a control group after propensity-score matching during the same study period.

Results

Among 36 registered patients, 6 were excluded from the study. Patient-specific 3-D anatomy reconstruction was successfully implemented without any problems in all 30 patients using preoperative CT. All vessels encountered during gastric cancer surgery were successfully reconstructed, and all vascular origins and variations were identical to operative findings. The operative data and short-term outcomes between the experimental and control group were comparable. The experimental group showed shorter anesthesia time (218.6 min vs. 230.3 min; P=0.299), operative time (177.1 min vs. 193.9 min; P=0.137), and console time (129.3 min vs. 147.4 min; P=0.101) than the control group, although the differences were not statistically significant.

Conclusions

Patient-specific 3-D surgical navigation system for robotic gastrectomy for gastric cancer is clinically feasible and applicable with an acceptable turnaround time. This system enables patient-specific preoperative planning and intraoperative navigation by visualizing all the anatomy required for gastrectomy in 3-D models without any error.

Clinical trial registration

Clinicaltrials.gov, identifier NCT05039333.

Evolving an Ultra-Sensitive Near-Infrared β-Galactosidase Fluorescent Probe for Breast Cancer Imaging and Surgical Resection Navigation

Early diagnosis and therapy are clinically crucial in decreasing mortality from breast carcinoma. However, the existing probes have difficulty in accurately identifying the margins and contours of breast carcinoma due to poor sensitivity and specificity. There is an urgent need to develop high-sensitive fluorescent probes for the diagnosis of breast carcinoma and for differentiating tumors from normal tissues during surgery. β-Galactosidase is a significant biomarker, whose overexpression is closely associated with the progression of breast tumors. Herein, we have constructed a β-galactosidase-activated fluorescent probe NIR-βgal-2 through rational design and molecular docking engineering simulations. The probe displayed superior sensitivity (detection limit = 2.0 × 10^-3 U/mL), great affinity (K_m = 1.84 μM), and catalytic efficiency (k_cat/K_m = 0.24 μM^-1 s^-1) for β-galactosidase. Leveraging this probe, we demonstrated the differentiation of cancer cells overexpressing β-galactosidase from normal cells and then applied the probe for intraoperative guided excision of breast tumors. Moreover, we exhibited the application of NIR-βgal-2 for the successful resection of orthotopic breast tumors by "in situ spraying" and monitored a good prognostic recovery. This work may promote the application of enzyme-activated near-infrared fluorescent probes for the development of carcinoma diagnosis and image-guided surgery.