Francesco Giorgio Domenic Volonte

Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion

BackgroundNew technologies can considerably improve preoperative planning, enhance the surgeon’s skill and simplify the approach to complex procedures. Augmented reality techniques, robot assisted operations and computer assisted navigation tools will become increasingly important in surgery and in residents’ education.MethodsWe obtained 3D reconstructions from simple spiral computed tomography (CT) slides using OsiriX, an open source processing software package dedicated to DICOM images. These images were then projected on the patients body with a beamer fixed to the operating table to enhance spatial perception during surgical intervention (augmented reality).ResultsChanging a windows deepness level allowed the surgeon to navigate through the patients anatomy, highlighting regions of interest and marked pathologies. We used image overlay navigation for laparoscopic operations such cholecystectomy, abdominal exploration, distal pancreas resection and robotic liver resection.ConclusionsAugmented reality techniques will transform the behaviour of surgeons, making surgical interventions easier, faster and probably safer. These new techniques will also renew methods of surgical teaching, facilitating transmission of knowledge and skill to young surgeons.

Intra-operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy.

Very recently, robotic single site cholecystectomy (RSSC) has been reported feasible and safe for selected cases. While an intra‐operative cholangiography can be performed, data is scarce with respect to its use. Indocyanin green (ICG) has been shown to be a viable option to visualize biliary anatomy. Since the introduction of a new near infrared camera integrated to the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA), the surgeon is able to assess the biliary anatomy by a non‐invasive and non‐ionizing method. This paper presents the first report of ICG imaging during a RSSC.

Augmented environments for the targeting of hepatic lesions during image-guided robotic liver surgery

BACKGROUND Stereotactic navigation technology can enhance guidance during surgery and enable the precise reproduction of planned surgical strategies. Currently, specific systems (such as the CAS-One system) are available for instrument guidance in open liver surgery. This study aims to evaluate the implementation of such a system for the targeting of hepatic tumors during robotic liver surgery. MATERIAL AND METHODS Optical tracking references were attached to one of the robotic instruments and to the robotic endoscopic camera. After instrument and video calibration and patient-to-image registration, a virtual model of the tracked instrument and the available three-dimensional images of the liver were displayed directly within the robotic console, superimposed onto the endoscopic video image. An additional superimposed targeting viewer allowed for the visualization of the target tumor, relative to the tip of the instrument, for an assessment of the distance between the tumor and the tool for the realization of safe resection margins. RESULTS Two cirrhotic patients underwent robotic navigated atypical hepatic resections for hepatocellular carcinoma. The augmented endoscopic view allowed for the definition of an accurate resection margin around the tumor. The overlay of reconstructed three-dimensional models was also used during parenchymal transection for the identification of vascular and biliary structures. Operative times were 240 min in the first case and 300 min in the second. There were no intraoperative complications. CONCLUSIONS The da Vinci Surgical System provided an excellent platform for image-guided liver surgery with a stable optic and instrumentation. Robotic image guidance might improve the surgeons orientation during the operation and increase accuracy in tumor resection. Further developments of this technological combination are needed to deal with organ deformation during surgery.

A lung segmentectomy performed with 3D reconstruction images available on the operating table with an iPad.

Anatomic lung segmentectomy is the procedure of choice in a growing number of patients, either because the lesion is small and/or because of poor lung function. The procedure requires a good knowledge of intrapulmonary anatomy. However, the experience for the different types of segmentectomy is not easy to obtain during thoracic surgical training due to the relatively small number of patients. Any help to better visualize and apprehend the anatomy pre- and intraoperatively is useful for training, teaching and for performing safer surgical procedures. This paper describes an anatomic segmentectomy procedure (upper segment of the left lower lobe) performed with the assistance of an iPad tablet used during the intervention to display and manipulate 3D images reconstructed prior to the surgery with the Open Source OsiriX software.

Augmented reality to the rescue of the minimally invasive surgeon. The usefulness of the interposition of stereoscopic images in the Da Vinci ™ robotic console

Computerized management of medical information and 3D imaging has become the norm in everyday medical practice. Surgeons exploit these emerging technologies and bring information previously confined to the radiology rooms into the operating theatre. The paper reports the authors’ experience with integrated stereoscopic 3D‐rendered images in the da Vinci surgeon console.

Console-integrated stereoscopic OsiriX 3D volume-rendered images for da Vinci colorectal robotic surgery.

The increased distance between surgeon and surgical field is a significant problem in laparoscopic surgery. Robotic surgery, although providing advantages for the operator, increases this gap by completely removing force feedback. Enhancement with visual tools can therefore be beneficial. The goal of this preliminary work was to create a custom plugin for OsiriX to display volume-rendered images in the da Vinci surgeon’s console. The TilePro multi-input display made the generated stereoscopic pairs appear to have depth. Tumor position, vascular supply, spatial location, and relationship between organs appear directly within the surgeon’s field of view. This study presents a case of totally robotic right colectomy for cancer using this new technology. Sight diversion was no longer necessary. Depth perception was subjectively perceived as profitable. Total immersion in the operative field helped compensate for the lack of tactile feedback specific to robotic intervention. This innovative tool is a step forward toward augmented-reality robot-assisted surgery.

Robotic single-site cholecystectomy.

Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy.

Learning Tools and Simulation in Robotic Surgery: State of the Art

Robotic surgery has emerged as a new technology over the last decade and has brought with it new challenges, particularly in terms of teaching and training. To overcome these challenges, robotic courses, virtual simulation, and dual consoles have been successfully introduced. In fact, there are several simulators currently on the market that have proven to be a valid option for training, especially for the novice trainee. Robotic courses have also found success around the world, allowing participants to implement robotic programs at their institution, typically with the help of a proctor. More recently, the dual console has enabled two surgeons to be operating at the same time. Having one experienced surgeon and one trainee each at his or her own console has made it an obvious choice for training. Although these methods have been successfully introduced, the data remain relatively scarce concerning their role in training. The aim of this article was to review the various methods and tools involved in the training of surgeons in robotic surgery.

Docking of the da Vinci Si Surgical System® with single-site technology

Strategies to spare operating room (OR) times are crucial to limiting the costs involved in robotic surgery. Among other factors, the pre‐operative set‐up and docking phases have been incriminated at first to be time consuming. The docking process on the standard multiport da Vinci Surgical System has not been shown to significantly prolong the overall OR time. This study aims to analyse whether the length of the docking process on the new da Vinci Si Surgical System with Single‐Site™ technology remains acceptable.

Three-dimensional laparoscopy: a step toward advanced surgical navigation

We read with interest the study comparing three-dimensional (3D) and 2D laparoscopy, recently published in Surgical Endoscopy [1]. Storz and colleagues [1] showed that a 3D high-definition (HD) system was superior to a 2D HD video system. This intuitive concept is unfortunately only poorly reported to date, but it opens very exciting roads. Since the introduction of laparoscopy almost 30 years ago, the surgeon has been confronted notably with the loss of binocular vision and a reduction in dexterity [2]. Although the implementation of minimally invasive surgery has gained acceptance in all surgical fields, the drawbacks of laparoscopy are real and explain, at least in part, the technical difficulty for advanced and complex procedures such as liver and pancreatic resections. To overcome these limitations, robotics has been proposed and adopted by many groups, especially for complex cases in which laparoscopy clearly has failed to establish itself as the gold standard [3]. However, the robotic technology, while bringing 3D vision and enhanced instrumentation with endo-wristed technology, has limits as well, including cost, size, and restriction for multiquadrant surgery. In the meantime, 3D screens have been developed and tested for conventional laparoscopy. However, the interest has been moderate, probably because the real benefices of this new equipment have been only poorly reported. In addition, the quality of the first screens was limited, and the eyestrain was higher than expected. We recently performed two procedures using a prototype of the 3D screen and endoscope (3D System; Karl Storz, Tuttlingen, Germany). An exploratory laparoscopy (Fig. 1) and a cholecystectomy (Fig. 2) were performed successfully using this new system. We were able to appreciate the comfort of glasses that did not impair vision if we looked away from the screen. Depth perception was perceived without eyestrain, and thus the vision was increased and spatial navigation facilitated. If subjective elements are clearly in favor of the 3D technology, objective data have lacked. Storz and colleagues [1] demonstrated clearly the interest of such new 3D systems. Although preliminary, these results have opened a road toward new horizons. With the development of augmented reality and surgical navigation, the 3D technology is an obvious and important step [4]. The integration of 3D laparoscopy with new devices and tools for real-time navigation can lead to a revolution (Fig. 3). Programing the intervention, simulating the procedure, and teaching the operation ex vivo are just some of the possibilities offered by these new surgical innovations. Even more interesting, findings have shown the navigation not only to be feasible and safe but also to be an obvious help during open surgery. Concerning minimally invasive surgery, the experience is more limited, but the possibilities are endless. The use of a 3D laparoscope coupled with a 3D screen, as we have tested, is just a step toward advanced surgical navigation. Many have recognized the interest of these techniques for solid organ tumor surgery. Hepatic resections probably are a good model for intraoperative navigation [5]. However, to offer a minimally invasive approach to these patients, a 3D environment is necessary and can be given by the 3D N. C. Buchs (&) F. Volonte F. Pugin C. Toso P. Morel Department of Surgery, Clinic for Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle-PerretGentil, 4, 1211 Geneva 14, Switzerland e-mail: nicolas.c.buchs@hcuge.ch