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Wahba R, Thomas MN, Bunck AC, Bruns CJ, Stippel DL. Clinical use of augmented reality, mixed reality, three-dimensional-navigation and artificial intelligence in liver surgery. Artif Intell Gastroenterol 2021; 2:94-104. [DOI: 10.35712/aig.v2.i4.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/10/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
A precise knowledge of intra-parenchymal vascular and biliary architecture and the location of lesions in relation to the complex anatomy is indispensable to perform liver surgery. Therefore, virtual three-dimensional (3D)-reconstruction models from computed tomography/magnetic resonance imaging scans of the liver might be helpful for visualization. Augmented reality, mixed reality and 3D-navigation could transfer such 3D-image data directly into the operation theater to support the surgeon. This review examines the literature about the clinical and intraoperative use of these image guidance techniques in liver surgery and provides the reader with the opportunity to learn about these techniques. Augmented reality and mixed reality have been shown to be feasible for the use in open and minimally invasive liver surgery. 3D-navigation facilitated targeting of intraparenchymal lesions. The existing data is limited to small cohorts and description about technical details e.g., accordance between the virtual 3D-model and the real liver anatomy. Randomized controlled trials regarding clinical data or oncological outcome are not available. Up to now there is no intraoperative application of artificial intelligence in liver surgery. The usability of all these sophisticated image guidance tools has still not reached the grade of immersion which would be necessary for a widespread use in the daily surgical routine. Although there are many challenges, augmented reality, mixed reality, 3D-navigation and artificial intelligence are emerging fields in hepato-biliary surgery.
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Affiliation(s)
- Roger Wahba
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne 50937, Germany
| | - Michael N Thomas
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne 50937, Germany
| | - Alexander C Bunck
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne 50937, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne 50937, Germany
| | - Dirk L Stippel
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne 50937, Germany
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Zygomalas A, Kehagias I. Up-to-date intraoperative computer assisted solutions for liver surgery. World J Gastrointest Surg 2019; 11:1-10. [PMID: 30705734 PMCID: PMC6354070 DOI: 10.4240/wjgs.v11.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/12/2018] [Accepted: 12/30/2018] [Indexed: 02/06/2023] Open
Abstract
Computer assisted surgical planning allowed for a better selection of patients, evaluation of operative strategy, appropriate volumetric measurements, identification of anatomical risks, definition of tumour resection margins and choice of surgical approach in liver oncologic resections and living donor liver transplantations. Although preoperative computer surgical analysis has been widely used in daily clinical practice, intraoperative computer assisted solutions for risk analysis and navigation in liver surgery are not widely available or still under clinical evaluation. Computer science technology can efficiently assist modern surgeons during complex liver operations, mainly by providing image guidance with individualized 2D images and 3D models of the various anatomical and pathological structures of interest. Intraoperative computer assisted liver surgery is particularly useful in complex parenchyma-sparing hepatectomies, for intraoperative risk analysis and for the effective treatment of colorectal metastases after neoadjuvant therapy or when they are multiple. In laparoscopic liver surgery, intraoperative computer aid is definitively more important as, apart from a restricted field of view, there is also loss of the fine haptic feedback. Intraoperative computer assisted developments face challenges that prevent their application in daily clinical practice. There is a vast variety of studies regarding intraoperative computer assisted liver surgery but there are no clear objective measurements in order to compare them and select the most effective solutions. An overview of up-to-date intraoperative computer assisted solutions for liver surgery will be discussed.
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Affiliation(s)
- Apollon Zygomalas
- Surgical Oncology, OLYMPION General Clinic of Patras, Patras 26442, Greece
| | - Ioannis Kehagias
- Department of Surgery, University Hospital of Patras, Patras 26500, Greece
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Heiselman JS, Clements LW, Collins JA, Weis JA, Simpson AL, Geevarghese SK, Kingham TP, Jarnagin WR, Miga MI. Characterization and correction of intraoperative soft tissue deformation in image-guided laparoscopic liver surgery. J Med Imaging (Bellingham) 2017; 5:021203. [PMID: 29285519 DOI: 10.1117/1.jmi.5.2.021203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022] Open
Abstract
Laparoscopic liver surgery is challenging to perform due to a compromised ability of the surgeon to localize subsurface anatomy in the constrained environment. While image guidance has the potential to address this barrier, intraoperative factors, such as insufflation and variable degrees of organ mobilization from supporting ligaments, may generate substantial deformation. The severity of laparoscopic deformation in humans has not been characterized, and current laparoscopic correction methods do not account for the mechanics of how intraoperative deformation is applied to the liver. We first measure the degree of laparoscopic deformation at two insufflation pressures over the course of laparoscopic-to-open conversion in 25 patients. With this clinical data alongside a mock laparoscopic phantom setup, we report a biomechanical correction approach that leverages anatomically load-bearing support surfaces from ligament attachments to iteratively reconstruct and account for intraoperative deformations. Laparoscopic deformations were significantly larger than deformations associated with open surgery, and our correction approach yielded subsurface target error of [Formula: see text] and surface error of [Formula: see text] using only sparse surface data with realistic surgical extent. Laparoscopic surface data extents were examined and found to impact registration accuracy. Finally, we demonstrate viability of the correction method with clinical data.
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Affiliation(s)
- Jon S Heiselman
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Logan W Clements
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Jarrod A Collins
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Jared A Weis
- Wake Forest School of Medicine, Department of Biomedical Engineering, Winston-Salem, North Carolina, United States
| | - Amber L Simpson
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Sunil K Geevarghese
- Vanderbilt University Medical Center, Division of Hepatobiliary Surgery and Liver Transplantation, Nashville, Tennessee, United States
| | - T Peter Kingham
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - William R Jarnagin
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Michael I Miga
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
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Collins JA, Weis JA, Heiselman JS, Clements LW, Simpson AL, Jarnagin WR, Miga MI. Improving Registration Robustness for Image-Guided Liver Surgery in a Novel Human-to-Phantom Data Framework. IEEE TRANSACTIONS ON MEDICAL IMAGING 2017; 36:1502-1510. [PMID: 28212080 PMCID: PMC5757161 DOI: 10.1109/tmi.2017.2668842] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In open image-guided liver surgery (IGLS), a sparse representation of the intraoperative organ surface can be acquired to drive image-to-physical registration. We hypothesize that uncharacterized error induced by variation in the collection patterns of organ surface data limits the accuracy and robustness of an IGLS registration. Clinical validation of such registration methods is challenged due to the difficulty in obtaining data representative of the true state of organ deformation. We propose a novel human-to-phantom validation framework that transforms surface collection patterns from in vivo IGLS procedures (n = 13) onto a well-characterized hepatic deformation phantom for the purpose of validating surface-driven, volumetric nonrigid registration methods. An important feature of the approach is that it centers on combining workflow-realistic data acquisition and surgical deformations that are appropriate in behavior and magnitude. Using the approach, we investigate volumetric target registration error (TRE) with both current rigid IGLS and our improved nonrigid registration methods. Additionally, we introduce a spatial data resampling approach to mitigate the workflow-sensitive sampling problem. Using our human-to-phantom approach, TRE after routine rigid registration was 10.9 ± 0.6 mm with a signed closest point distance associated with residual surface fit in the range of ±10 mm, highly representative of open liver resections. After applying our novel resampling strategy and improved deformation correction method, TRE was reduced by 51%, i.e., a TRE of 5.3 ± 0.5 mm. This paper reported herein realizes a novel tractable approach for the validation of image-to-physical registration methods and demonstrates promising results for our correction method.
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Affiliation(s)
| | - Jared A. Weis
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Jon S. Heiselman
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Logan W. Clements
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | | | | | - Michael I. Miga
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
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Usefulness of three-dimensional(3D) simulation software in hepatectomy for pediatric hepatoblastoma. Surg Oncol 2016; 25:236-43. [PMID: 27566028 DOI: 10.1016/j.suronc.2016.05.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/19/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatoblastoma (HB) is the most common malignant liver tumor in childhood. Complete HB surgical resection which is technically demanding is the cornerstone of effective therapy with a good prognosis. The aim of our study is to evaluate the usefulness of 3D simulation software in assisting hepatectomy in pediatric patients with HB. METHODS 21 children with HB who underwent hepatectomy were enrolled in this study. All patients underwent computer tomography (CT) imaging preoperatively. CT images from 11 cases (from September 2013 to August 2015) were reconstructed with Hisense CAS, and performed hetpatectomy. While 10 cases (from September 2011 to August 2013) without 3D simulation were token as the control group. The clinical outcome were analyzed and compared between the 2 groups. RESULTS All the HB were successfully removed for all patients and there was no positive margins in the surgical specimens, no complications, and no recurrences. For the reconstructing group, 3D simulation software successfully reconstructed the 3D images of liver and were used as a navigator in the operation room during hepatectomy. Anatomic hepatectomy were successfully completed for all patients after operation planning using the software. There was no obvious discrepancy between the virtual and the actual hepatectomy. The mean operation time was shorter (142.18 ± 21.87 min VS. the control group, 173.5 ± 54.88 min, p = 0.047) and intraoperative bleeding was less (28.73 ± 14.17 ml VS. 42.8 ± 41.12 ml, p = 0.011) in the reconstructing group. Moreover, postoperative hospital stay tended to be shorter in the reconstructing group (11.18 ± 2.78d VS. the control group 13 ± 3.46d, P = 0.257). CONCLUSIONS 3D simulation software facilitates the investigation of the complex liver structure, contributes to the optimal operation planning, and enables an individualized anatomic hepatectomy for each pediatric patient with HB.
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Rucker DC, Wu Y, Clements LW, Ondrake JE, Pheiffer TS, Simpson AL, Jarnagin WR, Miga MI. A Mechanics-Based Nonrigid Registration Method for Liver Surgery Using Sparse Intraoperative Data. IEEE TRANSACTIONS ON MEDICAL IMAGING 2014; 33:147-58. [PMID: 24107926 PMCID: PMC4057359 DOI: 10.1109/tmi.2013.2283016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
In open abdominal image-guided liver surgery, sparse measurements of the organ surface can be taken intraoperatively via a laser-range scanning device or a tracked stylus with relatively little impact on surgical workflow. We propose a novel nonrigid registration method which uses sparse surface data to reconstruct a mapping between the preoperative CT volume and the intraoperative patient space. The mapping is generated using a tissue mechanics model subject to boundary conditions consistent with surgical supportive packing during liver resection therapy. Our approach iteratively chooses parameters which define these boundary conditions such that the deformed tissue model best fits the intraoperative surface data. Using two liver phantoms, we gathered a total of five deformation datasets with conditions comparable to open surgery. The proposed nonrigid method achieved a mean target registration error (TRE) of 3.3 mm for targets dispersed throughout the phantom volume, using a limited region of surface data to drive the nonrigid registration algorithm, while rigid registration resulted in a mean TRE of 9.5 mm. In addition, we studied the effect of surface data extent, the inclusion of subsurface data, the trade-offs of using a nonlinear tissue model, robustness to rigid misalignments, and the feasibility in five clinical datasets.
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Affiliation(s)
- D. Caleb Rucker
- Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville, TN 37996 USA
| | - Yifei Wu
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Logan W. Clements
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Janet E. Ondrake
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Thomas S. Pheiffer
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | - Amber L. Simpson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
| | | | - Michael I. Miga
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235 USA
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Hansen C, Black D, Lange C, Rieber F, Lamadé W, Donati M, Oldhafer KJ, Hahn HK. Auditory support for resection guidance in navigated liver surgery. Int J Med Robot 2012. [PMID: 23192891 DOI: 10.1002/rcs.1466] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND An alternative mode of interaction with navigation systems for open liver surgery was requested. Surgeons who use such systems are impeded by having to constantly switch between viewing the navigation system screen and the patient during an operation. METHODS To this end, an auditory display system for open liver surgery is introduced with support for guiding the tracked instrument towards and remaining on a predefined resection line. To evaluate the method, a clinically orientated user study with 12 surgeons was conducted. RESULTS It is shown in qualitative results from the user study that the proposed auditory display is recognized as a useful addition to the current visual mode of interaction. It was revealed in a statistical analysis that participants spent less time looking on the screen (10% vs. 96%). Accuracy for resection guidance was significantly improved when using auditory display as an additional information channel (0.6 vs. 1.4 mm); however, the overall time for the resection task was shorter without auditory display (47 vs. 24 s). CONCLUSIONS By reducing dependence on the visual modality during resection guidance, the auditory display is well suited to become integrated in navigation systems for liver surgery.
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Affiliation(s)
- Christian Hansen
- Institute for Medical Image Computing, Fraunhofer MEVIS, Bremen, Germany.
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Abstract
BACKGROUND Drug-eluting polymer implants present a compelling parenteral route of administration for cancer chemotherapy. With potential for minimally invasive, image-guided placement and highly localized drug release, these delivery systems are playing an increasingly important role in cancer management. This is particularly true as the use of labile proteins and other bioactive molecules is likely to increase in the upcoming years. OBJECTIVE In this review, we present the current trends in the application of Pre-formed and in situ-forming systems as drug-eluting implants for cancer chemotherapy. METHODS We outline the clinically available options as well as up-and-coming technologies and their advantages and challenges. We also describe ongoing related innovations with image-guided drug delivery, mathematical modeling of implanted delivery systems and implanted drug delivery in combination with other therapies. RESULTS/CONCLUSION Whether used alone or combined with other minimally invasive procedures, drug-eluting polymeric implants will play a significant role in the future of cancer management.
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Affiliation(s)
- Agata A Exner
- Case Western Reserve University, Department of Radiology, 11100 Euclid Avenue, Cleveland, OH 44106-5056, USA.
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Beller S, Eulenstein S, Lange T, Niederstrasser M, Hünerbein M, Schlag PM. A new measure to assess the difficulty of liver resection. Eur J Surg Oncol 2008; 35:59-64. [PMID: 18789842 DOI: 10.1016/j.ejso.2008.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 07/22/2008] [Accepted: 07/24/2008] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There is no valid measure to assess surgical difficulty and feasibility of a planned liver resection. It is the objective of this study to evaluate a mathematical measure from a 3D graphical analysis. METHODS Eleven different 3D models of hepatic tumours were evaluated by experts for resectability and analysed with Amira graphic software taking into consideration the portal and hepatic venous vascular relationships. Virtual resection volumes with increasing resection margins from 1 to 30 mm were determined separately for portal veins, hepatic veins, their intersections and volume unions. The integral of the increasing resection volumes was defined as risk coefficient. The risk coefficients from this volumetric analysis were compared with the expert opinion. RESULTS The risk coefficient based on the integral of portal venous and hepatic venous volume unions reproduced the expert opinion highly significantly (correlation coefficient 0.9, p<0.05) and more accurately than volumetric analysis of the planned resection margin. CONCLUSION With automated volumetric analysis, anatomically problematic situations in liver surgery can be reproduced and scaled. The risk coefficient obtained is a suitable objective measure for defining risk areas in liver surgery.
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Affiliation(s)
- S Beller
- Surgical Research Unit OP 2000, Campus Berlin Buch, Charitè Universitätsmedizin, Berlin, Germany
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Beller S, Hünerbein M, Eulenstein S, Lange T, Schlag PM. Feasibility of navigated resection of liver tumors using multiplanar visualization of intraoperative 3-dimensional ultrasound data. Ann Surg 2007; 246:288-94. [PMID: 17667508 PMCID: PMC1933548 DOI: 10.1097/01.sla.0000264233.48306.99] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Intraoperative ultrasound is widely used in liver surgery, but primarily for diagnostic purposes. We have developed and evaluated a system for navigated liver resections using on intraoperatively acquired 3-dimensional (3D) ultrasound data. METHODS Navigation technique based on 3D ultrasound and an optical tracking system. Accuracy of the system was validated experimentally in a tumor model. Subsequently, clinical application was evaluated in 54 patients for resection of central liver tumors. Clinical feasibility and accuracy of the navigation technique were assessed with respect to practicability, adequacy of visualization, and precision of navigated resection (free margin). RESULTS Evaluation of the system in the tumor model showed a significant increase of the accuracy of navigated resections compared with conventional resection (P < 0.05). Clinical application of 3D ultrasound-based navigation was feasible in 52 of 54 patients. Sufficient visualization was obtained with 2 orthogonal section planes. This navigation strategy provided complete anatomic orientation and accurate position control of surgical instruments. Mean histologic resection margin was 9 mm with a maximum deviation of 8 mm from the planned virtual resection margins. CONCLUSIONS Optoelectronic navigation with section mode visualization in 2 orthogonal planes does sufficiently display intraoperative 3D data and enables accurate ultrasound-based navigation of liver resections.
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Affiliation(s)
- Siegfried Beller
- Charité Universitätsmedizin Berlin, Robert Rössle Klinik, Campus Berlin-Buch, Berlin, Germany
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Hünerbein M, Chopra SS, Schlag PM. [Transcutaneous ultrasound]. Chirurg 2007; 78:407-10, 412. [PMID: 17431555 DOI: 10.1007/s00104-007-1331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Preoperative transcutaneous ultrasound allows surgeons to assess the pathology directly, thus supplementing clinical examination of the patient. Technical advances including power doppler, three-dimensional ultrasound, and the advent of ultrasound contrast agents have increased the quality and broadened the diagnostic spectrum of ultrasound. This article reviews relevant new aspects of transcutaneous ultrasound in the surgical setting.
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Affiliation(s)
- M Hünerbein
- Klinik für Chirurgie und Chirurgische Onkologie, Charité Campus Buch, Universitätsmedizin Berlin, 13122 Berlin, Deutschland.
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