Thoracoscopic surgery for pulmonary metastases after chemotherapy using a tailor-made virtual lung

Extended, virtual and augmented reality in thoracic surgery: a systematic review

OBJECTIVES

Extended reality (XR), encompassing both virtual reality (VR) and augmented reality, allows the user to interact with a computer-generated environment based on reality. In essence, the immersive nature of VR and augmented reality technology has been warmly welcomed in all aspects of medicine, gradually becoming increasingly feasible to incorporate into everyday practice. In recent years, XR has become increasingly adopted in thoracic surgery, although the extent of its applications is unclear. Here, we aim to review the current applications of XR in thoracic surgery.

METHODS

A systematic database search was conducted of original articles that explored the use of VR and/or augmented reality in thoracic surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to December 2020.

RESULTS

Our search yielded 1494 citations, of which 21 studies published from 2007 to 2019 were included in this review. Three main areas were identified: (i) the application of XR in thoracic surgery training; (ii) preoperative planning of thoracic procedures; and (iii) intraoperative assistance. Overall, XR could produce progression along the learning curve, enabling trainees to reach acceptable standards before performing in the operating theatre. Preoperatively, through the generation of 3D-renderings of the thoracic cavity and lung anatomy, VR increases procedural accuracy and surgical confidence through familiarization of the patient's anatomy. XR-assisted surgery may have therapeutic use particularly for complex cases, where conventional methods would yield inadequate outcomes due to inferior accuracy.

CONCLUSION

XR represents a salient step towards improving thoracic surgical training, as well as enhancing preoperative planning and intraoperative guidance.

VATS segmentectomy: past, present, and future

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

The management of the advanced colorectal cancer: management of the pulmonary metastases

Pulmonary metastases from colorectal cancer present as systemic manifestation of the disease. As a general principle, the presence of metastases predispose to a poor prognosis. However, the application of some criteria of "operability" permitted the surgical resection resulting in prolonged survival (reported 5-year survival up to 50%), in better quality of life and in the cure of some patients. When the primary tumor site is controlled, and the metastatic disease is limited in lungs without extrapulmonary location (except for resectable or resected hepatic lesion) surgical removal is indicated. As significant prognostic factors in metastasectomies have been reported the synchronous or metachronous caracter of the metastases, the disease free survival, the complete removal of the metastases, the thoracic lymph node invasion, the CEA level before metastasectomy and 1 month after, the solitary vs. multiple pulmonary metastatic locations, the induction chemotherapy, the histological type and differentiation grade, as well as the vascular emboli in histopathological examination. Thorough preoperative evaluation of the patient includes oncological assessment and respiratory functional tests. Alternatively, when the patient is not a good surgical candidate, radiofrequency ablation is an option. Many surgical accesses have been validated, as posterolateral or lateral or even posterior thoracotomy, sternotomy, clamshell incision, and thoracoscopic techniques that offer the advantages of less pain, fast recovery, and less morbidity. Though thoracoscopic metastasectomies have been questioned concerning to the completeness of metastatic removal, no statistical difference in survival has been revealed in many series comparing thoracotomy to thoracoscopic techniques. As a conclusion, there are many advances in the management of pulmonary metastases from colorectal cancer during last decade, the results have been essentially optimized, the role of surgery has been established, and the multimodality approach has been recognized as the cornerstone of a successful outcome.

Utility of three-dimensional computed tomography in general thoracic surgery

It is important for general thoracic surgeons to understand the relationship between tumors and surrounding organs during surgery; however, many anatomical variations are possible in the thorax, which can complicate this goal. Multidetector computed tomography (MDCT) is the latest technical breakthrough in CT imaging. MDCT permits rapid scanning of large areas of the body with multiple detectors, thereby allowing for simultaneous acquisition of an increased number of transaxial CT slices, which reduce motion artifacts. Three-dimensional (3D) rendering involves the creation of two-dimensional images that convey the 3D relationship of objects. The 3D reconstruction allows for enormous quantity of data to be utilized intuitively and effectively. The final images can reveal various lesions or organs of interest with high anatomical detail and accuracy to the general thoracic surgeon, which is helpful in performing safer surgeries. Surgeries for the following can benefit from this technology: lung lobectomy or segmentectomy, pulmonary sequestration, cardiovascular malformation, tracheobronchial tree, mediastinum, and chest wall. This article reviews the utility of 3D-MDCT imaging in the field of general thoracic surgery.