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Zhan L, Ding H, Zhao Q, Liu J, Liang J, Xuan M, Kuang J, Yan J, Chen L, Cai W, Qiu W. Parathyroidectomy for solitary parathyroid adenoma via trans-areola single site endoscopic approach: Results of a case-match study. Cancer Med 2024; 13:e7290. [PMID: 38770646 PMCID: PMC11106683 DOI: 10.1002/cam4.7290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/22/2024] [Accepted: 05/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND This study aimed to establish the standardized procedure of trans-areola single site endoscopic parathyroidectomy (TASSEP), and to compare the performance of TASSEP with that of conventional open parathyroidectomy (COP). METHODS This study enrolled 40 patients with primary hyperparathyroidism (PHPT) who underwent TASSEP, and included 40 of 176 PHPT patients who underwent COP based on propensity score matching. The retrospective analysis was conducted based on prospectively collected data. Perioperative outcomes, including surgical profile, surgical burden and cosmetic results and follow-up were reported. The learning curve was described using a cumulative sum (CUSUM) analysis. RESULTS 40 TASSEPs were completed successfully without conversions or severe complications. There was no statistically significant difference in operation time between TASSEP and COP groups (80.83 ± 11.95 vs. 76.95 ± 7.30 min, p = 0.084). Experience of 17 cases was necessitated to reach the learning curve of TASSEP. Postoperative pain score and traumatic index (C-reactive protein and erythrocyte sedimentation rate) in TASSEP were apparently lower than those in COP group (p < 0.05). During the proliferation and stabilization phases, TASSEP was associated with significantly better incision recovery and cosmetic scores. Postoperative serum calcium and PTH levels throughout the follow-up period indicated satisfactory surgical qualities in both groups. CONCLUSION Based on precise preoperative localization and intraoperative planning facilitated by three-dimensional (3D) virtual modeling, TASSEP can be feasibly performed on selected patients with satisfactory success rates and low complication rates, providing preferable cosmetic results and alleviating the surgical burden to a certain extent.
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Affiliation(s)
- Ling Zhan
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Hao Ding
- Department of General Surgery, Ruijin Hospital Gubei CampusShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Qiwu Zhao
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jinyue Liu
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Juyong Liang
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ming Xuan
- Department of General Surgery, Ruijin Hospital Gubei CampusShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jie Kuang
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jiqi Yan
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lingxie Chen
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Wei Cai
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Weihua Qiu
- Department of General Surgery, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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Soriero D, Batistotti P, Malinaric R, Pertile D, Massobrio A, Epis L, Sperotto B, Penza V, Mattos LS, Sartini M, Cristina ML, Nencioni A, Scabini S. Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery—First Pilot Study. Healthcare (Basel) 2022; 10:healthcare10050900. [PMID: 35628036 PMCID: PMC9141148 DOI: 10.3390/healthcare10050900] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 02/01/2023] Open
Abstract
When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.
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Affiliation(s)
- Domenico Soriero
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
| | - Paola Batistotti
- Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, 16132 Genoa, Italy;
| | - Rafaela Malinaric
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
- Urological Clinical Unit, San Martino Hospital, 16132 Genoa, Italy
| | - Davide Pertile
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
| | - Andrea Massobrio
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
| | - Lorenzo Epis
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
| | - Beatrice Sperotto
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
| | - Veronica Penza
- Biomedical Robotics Lab, Department of Advanced Robotics, Istituto Italiano di Tecnologia, 16163 Genoa, Italy; (V.P.); (L.S.M.)
| | - Leonardo S. Mattos
- Biomedical Robotics Lab, Department of Advanced Robotics, Istituto Italiano di Tecnologia, 16163 Genoa, Italy; (V.P.); (L.S.M.)
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132 Genoa, Italy
- Operating Unit Hospital Hygiene, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Correspondence: (M.S.); (M.L.C.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132 Genoa, Italy
- Operating Unit Hospital Hygiene, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Correspondence: (M.S.); (M.L.C.)
| | - Alessio Nencioni
- Section of Geriatrics, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, 16132 Genoa, Italy;
- Gerontology and Geriatrics, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Stefano Scabini
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.S.); (R.M.); (D.P.); (A.M.); (L.E.); (B.S.); (S.S.)
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3
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Ignat M, Pérouse M, Lefebvre F, Kadoche D, Imperiale A, Swanstrom L, Vix M, Mutter D. Original Preoperative Localization Technique of Parathyroid Adenomas by 3-Dimensional Virtual Neck Exploration. Surg Innov 2021; 28:261-271. [PMID: 33745354 DOI: 10.1177/15533506211001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. Preoperative imaging in primary hyperparathyroidism (PHPT) is essential for planning of parathyroidectomy-particularly for selection of a minimally invasive approach. The objective of this cohort study was to evaluate the diagnostic precision of 3D virtual neck exploration (3D-VNE), to evaluate its impact on choice of surgical approach, and to document the correlation with long-term outcomes. Methods. 235 consecutive patients with PHPT were studied (January 2014 to December 2018), with 6-month follow-up. 220 patients had a preoperative computed tomography (CT), 172 of these had a 3D-VNE based on the CT, and 226 patients had a Tc-99m sestamibi scan. Results. Sensitivity of exact, per gland, adenoma localization was 57.09% (95% CI: 50.85-63.10%) for nonspecialized radiologist interpretation of CT scan, 58.17% (95% CI: 51.99-64.10%) for Tc-99m sestamibi scan, and 90.21% (95% CI: 85.21-93.64%) for 3D-VNE, and thereby favoring 3D-VNE compared to CT scan alone (OR 34.5, 95% CI: 9.19-290.56%, P < 2.2 × 10-16) and to Tc-99m sestamibi scan (OR 16.25, 95% CI: 6.05-61.42%, P = 3.1 × 10-15). Specificity was 87.38% for CT scan, 86.36% for 3D-VNE, and 90% for Tc-99m sestamibi scan (P > .05). The cure rate was 100%. The long-term recurrence rate (RR) was 2.978%. The RR was 1.324% in the video-assisted parathyroidectomy group of 151 patients and 5.952% in the group of 84 patients with cervicotomy (P = .0459). Conclusion. CT-based 3D-VNE proved to be the most accurate localizing study in PHPT and aided in selecting patients for targeted minimally invasive parathyroidectomy, which was associated with the lower recurrence rate. 3D-VNE could be proposed as a first-line imaging study in patients with PHPT.
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Affiliation(s)
- Mihaela Ignat
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Madeleine Pérouse
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - François Lefebvre
- Department of Medical Informatics, 27083University Hospital of Strasbourg, Strasbourg, France
| | - Deborah Kadoche
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Alessio Imperiale
- 27083Médecine Nucléaire et Imagerie Moléculaire, ICANS, Strasbourg, France.,Imagerie Moléculaire, DRHIM, Institut Pluridisciplinaire Hubert Curien (IPHC), UMR, CNRS / Unistra, Strasbourg, France
| | - Lee Swanstrom
- 54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Michel Vix
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Didier Mutter
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
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Forgione A, Barberio M, Agnus V, Swanström L, Marescaux J, Diana M, Gallix B. Precision image-guided colonic surgery: proof of concept for enhanced preoperative and intraoperative vascular imaging. Surg Endosc 2020; 35:962-970. [PMID: 32997271 DOI: 10.1007/s00464-020-08000-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/14/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal surgery has benefited from advances in precision medicine such as total mesorectal resection, and recently, mesocolon resection, fluorescent perfusion imaging, and fluorescent node mapping. However, these advances fail to address the variable quality of mesocolon dissection and the directed extent of vascular dissection (including high ligation) or pre-resection anastomotic perfusion mapping, thereby impacting anastomotic leaks. We propose a new paradigm of precision image-directed colorectal surgery involving 3D preoperative resection modeling and intraoperative fluoroscopic and fluorescence vascular imaging which better defines optimal dissection planes and vascular vs. anatomy-based resection lines according to our hypothesis. METHODS Six pigs had preoperative CT with vascular 3D reconstruction allowing for the preoperative planning of vascular-based dissection. Laparoscopic surgery was performed in a hybrid operating room (OR). Superselective arterial catheterization was performed in branches of the superior mesenteric artery (SMA) or the inferior mesenteric artery (IMA). Intraoperative boluses of 0.1 mg/kg or a continuous infusion of indocyanine green (ICG) (0.01 mg/mL) were administered to guide fluorescent-based sigmoid and ileocecal resections. Fluorescence was assessed using proprietary software at several regions of interest (ROI) in the right and left colon. RESULTS The approach was feasible and safe. Selective catheterization took an average of 43 min. Both bolus and continuous perfusion clearly marked pre-identified vessels (arteries/veins) and the target colon segment, facilitating precise resections based on the visible vascular anatomy. Quantitative software analysis indicated the optimal resection margin for each ROI. CONCLUSION Intra-arterial fluorescent mapping allows visualization of major vascular structures and segmental colonic perfusion. This may help to prevent any inadvertent injury to major vascular structures and to precisely determine perfusion-based resection planes and margins. This could enable tailoring of the amount of colon resected, ensure good anastomotic perfusion, and improve oncological outcomes.
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Affiliation(s)
- Antonello Forgione
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France.
| | - Manuel Barberio
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France
| | - Vincent Agnus
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France
| | - Lee Swanström
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France
| | - Jacques Marescaux
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France.,IRCAD, Research Institute against Digestive Cancer, Strasbourg, France
| | - Michele Diana
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France.,IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.,Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,ICUBE Laboratory, Photonics Instrumentation for Health, Strasbourg, France
| | - Benoit Gallix
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France.,University of Strasbourg, Strasbourg, France.,University Hospital of Strasbourg, Strasbourg, France.,Faculty of Medicine, McGill University, Montreal, Canada
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5
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Tsilimigras DI, Ntanasis-Stathopoulos I, Paredes AZ, Moris D, Gavriatopoulou M, Cloyd JM, Pawlik TM. Disappearing liver metastases: A systematic review of the current evidence. Surg Oncol 2019; 29:7-13. [PMID: 31196496 DOI: 10.1016/j.suronc.2019.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/10/2019] [Indexed: 12/14/2022]
Abstract
Advances in systemic chemotherapy have resulted in a significant increase in the reported response rates of colorectal liver metastases (CRLM) over time. Although radiologic response is usually prognostic of favorable outcomes, complete shrinkage of CRLM after chemotherapy, namely "disappearing liver metastases" (DLMs) poses significant therapeutic dilemmas. A systematic review of the literature was conducted to evaluate the existing evidence on the imaging and management of patients with DLMs using the PubMed (Medline), Embase and Cochrane library through December 21st, 2018. The following algorithm was used: "(disappearing OR vanishing OR missing OR (residual tiny)) AND ((liver OR hepatic) AND (metastasis OR metastases OR metastatic OR secondary))." From the 225 records retrieved, 15 studies were finally deemed eligible. A total of 479 patients with DLMs with a median age of 59.5 years (range, 30-83) were identified. Median number of DLM per patient ranged from 1 to 8.8. Median size of LMs prior to chemotherapy was 1.07 cm (range 0.3-3.5). The systemic treatment used to achieve DLMs included systemic chemotherapy alone (only 2 studies) or in combination with targeted agents (11 studies). The median number of chemotherapy cycles in the included studies was 7.8 (range 6-12). Identified factors predisposing to the development of DLM were small size (<2 cm), increased number of treatment cycles, oxaliplatin-based therapy, increased number of CRLM (≥3) and synchronous CRLM. Baseline and preoperative MRI with iv contrast showed the highest sensitivity for DLM detection. Fiducial placement facilitated pre- and intra-operative identification of DLM. Although resection of DLM decreased the local recurrence risk, there was no clearly demonstrated survival benefit after resecting all sites of disappearing lesions. Future randomized clinical trials are highly encouraged to provide strict, evidence-based recommendations for the treatment of patients with DLM.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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Quero G, Lapergola A, Soler L, Shahbaz M, Hostettler A, Collins T, Marescaux J, Mutter D, Diana M, Pessaux P. Virtual and Augmented Reality in Oncologic Liver Surgery. Surg Oncol Clin N Am 2018; 28:31-44. [PMID: 30414680 DOI: 10.1016/j.soc.2018.08.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Virtual reality (VR) and augmented reality (AR) in complex surgery are evolving technologies enabling improved preoperative planning and intraoperative navigation. The basis of these technologies is a computer-based generation of a patient-specific 3-dimensional model from Digital Imaging and Communications in Medicine (DICOM) data. This article provides a state-of-the- art overview on the clinical use of this technology with a specific focus on hepatic surgery. Although VR and AR are still in an evolving stage with only some clinical application today, these technologies have the potential to become a key factor in improving preoperative and intraoperative decision making.
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Affiliation(s)
- Giuseppe Quero
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Alfonso Lapergola
- IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Luc Soler
- IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Muhammad Shahbaz
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Alexandre Hostettler
- IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Toby Collins
- IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, Strasbourg 67091, France; IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Didier Mutter
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, Strasbourg 67091, France; IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France; Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg 67091, France
| | - Patrick Pessaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, Strasbourg 67091, France; IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l'Hôpital, Strasbourg 67091, France; Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg 67091, France.
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Lutz JC, Hostettler A, Agnus V, Nicolau S, George D, Soler L, Rémond Y. A New Software Suite in Orthognathic Surgery : Patient Specific Modeling, Simulation and Navigation. Surg Innov 2018; 26:5-20. [PMID: 30270757 DOI: 10.1177/1553350618803233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Orthognathic surgery belongs to the scope of maxillofacial surgery. It treats dentofacial deformities consisting in discrepancy between the facial bones (upper and lower jaws). Such impairment affects chewing, talking, and breathing and can ultimately result in the loss of teeth. Orthognathic surgery restores facial harmony and dental occlusion through bone cutting, repositioning, and fixation. However, in routine practice, we face the limitations of conventional tools and the lack of intraoperative assistance. These limitations occur at every step of the surgical workflow: preoperative planning, simulation, and intraoperative navigation. The aim of this research was to provide novel tools to improve simulation and navigation. We first developed a semiautomated segmentation pipeline allowing accurate and time-efficient patient-specific 3D modeling from computed tomography scans mandatory to achieve surgical planning. This step allowed an improvement of processing time by a factor of 6 compared with interactive segmentation, with a 1.5-mm distance error. Next, we developed a software to simulate the postoperative outcome on facial soft tissues. Volume meshes were processed from segmented DICOM images, and the Bullet open source mechanical engine was used together with a mass-spring model to reach a postoperative simulation accuracy <1 mm. Our toolset was completed by the development of a real-time navigation system using minimally invasive electromagnetic sensors. This navigation system featured a novel user-friendly interface based on augmented virtuality that improved surgical accuracy and operative time especially for trainee surgeons, therefore demonstrating its educational benefits. The resulting software suite could enhance operative accuracy and surgeon education for improved patient care.
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Affiliation(s)
- Jean-Christophe Lutz
- 1 Maxillo-Facial and Plastic Surgery Department, Strasbourg University Hospital, France.,2 Department of Computer Science, Research and Development, IRCAD, France.,3 Laboratory of Engineering Science, Computer Science and Imaging, CNRS, University of Strasbourg, France
| | | | - Vincent Agnus
- 2 Department of Computer Science, Research and Development, IRCAD, France
| | - Stéphane Nicolau
- 2 Department of Computer Science, Research and Development, IRCAD, France
| | - Daniel George
- 3 Laboratory of Engineering Science, Computer Science and Imaging, CNRS, University of Strasbourg, France
| | - Luc Soler
- 2 Department of Computer Science, Research and Development, IRCAD, France
| | - Yves Rémond
- 3 Laboratory of Engineering Science, Computer Science and Imaging, CNRS, University of Strasbourg, France
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8
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Mascagni P, Longo F, Barberio M, Seeliger B, Agnus V, Saccomandi P, Hostettler A, Marescaux J, Diana M. New intraoperative imaging technologies: Innovating the surgeon’s eye toward surgical precision. J Surg Oncol 2018; 118:265-282. [DOI: 10.1002/jso.25148] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/04/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Pietro Mascagni
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
| | - Fabio Longo
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
| | - Manuel Barberio
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
| | - Barbara Seeliger
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
| | - Vincent Agnus
- IRCAD, Research Institute against Digestive Cancer; Strasbourg France
| | - Paola Saccomandi
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
| | | | - Jacques Marescaux
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
- IRCAD, Research Institute against Digestive Cancer; Strasbourg France
| | - Michele Diana
- IHU-Strasbourg; Institute of Image-Guided Surgery; Strasbourg France
- IRCAD, Research Institute against Digestive Cancer; Strasbourg France
- Department of General, Digestive and Endocrine Surgery; University of Strasbourg; Strasbourg France
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9
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Abstract
BACKGROUND Medical software can build a digital clone of the patient with 3-dimensional reconstruction of Digital Imaging and Communication in Medicine images. The virtual clone can be manipulated (rotations, zooms, etc), and the various organs can be selectively displayed or hidden to facilitate a virtual reality preoperative surgical exploration and planning. OBJECTIVE We present preliminary cases showing the potential interest of virtual reality in colorectal surgery for both cases of diverticular disease and colonic neoplasms. DESIGN This was a single-center feasibility study. SETTINGS The study was conducted at a tertiary care institution. PATIENTS Two patients underwent a laparoscopic left hemicolectomy for diverticular disease, and 1 patient underwent a laparoscopic right hemicolectomy for cancer. The 3-dimensional virtual models were obtained from preoperative CT scans. The virtual model was used to perform preoperative exploration and planning. Intraoperatively, one of the surgeons was manipulating the virtual reality model, using the touch screen of a tablet, which was interactively displayed to the surgical team. MAIN OUTCOME MEASURES The main outcome was evaluation of the precision of virtual reality in colorectal surgery planning and exploration. RESULTS In 1 patient undergoing laparoscopic left hemicolectomy, an abnormal origin of the left colic artery beginning as an extremely short common trunk from the inferior mesenteric artery was clearly seen in the virtual reality model. This finding was missed by the radiologist on CT scan. The precise identification of this vascular variant granted a safe and adequate surgery. In the remaining cases, the virtual reality model helped to precisely estimate the vascular anatomy, providing key landmarks for a safer dissection. LIMITATIONS A larger sample size would be necessary to definitively assess the efficacy of virtual reality in colorectal surgery. CONCLUSIONS Virtual reality can provide an enhanced understanding of crucial anatomical details, both preoperatively and intraoperatively, which could contribute to improve safety in colorectal surgery.
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Siddaiah-Subramanya M, Tiang KW, Nyandowe M. A New Era of Minimally Invasive Surgery: Progress and Development of Major Technical Innovations in General Surgery Over the Last Decade. Surg J (N Y) 2017; 3:e163-e166. [PMID: 29134202 PMCID: PMC5680046 DOI: 10.1055/s-0037-1608651] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/26/2017] [Indexed: 12/15/2022] Open
Abstract
Minimally invasive surgery (MIS) continues to play an important role in general surgery as an alternative to traditional open surgery as well as traditional laparoscopic techniques. Since the 1980s, technological advancement and innovation have seen surgical techniques in MIS rapidly grow as it is viewed as more desirable. MIS, which includes natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), is less invasive and has better cosmetic results. The technological growth and adoption of NOTES and SILS by clinicians in the last decade has however not been uniform. We look at the differences in new developments and advancement in the different techniques in the last 10 years. We also aim to explain these differences as well as the implications in general surgery for the future.
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Affiliation(s)
- Manjunath Siddaiah-Subramanya
- Department of Surgery, Logan Hospital, Brisbane, Queensland, Australia.,Department of Medicine, Griffith University, Queensland, Australia.,Department of Medicine, University of Queensland, Queensland, Australia
| | - Kor Woi Tiang
- Department of Surgery, Logan Hospital, Brisbane, Queensland, Australia.,Department of Medicine, Griffith University, Queensland, Australia.,Department of Medicine, University of Queensland, Queensland, Australia
| | - Masimba Nyandowe
- Department of Surgery, Townsville Hospital, Townsville, Queensland, Australia
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Prospective Evaluation of Precision Multimodal Gallbladder Surgery Navigation: Virtual Reality, Near-infrared Fluorescence, and X-ray-based Intraoperative Cholangiography. Ann Surg 2017; 266:890-897. [PMID: 28742709 DOI: 10.1097/sla.0000000000002400] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We aimed to prospectively evaluate NIR-C, VR-AR, and x-ray intraoperative cholangiography (IOC) during robotic cholecystectomy. BACKGROUND Near-infrared cholangiography (NIR-C) provides real-time, radiation-free biliary anatomy enhancement. Three-dimensional virtual reality (VR) biliary anatomy models can be obtained via software manipulation of magnetic resonance cholangiopancreatography, enabling preoperative VR exploration, and intraoperative augmented reality (AR) navigation. METHODS Fifty-eight patients were scheduled for cholecystectomy for gallbladder lithiasis. VR surgical planning was performed on virtual models. At anesthesia induction, indocyanine green was injected intravenously. AR navigation was obtained by overlaying the virtual model onto real-time images. Before and after Calot triangle dissection, NIR-C was obtained by turning the camera to NIR mode. Finally, an IOC was performed. The 3 modality performances were evaluated and image quality was assessed with a Likert-scale questionnaire. RESULTS The three-dimensional VR planning enabled the identification of 12 anatomical variants in 8 patients, of which only 7 were correctly reported by the radiologists (P = 0.037). A dangerous variant identified at VR induced a "fundus first" approach. The cystic-common bile duct junction was visualized before Calot triangle dissection at VR in 100% of cases, at NIR-C in 98.15%, and in 96.15% at IOC.Mean time to obtain relevant images was shorter with NIR-C versus AR (P = 0.008) and versus IOC (P = 0.00000003). Image quality scores were lower with NIR-C versus AR (P = 0.018) and versus IOC (P < 0.0001). CONCLUSIONS This high-tech protocol illustrates the multimodal imaging of biliary anatomy towards precision cholecystectomy. Those visualization techniques could complement to reduce the likelihood of biliary injuries (NCT01881399).
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Sánchez-Margallo FM, Sánchez-Margallo JA, Moyano-Cuevas JL, Pérez EM, Maestre J. Use of natural user interfaces for image navigation during laparoscopic surgery: initial experience. MINIM INVASIV THER 2017; 26:253-261. [PMID: 28349758 DOI: 10.1080/13645706.2017.1304964] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Surgical environments require special aseptic conditions for direct interaction with the preoperative images. We aim to test the feasibility of using a set of gesture control sensors combined with voice control to interact in a sterile manner with preoperative information and an integrated operating room (OR) during laparoscopic surgery. MATERIAL AND METHODS Two hepatectomies and two partial nephrectomies were performed by three experienced surgeons in a porcine model. The Kinect, Leap Motion, and MYO armband in combination with voice control were used as natural user interfaces (NUIs). After surgery, surgeons completed a questionnaire about their experience. RESULTS Surgeons required <10 min training with each NUI. They stated that NUIs improved the access to preoperative patient information and kept them more focused on the surgical site. The Kinect system was reported as the most physically demanding NUI and the MYO armband in combination with voice commands as the most intuitive and accurate. The need to release one of the laparoscopic instruments in order to use the NUIs was identified as the main limitation. CONCLUSIONS The presented NUIs are feasible to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated OR functionalities during laparoscopic surgery.
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Affiliation(s)
| | - Juan A Sánchez-Margallo
- b Bioengineering and Health Technologies Unit , Jesús Usón Minimally Invasive Surgery Centre , Cáceres , Spain
| | - José L Moyano-Cuevas
- b Bioengineering and Health Technologies Unit , Jesús Usón Minimally Invasive Surgery Centre , Cáceres , Spain
| | - Eva María Pérez
- c Department of Surgery , University of Extremadura , Cáceres , Spain
| | - Juan Maestre
- d General Surgery Unit , Jesús Usón Minimally Invasive Surgery Centre , Cáceres , Spain
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Robust augmented reality registration method for localization of solid organs' tumors using CT-derived virtual biomechanical model and fluorescent fiducials. Surg Endosc 2016; 31:2863-2871. [PMID: 27796600 DOI: 10.1007/s00464-016-5297-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Augmented reality (AR) is the fusion of computer-generated and real-time images. AR can be used in surgery as a navigation tool, by creating a patient-specific virtual model through 3D software manipulation of DICOM imaging (e.g., CT scan). The virtual model can be superimposed to real-time images enabling transparency visualization of internal anatomy and accurate localization of tumors. However, the 3D model is rigid and does not take into account inner structures' deformations. We present a concept of automated AR registration, while the organs undergo deformation during surgical manipulation, based on finite element modeling (FEM) coupled with optical imaging of fluorescent surface fiducials. METHODS Two 10 × 1 mm wires (pseudo-tumors) and six 10 × 0.9 mm fluorescent fiducials were placed in ex vivo porcine kidneys (n = 10). Biomechanical FEM-based models were generated from CT scan. Kidneys were deformed and the shape changes were identified by tracking the fiducials, using a near-infrared optical system. The changes were registered automatically with the virtual model, which was deformed accordingly. Accuracy of prediction of pseudo-tumors' location was evaluated with a CT scan in the deformed status (ground truth). In vivo: fluorescent fiducials were inserted under ultrasound guidance in the kidney of one pig, followed by a CT scan. The FEM-based virtual model was superimposed on laparoscopic images by automatic registration of the fiducials. RESULTS Biomechanical models were successfully generated and accurately superimposed on optical images. The mean measured distance between the estimated tumor by biomechanical propagation and the scanned tumor (ground truth) was 0.84 ± 0.42 mm. All fiducials were successfully placed in in vivo kidney and well visualized in near-infrared mode enabling accurate automatic registration of the virtual model on the laparoscopic images. CONCLUSIONS Our preliminary experiments showed the potential of a biomechanical model with fluorescent fiducials to propagate the deformation of solid organs' surface to their inner structures including tumors with good accuracy and automatized robust tracking.
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Abstract
Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.
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Affiliation(s)
- Matthew Whealon
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Vinci
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, Orange, California
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Ntourakis D, Memeo R, Soler L, Marescaux J, Mutter D, Pessaux P. Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience. World J Surg 2016; 40:419-26. [PMID: 26316112 DOI: 10.1007/s00268-015-3229-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM. METHODS A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy. RESULTS AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months. CONCLUSIONS This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.
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Affiliation(s)
- Dimitrios Ntourakis
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France.
| | - Ricardo Memeo
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Luc Soler
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Jacques Marescaux
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Didier Mutter
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Patrick Pessaux
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France.
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Ntourakis D, Memeo R, Soler L, Marescaux J, Mutter D, Pessaux P. Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience. World J Surg 2016. [PMID: 26316112 DOI: 10.1007/-s00268-015-3229-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM. METHODS A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy. RESULTS AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months. CONCLUSIONS This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.
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Affiliation(s)
- Dimitrios Ntourakis
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France.
| | - Ricardo Memeo
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Luc Soler
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Jacques Marescaux
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Didier Mutter
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
| | - Patrick Pessaux
- IRCAD-IHU, University of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France.
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Diana M, Schiraldi L, Liu YY, Memeo R, Mutter D, Pessaux P, Marescaux J. High intensity focused ultrasound (HIFU) applied to hepato-bilio-pancreatic and the digestive system-current state of the art and future perspectives. Hepatobiliary Surg Nutr 2016; 5:329-44. [PMID: 27500145 DOI: 10.21037/hbsn.2015.11.03] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND High intensity focused ultrasound (HIFU) is emerging as a valid minimally-invasive image-guided treatment of malignancies. We aimed to review to current state of the art of HIFU therapy applied to the digestive system and discuss some promising avenues of the technology. METHODS Pertinent studies were identified through PubMed and Embase search engines using the following keywords, combined in different ways: HIFU, esophagus, stomach, liver, pancreas, gallbladder, colon, rectum, and cancer. Experimental proof of the concept of endoluminal HIFU mucosa/submucosa ablation using a custom-made transducer has been obtained in vivo in the porcine model. RESULTS Forty-four studies reported on the clinical use of HIFU to treat liver lesions, while 19 series were found on HIFU treatment of pancreatic cancers and four studies included patients suffering from both liver and pancreatic cancers, reporting on a total of 1,682 and 823 cases for liver and pancreas, respectively. Only very limited comparative prospective studies have been reported. CONCLUSIONS Digestive system clinical applications of HIFU are limited to pancreatic and liver cancer. It is safe and well tolerated. The exact place in the hepatocellular carcinoma (HCC) management algorithm remains to be defined. HIFU seems to add clear survival advantages over trans arterial chemo embolization (TACE) alone and similar results when compared to radio frequency (RF). For pancreatic cancer, HIFU achieves consistent cancer-related pain relief. Further research is warranted to improve targeting accuracy and efficacy monitoring. Furthermore, additional work is required to transfer this technology on appealing treatments such as endoscopic HIFU-based therapies.
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Affiliation(s)
- Michele Diana
- IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France;; IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Luigi Schiraldi
- IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France
| | - Yu-Yin Liu
- IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France;; Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Riccardo Memeo
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France;; Department of Digestive Surgery, University Hospital of Strasbourg, France
| | - Didier Mutter
- IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France;; Department of Digestive Surgery, University Hospital of Strasbourg, France
| | - Patrick Pessaux
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France;; Department of Digestive Surgery, University Hospital of Strasbourg, France
| | - Jacques Marescaux
- IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France;; IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
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Superselective intra-arterial hepatic injection of indocyanine green (ICG) for fluorescence image-guided segmental positive staining: experimental proof of the concept. Surg Endosc 2016; 31:1451-1460. [PMID: 27495341 DOI: 10.1007/s00464-016-5136-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 07/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intraoperative liver segmentation can be obtained by means of percutaneous intra-portal injection of a fluorophore and illumination with a near-infrared light source. However, the percutaneous approach is challenging in the minimally invasive setting. We aimed to evaluate the feasibility of fluorescence liver segmentation by superselective intra-hepatic arterial injection of indocyanine green (ICG). MATERIALS AND METHODS Eight pigs (mean weight: 26.01 ± 5.21 kg) were involved. Procedures were performed in a hybrid experimental operative suite equipped with the Artis Zeego®, multiaxis robotic angiography system. A pneumoperitoneum was established and four laparoscopic ports were introduced. The celiac trunk was catheterized, and a microcatheter was advanced into different segmental hepatic artery branches. A near-infrared laparoscope (D-Light P, Karl Storz) was used to detect the fluorescent signal. To assess the correspondence between arterial-based fluorescence demarcation and liver volume, metallic markers were placed along the fluorescent border, followed by a 3D CT-scanning, after injecting intra-arterial radiological contrast (n = 3). To assess the correspondence between arterial and portal supplies, percutaneous intra-portal angiography and intra-arterial angiography were performed simultaneously (n = 1). RESULTS Bright fluorescence signal enhancing the demarcation of target segments was obtained from 0.1 mg/mL, in matter of seconds. Correspondence between the volume of hepatic segments and arterial territories was confirmed by CT angiography. Higher background fluorescence noise was found after positive staining by intra-portal ICG injection, due to parenchymal accumulation and porto-systemic shunting. CONCLUSIONS Intra-hepatic arterial ICG injection, rapidly highlights hepatic target segment borders, with a better signal-to-background ratio as compared to portal vein injection, in the experimental setting.
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The quest for precision in transanal total mesorectal excision. Tech Coloproctol 2015; 20:11-8. [PMID: 26611358 DOI: 10.1007/s10151-015-1405-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/20/2015] [Indexed: 12/18/2022]
Abstract
Transanal total mesorectal excision (TME) is an emerging minimally invasive approach to rectal cancer, with encouraging preliminary results. However, the new surgical anatomy of the bottom-up approach complicates surgical understanding and increases the risks of inadvertent injuries to crucial anatomical structures, including nerves. Key elements to improve the safety and stimulate interest in such a complex technique might be robotics and image guidance, to enhance the level of precision. In this editorial, some of the technologies that could be used for precision TME are outlined, in light of the experience of our Institute for Image-Guided Surgery.
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A novel navigation system for maxillary positioning in orthognathic surgery: Preclinical evaluation. J Craniomaxillofac Surg 2015; 43:1723-30. [DOI: 10.1016/j.jcms.2015.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 11/22/2022] Open
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Magnabosco FF, Tavares MR, Montenegro FLDM. [Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature]. ACTA ACUST UNITED AC 2015; 58:562-71. [PMID: 25166048 DOI: 10.1590/0004-2730000003372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.
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Affiliation(s)
| | - Marcos Roberto Tavares
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Diana M, Marescaux J. Robotic surgery. Br J Surg 2015; 102:e15-28. [PMID: 25627128 DOI: 10.1002/bjs.9711] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/20/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proficiency in minimally invasive surgery requires intensive and continuous training, as it is technically challenging for unnatural visual and haptic perceptions. Robotic and computer sciences are producing innovations to augment the surgeon's skills to achieve accuracy and high precision during complex surgery. This article reviews the current use of robotically assisted surgery, focusing on technology as well as main applications in digestive surgery, and future perspectives. METHODS The PubMed database was interrogated to retrieve evidence-based data on surgical applications. Internal and external consulting with key opinion leaders, renowned robotics laboratories and robotic platform manufacturers was used to produce state-of-the art business intelligence around robotically assisted surgery. RESULTS Selected digestive procedures (oesophagectomy, gastric bypass, pancreatic and liver resections, rectal resection for cancer) might benefit from robotic assistance, although the current level of evidence is insufficient to support widespread adoption. The surgical robotic market is growing, and a variety of projects have recently been launched at both academic and corporate levels to develop lightweight, miniaturized surgical robotic prototypes. CONCLUSION The magnified view, and improved ergonomics and dexterity offered by robotic platforms, might facilitate the uptake of minimally invasive procedures. Image guidance to complement robotically assisted procedures, through the concepts of augmented reality, could well represent a major revolution to increase safety and deal with difficulties associated with the new minimally invasive approaches.
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Affiliation(s)
- M Diana
- Research Institute Against Cancer of the Digestive System (IRCAD), European Institute of TeleSurgery (EITS) and International Institute for Image-Guided Surgery (IHU Strasbourg), Strasbourg, France
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Marescaux J, Diana M. Next step in minimally invasive surgery: hybrid image-guided surgery. J Pediatr Surg 2015; 50:30-6. [PMID: 25598089 DOI: 10.1016/j.jpedsurg.2014.10.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 10/06/2014] [Indexed: 02/07/2023]
Abstract
Surgery, interventional radiology, and advanced endoscopy have all developed minimally invasive techniques to effectively treat a variety of diseases with positive impact on patients' postoperative outcomes. However, those techniques are challenging and require extensive training. Robotics and computer sciences can help facilitate minimally invasive approaches. Furthermore, surgery, advanced endoscopy, and interventional radiology could converge towards a new hybrid specialty, hybrid image-guided minimally invasive therapies, in which the three fundamental disciplines could complement one another to maximize the positive effects and reduce the iatrogenic footprint on patients. The present manuscript describes the fundamental steps of this new paradigm shift in surgical therapies that, in our opinion, will be the next revolutionary step in minimally invasive approaches.
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Affiliation(s)
- Jacques Marescaux
- IRCAD Research Institute Against Cancer of Digestive System, Strasbourg, France; IHU Strasbourg, Minimally-Invasive Image-Guided Surgical Institute, Strasbourg, France.
| | - Michele Diana
- IRCAD Research Institute Against Cancer of Digestive System, Strasbourg, France; IHU Strasbourg, Minimally-Invasive Image-Guided Surgical Institute, Strasbourg, France
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Marescaux J, Diana M, Soler L. Application of a Three-Dimensional Print of a Liver in Hepatectomy for Small Tumors Invisible by Intraoperative Ultrasonography: Preliminary Experience. World J Surg 2014. [DOI: 10.1007/s00268-014-2825-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pessaux P, Diana M, Soler L, Piardi T, Mutter D, Marescaux J. Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy. Langenbecks Arch Surg 2014; 400:381-5. [PMID: 25392120 DOI: 10.1007/s00423-014-1256-9] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 10/20/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Augmented reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative workup and real-time patient images in order to visualize unapparent anatomical details. The 3D model could be used for a preoperative planning of the procedure. The potential of AR navigation as a tool to improve safety of the surgical dissection is outlined for robotic hepatectomy. MATERIALS AND METHODS Three patients underwent a fully robotic and AR-assisted hepatic segmentectomy. The 3D virtual anatomical model was obtained using a thoracoabdominal CT scan with a customary software (VR-RENDER®, IRCAD). The model was then processed using a VR-RENDER® plug-in application, the Virtual Surgical Planning (VSP®, IRCAD), to delineate surgical resection planes including the elective ligature of vascular structures. Deformations associated with pneumoperitoneum were also simulated. The virtual model was superimposed to the operative field. A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. RESULTS Two totally robotic AR segmentectomy V and one segmentectomy VI were performed. AR allowed for the precise and safe recognition of all major vascular structures during the procedure. Total time required to obtain AR was 8 min (range 6-10 min). Each registration (alignment of the vascular anatomy) required a few seconds. Hepatic pedicle clamping was never performed. At the end of the procedure, the remnant liver was correctly vascularized. Resection margins were negative in all cases. The postoperative period was uneventful without perioperative transfusion. CONCLUSIONS AR is a valuable navigation tool which may enhance the ability to achieve safe surgical resection during robotic hepatectomy.
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Affiliation(s)
- Patrick Pessaux
- Institut Hospitalo-Universitaire de Strasbourg (IHU) Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France,
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Abstract
OBJECTIVE Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model. MATERIALS AND METHODS A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification. RESULTS Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments. CONCLUSIONS Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.
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Robotic duodenopancreatectomy assisted with augmented reality and real-time fluorescence guidance. Surg Endosc 2014; 28:2493-8. [PMID: 24609700 DOI: 10.1007/s00464-014-3465-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 01/24/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The minimally invasive surgeon cannot use 'sense of touch' to orientate surgical resection, identifying important structures (vessels, tumors, etc.) by manual palpation. Robotic research has provided technology to facilitate laparoscopic surgery; however, robotics has yet to solve the lack of tactile feedback inherent to keyhole surgery. Misinterpretation of the vascular supply and tumor location may increase the risk of intraoperative bleeding and worsen dissection with positive resection margins. METHODS Augmented reality (AR) consists of the fusion of synthetic computer-generated images (three-dimensional virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim of visualizing unapparent anatomical details. RESULTS In this article, we review the most common modalities used to achieve surgical navigation through AR, along with a report of a case of robotic duodenopancreatectomy using AR guidance complemented with the use of fluorescence guidance. CONCLUSIONS The presentation of this complex and high-technology case of robotic duodenopancreatectomy, and the overview of current technology that has made it possible to use AR in the operating room, highlights the needs for further evolution and the windows of opportunity to create a new paradigm in surgical practice.
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Marzano E, Piardi T, Soler L, Diana M, Mutter D, Marescaux J, Pessaux P. Augmented reality-guided artery-first pancreatico-duodenectomy. J Gastrointest Surg 2013; 17:1980-3. [PMID: 23943389 DOI: 10.1007/s11605-013-2307-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 07/29/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Augmented Reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim to visualize unapparent anatomical details. The potential of AR navigation as a tool to improve safety of the surgical dissection is presented in a case of pancreatico-duodenectomy (PD). METHODS A 77-year-old male patient underwent an AR-assisted PD. The 3D virtual anatomical model was obtained from thoraco-abdominal CT scan using customary software (VR-RENDER®, IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM®, Karl Storz, Tüttlingen, Germany) as well as different visible landmarks (inferior vena cava, left renal vein, aorta, superior mesenteric vein, inferior margin of the pancreas). A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Dissection of the superior mesenteric artery and the hanging maneuver were performed under AR guidance along the hanging plane. RESULTS AR allowed for precise and safe recognition of all the important vascular structures. Operative time was 360 min. AR display and fine registration was performed within 6 min. The postoperative course was uneventful. The pathology was positive for ampullary adenocarcinoma; the final stage was pT1N0 (0/43 retrieved lymph nodes) with clear surgical margins. CONCLUSIONS AR is a valuable navigation tool that can enhance the ability to achieve a safe surgical resection during PD.
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Affiliation(s)
- Ettore Marzano
- IRCAD-IHU University Hospital of Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg, France
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Diana M, Pessaux P, Marescaux J. New technologies for single-site robotic surgery in hepato-biliary-pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:34-42. [PMID: 24124162 DOI: 10.1002/jhbp.39] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Laparoendoscopic single-site surgery (LESS) aims to reduce incision-related complications by using a single surgical access through which multiple instruments are inserted simultaneously. First descriptions of LESS procedures date back to the early 90 s, but the approach initially failed to gain popularity because of technical challenges that markedly impair the principles of laparoscopic ergonomics. In recent years LESS has been increasingly applied to hepatobiliary procedures including cholecystectomies and liver resections. However, the uptake of LESS in hepatobiliary is limited. The surgical robotic platform might play a fundamental role in facilitating the uptake of LESS by the surgical community since robotic science made it possible to develop adequate technology to deal with some of the LESS issues such as restoring surgical triangulation. In this paper the current state-of-the-art for robotic LESS applied to the hepatobiliary system and emerging technologies enabling safer LESS procedures have been reviewed and future perspectives commented on the light of our experience.
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Affiliation(s)
- Michele Diana
- IRCAD-IHU, General, Digestive and Endocrine Surgery, University of Strasbourg, 1 Place de l'Hôpital, Strasbourg, 67091, France
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Three-Dimensional Metabolic and Radiologic Gathered Evaluation Using VR-RENDER Fusion: A Novel Tool to Enhance Accuracy in the Localization of Parathyroid Adenomas. World J Surg 2013; 37:1618-25. [DOI: 10.1007/s00268-013-2021-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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