Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy.
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.


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.
Institut Hospitalo-Universitaire de Strasbourg (IHU) Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France, patrick.pessaux@chru-strasbourg.fr.
Patrick
P
Pessaux
Michele
M
Diana
Luc
L
Soler
Tullio
T
Piardi
Didier
D
Mutter
Jacques
J
Marescaux
D003491:Cybernetics; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D011857:Radiographic Image Interpretation, Computer-Assisted; D012371:Robotics; D012984:Software; D025321:Surgery, Computer-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed