Evolution of image-guided liver surgery: transition from open to laparoscopic procedures

Abstract

Introduction: Indications for liver surgery to treat primary and secondary hepatic malignancies are broadening. Utilizing data from B-mode or 2-D intraoperative ultrasound, it is often challenging to replicate the findings from preoperative CT or MRI scans. Additional data from more recently developed image-guidance technology, which registers preoperative axial imaging to a 3-D real-time model, may be used to improve operative planning, locate difficult to find hepatic tumors, and guide ablations.

Methods: Laparoscopic liver procedures are often more challenging than their open counterparts. Image-guidance technology can assist in overcoming some of the obstacles to minimally invasive liver procedures by enhancing ultrasound findings and ablation guidance. This manuscript describes a protocol that evaluated an open image-guidance system, and a subsequent protocol that directly compared, for validation, a laparoscopic with an open image-guidance system. Both protocols were limited to ablations within the liver.

Discussion: The laparoscopic image-guidance system successfully creates a 3-D model at both 7 and 14 mm Hg that is similar to the open 3-D model. Ultimately, improving intraoperative image guidance can help expand the ability to perform both laparoscopic and open liver surgeries.

Figures

Figure 1

Flowchart of two image-guided liver surgery protocols.

Figure 2

Screen capture of the user interface for the Scout™ Liver preoperative surgical planning software (left). The resection planning interface highlighting the tumor margin “heat map” is also shown (right). Once the resection plan has been finalized, the resection margin and volumetric calculations, including total liver volume and functional liver remnant volume, can be performed for evaluation by the clinician.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 3

a. Salient anatomical features used for surface registration in open hepatic IGS. The standard liver (far left) features are the groove along the falciform ligament [red], the round ligament (at junction of red, green, and blue lines), the inferior ridge along segment III [blue] and the inferior ridge along segments IV, V, and VI [green]. (IGS= image-guided surgery) b. The laparoscopic surface acquisition points used to compute the physical-to-image space registration are demonstrated in yellow. The graphical user interface (GUI) in the larger, left panel allows the surgeon to visualize the alignment of the preoperative image surface with the intraoperatively swabbed surface.

Figure 4

Visualization of the qualitative registration evaluation performed by the clinician while using the Explorer™ MIL device during laparoscopic staging. There is a strong agreement between the guidance system display (right) and the true location of the probe as visualized via the laparoscope (left).