Development of a precision multimodal surgical navigation system for lung robotic segmentectomy

Abstract

Minimally invasive sublobar anatomical resection is becoming more and more popular to manage early lung lesions. Robotic-assisted thoracic surgery (RATS) is unique in comparison with other minimally invasive techniques. Indeed, RATS is able to better integrate multiple streams of information including advanced imaging techniques, in an immersive experience at the level of the robotic console. Our aim was to describe three-dimensional (3D) imaging throughout the surgical procedure from preoperative planning to intraoperative assistance and complementary investigations such as radial endobronchial ultrasound (R-EBUS) and virtual bronchoscopy for pleural dye marking. All cases were operated using the DaVinci SystemTM. Modelisation was provided by Visible Patient™ (Strasbourg, France). Image integration in the operative field was achieved using the Tile Pro multi display input of the DaVinci console. Our experience was based on 114 robotic segmentectomies performed between January 2012 and October 2017. The clinical value of 3D imaging integration was evaluated in 2014 in a pilot study. Progressively, we have reached the conclusion that the use of such an anatomic model improves the safety and reliability of procedures. The multimodal system including 3D imaging has been used in more than 40 patients so far and demonstrated a perfect operative anatomic accuracy. Currently, we are developing an original virtual reality experience by exploring 3D imaging models at the robotic console level. The act of operating is being transformed and the surgeon now oversees a complex system that improves decision making.

Keywords: Lung segmentectomy; augmented reality; image assisted surgery; robotic surgery; surgical navigation/operative planning.

Conflict of interest statement

Conflicts of Interest: Jean Marc Baste declares lecturing and proctoring for Intuitive Surgical. The other authors have no conflicts of interest to declare.

Figures

Figure 1

Flow chart of the implementation of our robotic technique of segmentectomy reinforced by our multimodal imaging system (5-7).

Figure 2

Minimal invasive segmentectomies from 2008 to 2017 in our institution epithor registry. VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery.

Figure 3

The workflow to get 3D reconstruction from outpatients’ clinic to the surgical field. 3D, three-dimensional.

Figure 4

Operative planning using the 3D model provided by VP® using the software Anywhere by Therapixel®. Evolution with segmentation at the end of 2016 (right corner). 3D, three-dimensional.

Figure 5

S1 segmentectomy with pleural dye marking with methylene blue without 3D reconstruction. 3D, three-dimensional.

Figure 6

Blue pleural dye marking for lesion close to the intersegmental plan S1/S2.

Figure 7

Visualization of the 3D model and exploration on the fluid console (9). 3D, three-dimensional. Available online: http://www.asvide.com/article/view/24363

Figure 8

Pleural dye marking before right S1 segmentectomy for better margin resection (10). Available online: http://www.asvide.com/article/view/24364

Figure 9

Left S6 with capture of the robotic console and 3D model (11). 3D, three-dimensional. Available online: http://www.asvide.com/article/view/24365

Figure 10

Double segmentectomies right S2 + S6 with capture of the robotic console and 3D model (12). 3D, three-dimensional. Available online: http://www.asvide.com/article/view/24366

Figure 11

Left S2 segmentectomy.

Figure 12

Left S2 segmentectomy using the per-operative 3D reconstruction (13). 3D, three-dimensional. Available online: http://www.asvide.com/article/view/24367

Figure 13

Right S6 segmentectomy with rare anatomical variation: 2 arteries and 2 segmental bronchus.