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 System TM . 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.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives—State of the Art

“…The technical challenge of segmentectomy is to perform a true anatomical and oncologic resection with safe margins. A multimodality imaging approach [89,90] to segmentectomy, using a combination of colored or fluoroscopic endoscopic [91][92][93] or physical X-ray [94,95] markings and 3D reconstructions of segmental vessels and bronchus, segments and tumor [89,96,97], helps surgeons to identify small, non-visible, and non-palpable tumors, and to anticipate individual anatomy in the surgical space and expected oncologic margins to perform oncologically effective and safe personalized tailored segmentectomy (Figure 4). These imaging tools are helpful for open segmentectomy, and even more for minimally invasive approaches, using indocyanine green and near-infrared angiography [98][99][100] to identify the intersegment plan.…”

Midterm survival of imaging-assisted robotic lung segmentectomy for non-small-cell lung cancer

“…The use of infra-red light with green ICG [ 19 ] orients surgeons towards the inter-segmental plane with excellent precision in order to preserve healthy lung parenchyma. It has been demonstrated that a multimodal system including 3D imaging has good operative anatomical accuracy and provides more comfort, helping surgeons to make decisions when they encounter complex situations [ 27 ]. Moreover, this technique helped us to perform a picking lymphadenectomy for indolent lesions (ground-glass nodules, lesions smaller than 2 cm, slowly evolving, with low metabolic activity on a positron emission tomography scan) with good results and few long-term recurrences.…”

Interest of anatomical segmentectomy over lobectomy for lung cancer: a nationwide study

“…In recent years, the practice of segmentectomy has expanded. Several reasons could explain this trend: firstly, the increased incidence of early stage LC managed by surgery, secondly, the ageing of patients with localized LC, and, thirdly, the development of multimodal surgical navigation systems and minimally invasive surgery (4)(5)(6)(7)(8)(9).…”