Real-time stereotactic navigation for the laparoscopic excision of a pelvic neoplasm

Abstract

Navigation for surgery is an important tool that can provide surgeons with enhanced information when operating on fixed anatomic targets [1]. The use of augmented reality for improved surgical precision [2] has recently been applied to pelvic surgery [3], and the use of these approaches could help improve resection quality as digital information from various source data can aid surgeons by providing real-time, usable and relevant data [4][5][6].Stereotactic navigation for surgery utilizes computed tomography (CT) or magnetic resonance imaging (MRI) images that are rendered in a multiplanar format such that the data points can be interpreted by the navigation software [6]. Using infrared trackers and a ceiling mounted infrared camera, 3D data from body imaging can be used in real time to perform 'digital surgery' [4].In this video, the technique of real-time navigation is applied to the laparoscopic excision of a pelvic neoplasm. The video emphasizes how the operating surgeon is able to interpret and utilize stereotactic navigation during surgery to localize and then excise a pelvic neoplasm in the deep perirectal space.In this clinical example, a 79-year-old female presented with chronic pelvic pain. Workup included physical examination-including anoscopy, proctoscopy and colonoscopy which were all unremarkable. However, a pelvic MRI demonstrated a complex, mixed cystic and solid neoplasm in the left perirectal space measuring 2 9 2.3 9 2.9 cm in dimension with an ill-defined solid, internal component measuring 1.1 cm. Malignancy could not be excluded by radiographic criterion. Surgical intervention using a minimally invasive, laparoscopic technique was utilized to perform a complete excision of the neoplasm, which was removed intact. The navigation accuracy (mean deviation) measured ±1.8 mm. Operative time was 124 min which included 38 min of navigation setup time. The setup time included time for intra-operative CT scan with placement of skin fixed fiducials, navigation software and instrument calibration.The patient was discharged on the first postoperative day. There was no perioperative morbidity. At 10-week follow-up, the patient reported complete resolution of her pelvic pain. Finally, pathology revealed a 50 % solid and 50 % cystic neoplasm measuring 3.0 9 2.0 9 1.5 cm and was consistent with a serous cyst adenofibroma of the ovary with an atypical placement beneath the peritoneal reflection.The video forum provides a description of the operation as seen from the surgeon's point of view to help viewers understand how augmented reality can aid in the localization of fixed anatomic targets with precision.

Stereotactic Navigation-Assisted Laparoscopic Resection of Challenging Low Pelvic Tumors: A Case Series

“…Our SNS strategy was similar to that applied by Atallah et al [ 4 , 5 , 6 , 7 , 15 ] and Kwak et al [ 3 ]; however, our strategy may be technically easier. First, we adopted a reduced number of only eight skin-fixed fiducials as a more practical strategy, which still allowed for a good fiducial registration error that was similar to those of previous reports.…”

“…SNS was then successfully applied to a transanal total mesorectal excision (TaTME) to provide real-time position assessment during the transanal phase, improving the surgeon’s spatial awareness and accuracy, and the safety of the TaTME [ 3 , 5 , 6 ]. SNS was also applied to assist en bloc pelvic neoplastic resections [ 7 , 8 ] and laparoscopic lateral pelvic lymph node dissections (LPLND) [ 9 ].…”

Transanal minimal invasive surgery - pushing the boundaries of transanal surgery

“…Where uncertainty or complexity exists pre-operative planning and rehearsal with imaging adjuncts has been shown to be beneficial and can aid guide surgery in complex cases [64] . The utility of novel imaging techniques (e.g., 3D imaging, stereotactic surgery) in preoperative surgical planning and intraoperative mapping has been recently showed both in benign conditions and cancer [65][66][67][68][69] . This might allow a truly personalized approach with TAMIS proctectomy, where the extent of the TME can be adapted to disease features and patient needs.…”

Future Directions

“…After this first description, three cases of locally advanced rectal cancers have been described with no intraoperative complications, Quirke 3 pathological specimens, and an accuracy of between AE 3.20 and AE 4.02 mm. 27 The use of navigation for the excision of a serous cyst adenofibroma beneath the peritoneal reflection has also been reported, 28 with an accuracy of AE 1.8 mm. The average navigation setup time was 47 minutes.…”