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Augmented-Reality–Assisted Laparoscopic Adrenalectomy
To the Editor: Augmented reality (AR) is the superimposition of virtual-reality reconstructions onto a real patient’s images, in real time.1 This results in the visualization of internal structures through overlying tissues, providing a virtual transparency vision of surgical anatomy. Augmented reality has been applied to neurosurgery,2-3 which has a relatively fixed space, frames, and bony reference; this facilitates relating virtual and real data, and registering both images to each other. In contrast, the deformation of abdominal organs due to the heartbeat, ventilation, or laparoscopic insufflation has limited the application of AR in general surgery.4-5 We report what we believe is the first use of AR technology for general surgery in humans.
Report of a Case
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A 45-year-old man with a 1-cm Conn adenoma in the right adrenal gland underwent laparoscopic right adrenalectomy with AR assistance after providing oral informed consent for the procedure. This patient was chosen because his moderate obesity would likely render the dissection of adrenal vein and gland more difficult than usual due to increased retroperitoneal fat. Institutional review board approval was not required because of the absence of additional risk or discomfort for the patient.
Using 3-dimensional (3-D) virtual reality proprietary software (3D VSP Virtual Surgical Planning) developed at our institution6 and 2-mm slice-enhanced spiral computed tomography scanning (Somatom Plus 4 Volume 200M; Siemens, Erlangen, Germany), we achieved detection, delineation, and 3-D reconstruction of the lesion, the adrenal gland, and other intra-abdominal organs of the patient. Intraoperatively, 1 camera placed on a scialitic light source provided an external view of the abdomen, whereas the laparoscopic camera provided the view of internal anatomy (Figure) (also see video). The 2 types of images were sent via a fiberoptic network to a separate video room at our institution in which 2 displays were used for the internal and external images of the patient. A third display connected to a notebook computer was used to show the 3-D modeling of the patient. A fourth video screen displayed the AR images. By using 7 different visible landmarks on the skin (right costal margin and 3 trocar sites) and inside the abdomen (inferior vena cava and 2 laparoscopic tools), an independent operator manually merged the virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. The accuracy of image registration was verified by the correct superimposition of each pair of virtual and real laparoscopic tools.
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Figure. Actual and Augmented-Reality Images of Laparoscopic Adrenalectomy
Augmented-reality images result from the superimposition of virtual and real anatomy of the patient (panels A-C and D-F). Augmented reality allows visualization of intra-abdominal structures through virtual transparency of the abdominal wall (panel C) and recognition of important surgical anatomy through the retroperitoneal fat (panel F: adrenal gland and main adrenal vein seen through the periadrenal fat tissue). CT indicates computed tomography.
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In the operating room the surgeons used a conventional laparoscopic video screen for visualization of the standard imaging, and a second video screen for AR images. The real-time interactivity between the surgeons and the operator at the remote location overcame the issue of inherent deformation and motility of intra-abdominal structures with no need to halt the patient’s ventilation. The initial image registration took less than 5 minutes; each subsequent real-time adaptation by the operator did not cause any significant delay in the surgical procedure. There were no surgical complications.
Comment
Augmented reality aided the laparoscopic adrenalectomy by helping determine the correct dissection planes and by localizing the tumor, adjacent organs, and blood vessels. Augmented reality was most useful during identification of the main adrenal vein, the location of which was accurately predicted by the AR imaging, leading to its safe isolation through a virtual transparency of the fatty tissue in which it was embedded.
Potential advantages of the use of AR in general surgery include the delineation of dissection planes or resection margins and the avoidance of injury to invisible structures. Augmented reality has the potential to facilitate performance of radical surgical therapy by minimizing dissection and resection of neighboring tissues and organs and may be useful as a tool for a more interactive form of expert distant telementoring. Furthermore, by enabling visualization of intra-abdominal structures through virtual transparency of the abdominal wall, AR might improve safety and efficacy of various percutaneous techniques such as radiofrequency liver tumor ablation. The use of AR in general surgery will be simplified if automated image registration is developed.
This article was corrected on 11/10/2004, prior to publication of the correction in print.
Related Information: See Online video.
Jacques Marescaux, MD
jacques.marescaux{at}ircad.u-strasbg.fr
Francesco Rubino, MD;
Mara Arenas, MD;
Didier Mutter, MD, PhD;
Luc Soler, PhD
IRCAD-EITS (European Institute of Telesurgery)
Louis Pasteur University
Strasbourg, France
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6. Soler L, Ayache N, Nicolau S, et al. Virtual reality, augmented reality and robotics in digestive surgery. In: Buzug TM, Lueth TC, eds. Perspectives in Image Guided Surgery: Proceedings of the Scientific Workshop on Medical Robotics, Navigation and Visualization; March 11-12; Remagen, Germany. Hackensack, NJ: World Scientific Publishing Co Inc; 2004:476-484.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2004;292:2214-2215.
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ABSTRACT
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