Intraoperative Imaging Powerfully Combined
The team around Medical Manager Rodrigo Gobbo Garcia, MD, from the Interventional Medical Center of the Albert Einstein Hospital in São Paulo, Brazil, managed to perform a minimally invasive liver resection for the first time in a hybrid OR using da Vinci®, a surgical robot, and Artis zeego1, an imaging system based on robotic technology.
Adjusting the trapezoid controls on the table window enables good liver segmentation
A new preset can be created to support the segmentation in other procedures.
syngo Embolization Guidance to highlight and locate the tumor.
Many sources, many problems
While relatively new, robotic surgery has already become standard of care for many types of surgical procedures. One of these is liver tumor resection. For resection of endophytic liver tumors, the success of the surgery largely depends on the quality of the images acquired before and during the procedure. This is exactly where the rise of hybrid operating environments comes into play: The quality, but also the variety of imaging available while performing surgery has never been greater. As is often the case, however, many hands do not always make light work: Drawing on a large number of images from different sources creates more problems than it solves if there is no practical way to collate them – with extreme precision and preferably in real time. Gobbo Garcia has demonstrated how this challenge can be overcome with a combination of the Artis zeego1 angio system and syngo DynaCT software.
Planning with imaging
In one of the hospital’s 489 beds lies a patient suffering from three hypovascular endophytic tumors in his liver. The liver tumor resection for this patient is to be performed using the da Vinci surgical system, a high-end multi-arm operating robot. Robotic surgery, in the case of endophytic liver tumors however, has a downside. It is very limited in its ability to locate endophytic liver tumors. Surgeons cannot palpate the tumors, as they can in open surgery. The standard of care for robotic surgical procedures is to use intraoperative ultrasound imaging to mark the tumors before surgery. This sequential tumor-by-tumor method is, however, both time-consuming and imprecise. Instead, Gobbo’s team decided to rely on a combination of a preoperative CT image and intraoperative imaging with Artis zeego to visualize all three tumors.
Right tool for the job
Using preoperative CT imaging has several advantages for robotic liver tumor resection surgery. First, it is a real time-saver, especially since the image already exists preoperatively. Second, hypovascular tumors are clearly visible in the preoperative CT. Yet, there is also a disadvantage: namely, during the robotic liver tumor resection surgery, the patient’s abdomen needs to be insufflated with CO2. This creates pressure that changes the shape of the liver compared with its preoperative state. Intraoperative syngo DynaCT with Artis zeego can overcome this issue by visualizing the liver in its current state during the procedure. At the start of the robotic surgery procedure, the patient’s abdomen was insufflated with CO2. As a consequence, the liver – along with other organs – was compressed in the axial direction. Subsequently, a syngo DynaCT Large Volume was performed to image the whole organ. Next, Gobbo’s team fused the preoperative CT image with the intraoperative syngo DynaCT Large Volume image to create a combined 3D dataset.
Fusing preoperative CT imaging with the intraoperative syngo DynaCT Large Volume image opened up interesting possibilities: By adjusting the trapezoid controls on the table window, the surgery team was able to obtain a very good manual liver segmentation – which can even be saved as a preset to support segmentation in future procedures. Finally, they used the syngo Embolization Guidance software on the combined 3D dataset to highlight and locate the tumor along with its feeding arteries. After Artis zeego was parked away from the surgical table, the da Vinci system was rolled next to the operating table and docked to the patient. During the liver tumor resection using the da Vinci system, the surgeon used the combined 3D dataset with the highlighted tumors as a reference to assist navigation to the tumors during the robotic surgery. The consensus feeling was one of surprise and appreciation for how much more convenient and precise it was to use the combined 3D dataset versus surgical ultrasound during the surgery. They were so impressed, in fact, that the hospital plans to extend this method to other kinds of procedures such as the resection of kidneys or lung cancer.
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1This article refers to an installation of Artis zeego. Artis zeego is no longer available and is replaced by ARTIS pheno.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.