FURTHER DEVELOPMENTS Augmented reality and minimal

FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts

The future of minimal access surgery will almost certainly feature more advanced applications of adjuncts to facilitate anatomical recognition and the localisation of pathology . These are becoming commonplace in both video-assisted and robotic-assisted procedures. Augmented reality Augmented reality by definition comprises the fusion of projected computerised images with a real environment. In surgery , this involves the application of real-time imaging or other data overlaid via computer processing software onto the surgical field. Such technology may be particularly beneficial in minimal access surgery where the localisation of pathology and identification of anatomy may be more di ffi cult than in open surgery because of the lack of digital palpation of the relevant structures. At an elementary level, examples include the use of indocyanine green for immunofluorescent localisation of tumours as well as vascular, bronchial or lymphatic structures. When bound to plasma proteins, indocyanine green emits light with near-infrared light. Through use of a specifically designed HD camera and software system with imposed pseudo-colour, areas of di ff er ential tissue density and vascular supply can be detected clearly without the need for digital palpation, thus facilitating complete resection and clear surgical margins. Its use is now well established in procedures such as minimal access liver, lung, renal and prostatic resections, and its role in other specialties such as colorectal surgery is also under investigation. The technology can be integrated into both video-assisted and robotic-assisted surgical procedures and is available within ® the da Vinci Xi and X robotic surgical systems as the Firefly mode, which can be turned on as required from the surgical console ( Figure 10.7 ) . - Another role for augmented reality in minimal access sur - gery is the overlay of imaging beside or directly onto the surgi - cal field, ‘navigating’ the surgeon to the site of interest without the need to look away from the patient to review imaging. Such navigational techniques originated in image-guided diagnos - tics, enabling identifica tion of pathology in areas more di ffi cult to reach anatomically . Through increasing adoption of hybrid theatre complexes, these approaches ma y be utilised for both diagnosis and treatment in a single setting. An example is the use of navigational bronchoscopy to identify , diagnose and treat di ffi cult to reach or small lung nodules. Preoperative planning CT scan is reconstructed by specialist software. The result is a 3D ‘road map’ of the bronchial tree and a side-by-side picture of real-time endobronchial images with those from the imag - ing system ( Figure 10.8 ). The surgeon is then guided directly along the airway to the lesion of interest that can be biopsied with on-site frozen section. Where the lesion is resectable but di ffi cult to localise, a fiducial marker may be placed to enable localisation under fluoroscopy guidance in a second-stage pro - cedur e performed in a hybrid theatre ( Figure 10.9 ). Where resection is not possible, ablation or other treatment may be o ff ered in the same setting, both reducing surgical in vasiveness and increasing the provision of curative surgery to patients who may not otherwise be candidates for resection. An area of interest is the application of head-mounted dis - plays and eyeglasses to minimal access surgery . Although the majority of applications remain in the realm of simulation and training, the promise of real-time image guidance by means of multiplanar or imaging over lay of the surgeon’s view is par - ticularly attractive. Head-mounted displays may also provide data display or communication tools, reducing the need for the surgeon to look away from the operative field and allow real-time guidance by a trainer or pr octor. To date, clinical application is limited owing to time lag, the need for high-speed wireless Internet or Bluetooth connection and device weight and battery life; application to minimal access surgery remains under development. FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts

The future of minimal access surgery will almost certainly feature more advanced applications of adjuncts to facilitate anatomical recognition and the localisation of pathology . These are becoming commonplace in both video-assisted and robotic-assisted procedures. Augmented reality Augmented reality by definition comprises the fusion of projected computerised images with a real environment. In surgery , this involves the application of real-time imaging or other data overlaid via computer processing software onto the surgical field. Such technology may be particularly beneficial in minimal access surgery where the localisation of pathology and identification of anatomy may be more di ffi cult than in open surgery because of the lack of digital palpation of the relevant structures. At an elementary level, examples include the use of indocyanine green for immunofluorescent localisation of tumours as well as vascular, bronchial or lymphatic structures. When bound to plasma proteins, indocyanine green emits light with near-infrared light. Through use of a specifically designed HD camera and software system with imposed pseudo-colour, areas of di ff er ential tissue density and vascular supply can be detected clearly without the need for digital palpation, thus facilitating complete resection and clear surgical margins. Its use is now well established in procedures such as minimal access liver, lung, renal and prostatic resections, and its role in other specialties such as colorectal surgery is also under investigation. The technology can be integrated into both video-assisted and robotic-assisted surgical procedures and is available within ® the da Vinci Xi and X robotic surgical systems as the Firefly mode, which can be turned on as required from the surgical console ( Figure 10.7 ) . - Another role for augmented reality in minimal access sur - gery is the overlay of imaging beside or directly onto the surgi - cal field, ‘navigating’ the surgeon to the site of interest without the need to look away from the patient to review imaging. Such navigational techniques originated in image-guided diagnos - tics, enabling identifica tion of pathology in areas more di ffi cult to reach anatomically . Through increasing adoption of hybrid theatre complexes, these approaches ma y be utilised for both diagnosis and treatment in a single setting. An example is the use of navigational bronchoscopy to identify , diagnose and treat di ffi cult to reach or small lung nodules. Preoperative planning CT scan is reconstructed by specialist software. The result is a 3D ‘road map’ of the bronchial tree and a side-by-side picture of real-time endobronchial images with those from the imag - ing system ( Figure 10.8 ). The surgeon is then guided directly along the airway to the lesion of interest that can be biopsied with on-site frozen section. Where the lesion is resectable but di ffi cult to localise, a fiducial marker may be placed to enable localisation under fluoroscopy guidance in a second-stage pro - cedur e performed in a hybrid theatre ( Figure 10.9 ). Where resection is not possible, ablation or other treatment may be o ff ered in the same setting, both reducing surgical in vasiveness and increasing the provision of curative surgery to patients who may not otherwise be candidates for resection. An area of interest is the application of head-mounted dis - plays and eyeglasses to minimal access surgery . Although the majority of applications remain in the realm of simulation and training, the promise of real-time image guidance by means of multiplanar or imaging over lay of the surgeon’s view is par - ticularly attractive. Head-mounted displays may also provide data display or communication tools, reducing the need for the surgeon to look away from the operative field and allow real-time guidance by a trainer or pr octor. To date, clinical application is limited owing to time lag, the need for high-speed wireless Internet or Bluetooth connection and device weight and battery life; application to minimal access surgery remains under development.