Augmented Reality-Guided Artery-First Pancreatico-Duodenectomy

Augmented Reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim to visualize unapparent anatomical details. The potential of AR navigation as a tool to improve safety of the surgical dissection is presented in a case of pancreatico-duodenectomy (PD). A 77-year-old male patient underwent an AR-assisted PD. The 3D virtual anatomical model was obtained from thoraco-abdominal CT scan using customary software (VR-RENDERA (R), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOMA (R), Karl Storz, Tuttlingen, Germany) as well as different visible landmarks (inferior vena cava, left renal vein, aorta, superior mesenteric vein, inferior margin of the pancreas). A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Dissection of the superior mesenteric artery and the hanging maneuver were performed under AR guidance along the hanging plane. AR allowed for precise and safe recognition of all the important vascular structures. Operative time was 360 min. AR display and fine registration was performed within 6 min. The postoperative course was uneventful. The pathology was positive for ampullary adenocarcinoma; the final stage was pT1N0 (0/43 retrieved lymph nodes) with clear surgical margins. AR is a valuable navigation tool that can enhance the ability to achieve a safe surgical resection during PD.