Video-assisted Thoracoscopic Surgery In Augmented Reality With Cone Beam Computed Tomography Assistance For Nodule Localization
Simon B. Rouze1, Pablo arturo Alvarez2, Bertrand Richard de Latour1, Miguel Castro3, Marie Aymami1, Jean-Louis Dillenseger3, Jean-Philippe Verhoye1.
1Department of Cardio-Thoracic and Vascular Surgery, Rennes University Hospital, rennes, France, 2Department of Cardio-Thoracic and Vascular Surgery, Rennes University Hospital, Université de Rennes 1, LTSI, Rennes, France, France, 3Université de Rennes 1, LTSI, Rennes, France, rennes, France.
BACKGROUND: Pulmonary nodules may be challenging to localize in video-assisted thoracoscopic surgery (VATS). Many procedures have been developed to help their localization. Most of them are invasive, with variable results. Herein we present a non-invasive localization system, using VATS associated with augmented reality thanks to Cone Beam Computed Tomography (CBCT).
METHODS: Patient with a nodule between 5 and 20mm were included. The surgery happened in a hybrid theater equipped with a C-arm that was able to performed CBCT acquisitions. The patient was installed in lateral decubitus thanks to dedicated beanbag. The surgery was beginning as usual with trocar insertion and pneumothorax creation. Once the pneumothorax created, the CBCT acquisition was performed. The nodule was identified on the CBCT images and segmented. The 3D segmented volume of the nodule was then integrated to fluoroscopic images. Afterwards, in real time, fluoroscopy in augmented reality and the VATS performed together allowed the nodule localization and its resection (Figure 1).
RESULTS: Between March 2014 and November 2017, 20 patients have been included (mean age 64 ±11 years). The mean size of the lesions was 13 ±5mm; their mean depth regarding parietal pleura was 19 ±14mm; and their density was 5 ±114HU (8 ground glass opacities have been included). We have been able to identify the nodule on the CBCT images during all the procedures. All the nodules have been localized successfully during the VATS associated with the fluoroscopy in augmented reality. Thirteen patients (65%) underwent a wedge resection; the remaining 7 (35%) underwent a lobectomy mainly because of this histology of the tumor (primitive lung cancer). One of them underwent a vascular injury necessitating a conversion. The mean time between CBCT acquisition and the nodule finding was 12 ±3min. The mean X-ray dose was 4120 ±1748μGym2. No complication has been induced by the localization procedure.
CONCLUSIONS: VATS associated with augmented reality thanks to CBCT is safe and efficient. It is an innovative, single step and non-invasive alternative to conventional localization procedures.
LEGEND: Figure 1: Localization procedure: A: straightforward fluoroscopy; B: operative field; C: fluoroscopy in augmented reality; D: VATS view 
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