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Minimally Invasive Laparoscopic Adrenalectomy with Endoscope Fusion A World Premiere of this Technique Better Visualization with Overlay A patient with an adenoma of the adrenal gland was positioned in a lateral (kidney) position for better access to the tumor. The Artis zeego offers a complete table integration, so target organs even in sophisticated positions can be visualized. Trokars were placed, the abdomen was insufflated with CO2 and the anatomy was prepared. Color-coded radiopaque markers were placed on the tumor and around it. These markers are important for the endoscope registration process. Then the urologist acquired a syngo DynaCT with an 8s protocol. The first step was to evaluate the differences of the preoperative CT and intraoperative syngo DynaCT. The overlay of the two 3D volumes matched and the syngo DynaCT proved to be of sufficient quality for the procedure. The markers could also be seen. In a second step the syngo DynaCT data was segmented for an overlay using syngo iPilot. The segmentation was necessary because the tumor did not take up contrast agent and could hardly be seen in either of the two 3D volumes. Software Calculation The third step consisted of endoscope registration using special software provided by the German Cancer Research Center (DKFZ) and the segmentation of the syngo DynaCT (Fig. 3). The endoscope was registered with the software which allowed the endoscope to detect the different colors of the markers. The syngo DynaCT data were loaded into the software and the adenoma of the adrenal gland and the kidney were segmented. These images could At the University of Heidelberg in the Department of Urology, Dogu Teber, MD, performed a minimally invasive adrenalectomy using the Artis zeego and fusion of the intraoperative acquired images with an endoscope for surgical guidance. This surgery took place in the hybrid operating room of the Department of Vascular Surgery, owned by Prof. Dittmar Böckler, MD. After the first laparoscopic partial liver resection a year ago, technology and techniques have been further developed and the next minimally invasive laparoscopic approach was planned. Minimally invasive surgery offers major benefits for patients but also challenges the surgeon due to the lack of natural 3D vision as well as the lack of tactile sensing. Intraoperative imaging and especially fusion imaging can help the surgeon to better guide his instruments and offers a real-time update of the changing anatomy when preoperative imaging loses its value. In laparoscopic surgery in particular, the benefit of intraoperative soft tissue imaging can be very helpful. Tumor Detection A kidney urinary bladder tract (KUB) of an animal was used as a first phantom. An artificial Aggar tumor was injected into the kidney and a syngo DynaCT was performed (Fig. 1). The artificial tumor could be easily detected in the syngo DynaCT. The workflow that is described in detail below was tested and proved to be practical. Also, patient positioning, access, and image acquisition capabilities in this new and sophisticated environment were tested. Then the first patient was scheduled in the hybrid operating room. now be overlayed in the real time endoscopy image. Even movement of the structures could be detected because the software calculates the locations of the markers relative to one another. An optimal superimposed image was generated (Fig. 4). All Essential Information In a final step, for image guidance 3D overlay was used in live fluoroscopy to guide the instruments and evaluate the depth, which is not provided by the endoscope. By changing the angulation of the Artis zeego the images also adjusted and allowed the surgeon additional 3D information for the procedure (Fig. 5). This surgery was intended to prove that these principles can be applied and can help surgeons to optimize the procedure, particularly for critical structures. Further development and further research will follow. It was the first operation of its kind and it is obvious that technology and workflow offer a wide-open area for innovations. However, it also demonstrated that surgery of this quality can really change paradigms in minimally invasive surgery. Contact ina.schwabenland@siemens.com Surgery Urology 58  AXIOM Innovations | December 2013 | www.siemens.com/angiography


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