Steerable DROP-IN radioguidance during minimal-invasive non-robotic cervical and endometrial sentinel lymph node surgery.

PURPOSE: The recently introduced tethered DROP-IN gamma probe has revolutionized the way robotic radioguided surgery is performed, fully exploiting the nature of steerable robotic instruments. Given this success, the current first-in-human study investigates if the DROP-IN can also provide benefit in combination with steerable non-robotic instruments during conventional laparoscopic surgery, showing equivalence or even benefit over a traditional rigid gamma probe. METHODS: The evaluation was performed in ten patients during laparoscopic cervical (n = 4) and endometrial (n = 6) cancer sentinel lymph node (SLN) procedures. Surgical guidance was provided using the hybrid, or bi-modal, SLN tracer ICG-99mTc-nanocolloid. SLN detection was compared between the traditional rigid laparoscopic gamma probe, the combination of a DROP-IN gamma probe and a steerable laparoscopic instrument (LaproFlex), and fluorescence imaging. RESULTS: The gynecologists experienced an enlarged freedom of movement when using the DROP-IN + LaproFlex combination compared to the rigid laparoscopic probe, making it possible to better isolate the SLN signal from background signals. This did not translate into a change in the SLN find rate yet. In both cervical and endometrial cancer combined, the rigid probe and DROP-IN + LaproFlex combination provided an equivalent detection rate of 96%, while fluorescence provided 85%. CONCLUSION: We have successfully demonstrated the in-human use of steerable DROP-IN radioguidance during laparoscopic cervical and endometrial cancer SLN procedures, expanding the utility beyond robotic procedures. Indicating an improved surgical experience, these findings encourage further investigation and consideration on a path towards routine clinical practice and improved patient outcome. TRIAL REGISTRATION: HCB/2021/0777 and NCT04492995; https://clinicaltrials.gov/study/NCT04492995.

Advances in the development and application of non-contact intraoperative image access systems.

This article provides an overview of recent progress in the achievement of non-contact intraoperative image control through the use of vision and sensor technologies in operating room (OR) environments. A discussion of approaches to improving and optimizing associated technologies is also provided, together with a survey of important challenges and directions for future development aimed at improving the use of non-contact intraoperative image access systems.

State of the art medical devices for fluorescence-guided surgery (FGS): technical review and future developments.

BACKGROUND: Medical devices for fluorescence-guided surgery (FGS) are becoming available at a fast pace. The main challenge for surgeons lies in the lack of in-depth knowledge of optical imaging, different technical specifications and poor standardisation, and the selection of the best device based on clinical application. METHODS: This manuscript aims to provide an up-to-date description of the commercially available fluorescence imaging platforms by comparing their mode of use, required settings, image types, compatible fluorophores, regulatory approval, and cost. We obtained this information by performing a broad literature search on PubMed and by contacting medical companies directly. The data for this review were collected up to November 2023. RESULTS: Thirty-two devices made by 19 medical companies were identified. Ten systems are surgical microscopes, 5 can be used for both open and minimally invasive surgery (MIS), 6 can only be used for open surgery, and 10 only for MIS. One is a fluorescence system available for the Da Vinci robot. Nineteen devices can provide an overlay between fluorescence and white light image. All devices are compatible with Indocyanine Green, the most common fluorescence dye used intraoperatively. There is significant variability in the hardware and software of each device, which resulted in different sensitivity, fluorescence intensity, and image quality. All devices are CE-mark regulated, and 30 were FDA-approved. CONCLUSION: There is a prolific market of devices for FGS and healthcare professionals should have basic knowledge of their technical specifications to use it at best for each clinical indication. Standardisation across devices must be a priority in the field of FGS, and it will enhance external validity for future clinical trials in the field.

Does Freehand, Patient-specific Instrumentation or Surgical Navigation Perform Better for Allograft Reconstruction After Tumor Resection? A Preclinical Synthetic Bone Study.

BACKGROUND: Joint-sparing resection of periarticular bone tumors can be challenging because of complex geometry. Successful reconstruction of periarticular bone defects after tumor resection is often performed with structural allografts to allow for joint preservation. However, achieving a size-matched allograft to fill the defect can be challenging because allograft sizes vary, they do not always match a patient's anatomy, and cutting the allograft to perfectly fit the defect is demanding. QUESTIONS/PURPOSES: (1) Is there a difference in mental workload among the freehand, patient-specific instrumentation, and surgical navigation approaches? (2) Is there a difference in conformance (quantitative measure of deviation from the ideal bone graft), elapsed time during reconstruction, and qualitative assessment of goodness-of-fit of the allograft reconstruction among the approaches? METHODS: Seven surgeons used three modalities in the same order (freehand, patient-specific instrumentation, and surgical navigation) to fashion synthetic bone to reconstruct a standardized bone defect. National Aeronautics and Space Administration (NASA) mental task load index questionnaires and procedure time were captured. Cone-beam CT images of the shaped allografts were used to measure conformance (quantitative measure of deviation from the ideal bone graft) to a computer-generated ideal bone graft model. Six additional (senior) surgeons blinded to modality scored the quality of fit of the allografts into the standardized tumor defect using a 10-point Likert scale. We measured conformance using the root-mean-square metric in mm and used ANOVA for multipaired comparisons (p < 0.05 was significant). RESULTS: There was no difference in mental NASA total task load scores among the freehand, patient-specific instrumentation, and surgical navigation techniques. We found no difference in conformance root-mean-square values (mean ± SD) between surgical navigation (2 ± 0 mm; mean values have been rounded to whole numbers) and patient-specific instrumentation (2 ± 1 mm), but both showed a small improvement compared with the freehand approach (3 ± 1 mm). For freehand versus surgical navigation, the mean difference was 1 mm (95% confidence interval [CI] 0.5 to 1.1; p = 0.01). For freehand versus patient-specific instrumentation, the mean difference was 1 mm (95% CI -0.1 to 0.9; p = 0.02). For patient-specific instrumentation versus surgical navigation, the mean difference was 0 mm (95% CI -0.5 to 0.2; p = 0.82). In evaluating the goodness of fit of the shaped grafts, we found no clinically important difference between surgical navigation (median [IQR] 7 [6 to 8]) and patient-specific instrumentation (median 6 [5 to 7.8]), although both techniques had higher scores than the freehand technique did (median 3 [2 to 4]). For freehand versus surgical navigation, the difference of medians was 4 (p < 0.001). For freehand versus patient-specific instrumentation, the difference of medians was 3 (p < 0.001). For patient-specific instrumentation versus surgical navigation, the difference of medians was 1 (p = 0.03). The mean ± procedural times for freehand was 16 ± 10 minutes, patient-specific instrumentation was 14 ± 9 minutes, and surgical navigation techniques was 24 ± 8 minutes. We found no differences in procedure times across three shaping modalities (freehand versus patient-specific instrumentation: mean difference 2 minutes [95% CI 0 to 7]; p = 0.92; freehand versus surgical navigation: mean difference 8 minutes [95% CI 0 to 20]; p = 0.23; patient-specific instrumentation versus surgical navigation: mean difference 10 minutes [95% CI 1 to 19]; p = 0.12). CONCLUSION: Based on surgical simulation to reconstruct a standardized periarticular bone defect after tumor resection, we found a possible small advantage to surgical navigation over patient-specific instrumentation based on qualitative fit, but both techniques provided slightly better conformance of the shaped graft for fit into the standardized post-tumor resection bone defect than the freehand technique did. To determine whether these differences are clinically meaningful requires further study. The surgical navigation system presented here is a product of laboratory research development, and although not ready to be widely deployed for clinical practice, it is currently being used in a research operating room setting for patient care. This new technology is associated with a learning curve, capital costs, and potential risk. The reported preliminary results are based on a preclinical synthetic bone tumor study, which is not as realistic as actual surgical scenarios. CLINICAL RELEVANCE: Surgical navigation systems are an emerging technology in orthopaedic and reconstruction surgery, and understanding their capabilities and limitations is paramount for clinical practice. Given our preliminary findings in a small cohort study with one scenario of standardized synthetic periarticular bone tumor defects, future investigations should include different surgical scenarios using allograft and cadaveric specimens in a more realistic surgical setting.

Navigation surgery in musculoskeletal disorders.

BACKGROUND: This collection focuses on Navigation Surgery, we aim to explore the intersection of cutting-edge technology and musculoskeletal surgery. It covers recent advancements, challenges, and future directions in navigational techniques. Navigation devices reconstruct 3D surgical information on monitors, aiding in safer and more accurate operations across orthopedic surgeons. While beneficial, there are risks like misplaced implants, necessitating careful navigation usage. The collection encourages discussions on clinical applications and the ongoing evolution of navigation surgeries.

Robotic-assisted total knee arthroplasty is associated with the use of thinner polyethylene liners compared to navigation-guided and manual techniques.

PURPOSE: The purpose of this study was to examine the effects of intraoperative technology use on the rate of using polyethylene liners 15 mm or greater during primary total knee arthroplasty (TKA). METHODS: There were 103,295 implants from 16,386 primary unilateral TKAs performed on 14,253 patients at a single institution between 1 January 2018, and 30 June 2022, included in the current study. Robotic assistance and navigation guidance were used in 1274 (8%) and 8345 (51%) procedures, respectively. The remaining 6767 TKAs (41%) were performed manually. Polyethylene liners were manually identified and further subcategorised by implant thickness. Patients who underwent robotic-assisted TKA were younger (p < 0.001) and more likely to be male (p < 0.001) compared to patients who underwent navigation-guided or manual TKAs. RESULTS: Average polyethylene liner thickness was similar between groups (10.5 ± 1.5 mm for robotic-assisted TKAs, 10.9 ± 1.8 mm for navigation-guided TKAs and 10.8 ± 1.8 mm for manual TKAs). The proportions of polyethylene liners 15 mm or greater used were 4.9%, 3.8% and 1.9% for navigation-guided, manual and robotic-assisted procedures, respectively (p < 0.001). Multivariate regression analyses demonstrated that navigation-guided (odds ratio [OR]: 2.6, 95% confidence Interval [CI]: [1.75-4.07], p < 0.001) and manual (OR: 2.0, 95% CI: [1.34-3.20], p = 0.001) procedures were associated with an increased use of polyethylene liners 15 mm or greater. CONCLUSION: Robotic-assisted TKA was associated with a lower proportion of polyethylene liners 15 mm or greater used compared to navigation-guided and manual TKA. These findings suggest that robotic assistance can reduce human error via a more precise cutting system, limit over-resection of the tibia and flexion-extension gap mismatch and ultimately allow for more appropriately sized implants. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Distortion-Free Magnetic Tracking of Metal Instruments in Image-Guided Interventions.

Electromagnetic tracking (EMT) can benefit image-guided interventions in cases where line of sight is unavailable. However, EMT can suffer from electromagnetic distortion in the presence of metal instruments. Metal instruments are widely used in laparoscopic surgery, ENT surgery, arthroscopy and many other clinical applications. In this work, we investigate the feasibility of tracking such metal instruments by placing the inductive sensor within the instrument shaft. We propose a magnetostatic model of the field within the instrument, and verify the results experimentally for frequencies from 6 kHz to 60 kHz. The impact of the instrument's dimensions, conductivity and transmitting field frequency is quantified for ranges representative of typical metal instruments used in image-guided interventions. We then performed tracking using the open-source Anser EMT system and quantify the error caused by the presence of the rod as a function of the frequency of the eight emitting coils for the system. The work clearly demonstrates why smaller tool diameters (less than 8 mm) are less susceptible to distortion, as well as identifying optimal frequencies (1 kHz to 2 kHz) for transmitter design to minimise for distortion in larger instruments.

A Method to Reduce Tension Differences in Pull/Push Manipulation for a Robot in Fluorescence Emission-Guided Surgical Microscopy.

MOTIVATION: A fluorescence emission-guided microscope used to monitor the outcome of cancer removal surgery is highly effective when employing a manipulator to motorize and switch the observation direction. It is necessary to minimize the alignment of looper tension between the stands for pull/push to change the direction of the manipulator and reduce the error rate caused by tension differences. This paper presents a method to minimize the error rate of looper tension between the stands. METHODS: \The looper is inserted between the stands of the manipulator to minimize the difference in tension and make the stress on the pull and push of the looper constant. The constant stress allows the manipulator to move stably in left/right, up/down, and left/right movements, which will be effective for full-camera observation and close-up shots of the end effector. RESULTS: Reducing the tolerance for differences in the manipulator's looper tension (angle and tension) is crucial. When the input value of the looper tension angle is 50°, the output should closely match 50°. Consequently, the measured response has a tolerance of ±49.98%, resulting in an error rate of .02% (1/50th level). CONCLUSION: A method is proposed to minimize the error rate of the manipulator's looper tension in a robot-based fluorescence emission-guided microscope used to observe the status of cancer surgery. As a result, a stable manipulator with a minimal error rate can achieve a 3.986x magnification for close-up observation by switching between high and low orientations.

Direct Anterior Total Hip Arthroplasty with VELYS™ Hip Navigation.

We describe the technique of total hip arthroplasty via a direct anterior approach using the Depuy Synthes (Raynham, MA) VELYS™ Hip Navigation system This technique allows one to accurately set the acetabular component position as well as recreate leg length and offset to meet the goals of hip reconstruction in a precise and efficient manner.

Initial Experience With Ultra-High-Definition 3D Exoscope in Thyroid and Parathyroid Surgery.

BACKGROUND: Operation with a 3D exoscope has recently been introduced in clinical practice. The exoscope consists of two cameras placed in front of the operative field. Images are shown on a large 3D screen with high resolution. The system can be used to enhance precise dissection and provides new possibilities for improved ergonomics, fluorescence, and other optical-guided modalities. METHODS: Initial experience with the ultra-high-definition (4K) 3D exoscope in thyroid and parathyroid operations. The exoscope (OrbEyeTM) was mounted on a holding system (Olympus). RESULTS: We used the exoscope in parathyroidectomy (N = 6) and thyroidectomy (N = 6). Immediate advantages and disadvantages were discussed and recorded. The learning curve for use of the exoscope may be shorter for surgeons with training in endoscopic or robotic procedures. There may be improved ergonomics compared with normal open-neck operations. Further, the optical guided operations can be used with fluorescence and have potential for different on-lay techniques in the future. The 4 K 3D image quality is state-of-art and is highly appreciated during fine surgical dissection and eliminates the need for loupes. CONCLUSION: In several ways, using the ORBEYE™ in thyroid and parathyroid surgery provides the surgical team with a new and enhanced experience. This includes improved possibility for teaching, surgical ergonomics, and a 4K 3D camera with a powerful magnification system. However, it is not clear if utilization of these features would improve surgical outcomes. Furthermore, the ORBEYE™ lacks incorporation of parathyroid autofluorescence, and the current costs for the system do not facilitate general access to exoscope assisted operations.

Three-Dimensional Holographic-Guided Robotic Lung Segmentectomy for Deep Pulmonary Nodules: Technique and Initial Results.

Background: Diagnosis and treatment of small and isolated lung nodules remain challenging issues. Purpose: The aim of this article is to report the technique of real-time navigation using holographic reconstruction technology combined with a robot assisted thoracic surgery (RATS) platform for lung resection in patients with small deep nodules.Research Design: The pre-surgery 3D planning was based on the chest CT scan. The reconstruction was uploaded to a head-mounted display for real-time navigation during mini invasive robot assisted surgery performed with an open console platform. We evaluated this technique with the success rate of diagnosis, the operative time and the post-operative course.Study Sample: This technique was performed in 6 patients (4 female, mean age 65 years) to date.Results: The precision of the head-mounted display based localization system was effective in all cases without the need of open conversion. The mean diameter of the nodules was 8 mm (6-9). The diagnosis was a lung cancer (n = 5) and tuberculoma (n = 1). The mean operative time was 125 min (100-145). The mean hospital stay was 2.5 days (1-3).Conclusions: In conclusion, the intraoperative navigation using the 3D holographic assistance was an helpful tool for mini invasive RATS lung segmentectomy without the need of preoperative localization.

Comparison of the positional accuracy of robotic guided dental implant placement with static guided and dynamic navigation systems: A systematic review and meta-analysis.

STATEMENT OF PROBLEM: The development of robotic computer assisted implant surgery (r-CAIS) offers advantages, but how the positional accuracy of r-CAIS compares with other forms of guided implant surgery remains unclear. PURPOSE: The purpose of this systematic review and meta-analysis was to evaluate the positional accuracy of r-CAIS and to compare the positional accuracy of r-CAIS with s-CAIS and d-CAIS. MATERIAL AND METHODS: Five databases were systematically searched by 2 independent reviewers for articles published before May 2023. A manual search was also performed. Articles evaluating the positional accuracy of r-CAIS were included. The Cochrane risk of bias tool was used for the clinical studies, whereas the QUIN tool was used for the in vitro studies. A meta-analysis was performed to compare the positional accuracy of r-CAIS with d-CAIS. RESULTS: Thirteen studies were included, with 9 in vitro studies, 4 clinical studies, and a total of 920 dental implants. A high risk of bias was noted in 6 studies and low to moderate in 7 studies. R-CAIS showed greater accuracy for the coronal, apical, and angular deviations compared with d-CAIS. (-0.17 [-0.24, 0.09], (P<.001); -0.21 [-0.36, -0.06] (P=.006), and -1.41 [-1.56, -1.26] (P<.001)) CONCLUSIONS: R-CAIS can provide improved positional accuracy compared with d-CAIS when considering coronal, apical, and angular deviations. However, evidence to compare the positional accuracy of r-CAIS with s-CAIS was insufficient. These results should be interpreted with caution because of the limited data and the bias noted in several studies.

Ex vivo comparison of pin placement with patient-specific drill guides or freehand technique in canine cadaveric spines.

OBJECTIVE: To compare vertebral implant placement in the canine thoracolumbar spine between 3D-printed patient-specific drill guides (3DPG) and the conventional freehand technique (FH). STUDY DESIGN: Ex vivo study. ANIMALS: Cadaveric canine spines (n = 24). METHODS: Implant trajectories were established for the left and right sides of the T10 through L6 vertebrae based on computed tomography (CT) imaging. Customized drill guides were created for each vertebra of interest. Each cadaver was randomly assigned to one of six veterinarians with varying levels of experience placing vertebral implants. Vertebrae were randomly assigned a surgical order and technique (3DPG or FH) for both sides. Postoperative CT images were acquired. A single, blinded observer assessed pin placement using a modified Zdichavsky classification. RESULTS: A total of 480 implants were placed in 240 vertebrae. Three sites were excluded from the analysis; therefore, a total of 238 implants were evaluated using the FH technique and 239 implants using 3DPG. When evaluating implant placement, 152/239 (63.6%) of 3DPG implants were considered to have an acceptable placement in comparison with 115/248 (48.32%) with FH. Overall, pin placement using 3DPG was more likely to provide acceptable pin placement (p < .001) in comparison with the FH technique for surgeons at all levels of experience. CONCLUSION: The use of 3DPG was shown to be better than the conventional freehand technique regarding acceptable placement of implants in the thoracolumbar spine of canine cadavers. CLINICAL SIGNIFICANCE: Utilizing 3DPG can be considered better than the traditional FH technique when placing implants in the canine thoracolumbar spine.

Retrospective study comparing the accuracies of handheld infrared stereo camera and augmented reality-based navigation systems for total hip arthroplasty.

BACKGROUND: The use of portable navigation systems (PNS) in total hip arthroplasty (THA) has become increasingly prevalent, with second-generation PNS (sPNS) demonstrating superior accuracy in the lateral decubitus position compared to first-generation PNS. However, few studies have compared different types of sPNS. This study retrospectively compares the accuracy and clinical outcomes of two different types of sPNS instruments in patients undergoing THA. METHODS: A total of 158 eligible patients who underwent THA at a single institution between 2019 and 2022 were enrolled in the study, including 89 who used an accelerometer-based PNS with handheld infrared stereo cameras in the Naviswiss group (group N) and 69 who used an augmented reality (AR)-based PNS in the AR-Hip group (group A). Accuracy error, navigation error, clinical outcomes, and preparation time were compared between the two groups. RESULTS: Accuracy errors for Inclination were comparable between group N (3.5° ± 3.0°) and group A (3.5° ± 3.1°) (p = 0.92). Accuracy errors for anteversion were comparable between group N (4.1° ± 3.1°) and group A (4.5° ± 4.0°) (p = 0.57). The navigation errors for inclination (group N: 2.9° ± 2.7°, group A: 3.0° ± 3.2°) and anteversion (group N: 4.3° ± 3.5°, group A: 4.3° ± 4.1°) were comparable between the groups (p = 0.86 and 0.94, respectively). The preparation time was shorter in group A than in group N (p = 0.036). There were no significant differences in operative time (p = 0.255), intraoperative blood loss (p = 0.387), or complications (p = 0.248) between the two groups. CONCLUSION: An Accelerometer-based PNS using handheld infrared stereo cameras and AR-based PNS provide similar accuracy during THA in the lateral decubitus position, with a mean error of 3°-4° for both inclination and anteversion, though the AR-based PNS required a shorter preparation time.

A novel imageless accelerometer-based navigation system improves acetabular cup placement accuracy during total hip arthroplasty in the lateral decubitus position.

INTRODUCTION: The accuracy of acetabular cup placement using conventional portable imageless navigation systems in total hip arthroplasty (THA) in the lateral decubitus position remains challenging. Several novel portable imageless navigation systems have been developed recently to improve cup placement accuracy in THA. This study compared the accuracy of acetabular cup placement using a conventional accelerometer-based portable navigation (c-APN) system and a novel accelerometer-based portable navigation (n-APN) system during THA in the lateral decubitus position. MATERIALS AND METHODS: This retrospective cohort study compared 45 THAs using the c-APN and 45 THAs using the n-APN system. The primary outcomes were the absolute errors between the intraoperative and postoperative values of acetabular cup radiographic inclination and anteversion angles and the percentage of cases with absolute errors within 5°. Intraoperative values were shown on navigation systems, and postoperative measurements were conducted using computed tomography images. RESULTS: The median absolute errors of the cup inclination angles were significantly smaller in the n-APN group than in the c-APN group (3.9° [interquartile range 2.2°-6.0°] versus 2.2° [interquartile range 1.0°-3.3°]; P = 0.002). Additionally, the median absolute errors of the cup anteversion angles were significantly smaller in the n-APN group than in the c-APN group (4.4° [interquartile range 2.4°-6.5°] versus 1.9° [interquartile range 0.8°-2.7°]; P < 0.001). Significant differences were observed in the percentage of cases with absolute errors within 5° of inclination (c-APN group 67% versus n-APN group 84%; P = 0.049) and anteversion angles (c-APN group 62% versus n-APN group 91%; P = 0.001). CONCLUSIONS: The n-APN system improved the accuracy of the cup placement compared to the c-APN system for THA in the lateral decubitus position.

Augmenting Reality in Spinal Surgery: A Narrative Review of Augmented Reality Applications in Pedicle Screw Instrumentation.

Background and Objectives: The advent of augmented reality (AR) in spinal surgery represents a key technological evolution, enhancing precision and safety in procedures such as pedicle screw instrumentation. This review assesses the current applications, benefits, and challenges of AR technology in spinal surgery, focusing on its effects on surgical accuracy and patient outcomes. Materials and Methods: A comprehensive review of the literature published between January 2023 and December 2024 was conducted, focusing on AR and navigational technologies in spinal surgery. Key outcomes such as accuracy, efficiency, and complications were emphasized. Results: Thirteen studies were included, highlighting substantial improvements in surgical accuracy, efficiency, and safety with AR and navigational systems. AR technology was found to significantly reduce the learning curve for spinal surgeons, improve procedural efficiency, and potentially reduce surgical complications. The challenges identified include high system costs, the complexity of training requirements, the integration with existing workflows, and limited clinical evidence. Conclusions: AR technology holds promise for advancements in spinal surgery, particularly in improving the accuracy and safety of pedicle screw instrumentation. Despite existing challenges such as cost, training needs, and regulatory hurdles, AR has the potential to transform spinal surgical practices. Ongoing research, technological refinements, and the development of implementation strategies are essential to fully leverage AR's capabilities in enhancing patient care.

EndoNaut two-dimensional fusion imaging with a mobile C-arm for endovascular treatment of occlusive peripheral arterial disease.

BACKGROUND: Endovascular treatment has become the first-line strategy for peripheral arterial disease (PAD). Given the number of procedures required, any technology associated with a reduction in radiation exposure and contrast volume is highly relevant. In the present study, we evaluated whether two-dimensional (2D) fusion imaging could reduce the radiation exposure and contrast volume during endovascular treatment of occlusive PAD. METHODS: Our consecutive, retrospective, single-center, nonrandomized comparative trial included patients with PAD at the femoral, popliteal, and/or tibial level, at any clinical stage, if they were candidates for endovascular revascularization. Patients were treated with or without the EndoNaut 2D fusion imaging system (Therenva, Rennes, France) in a nonhybrid room with the same Cios Alpha mobile C-arm (Siemens, Munich, Germany). The indirect dose-area product and contrast medium volume were recorded. RESULTS: Between March 2018 and April 2020, 255 patients underwent endovascular femoropopliteal revascularization with (n = 124) or without (n = 131) 2D fusion imaging. The volume of injected contrast medium (34.7 ± 13.8 mL vs 51.3 ± 26.7 mL; P < .001) and dose-area product (8.9 ± 9.9 Gy/cm2 vs 13.5 ± 14.0 Gy/cm2; P = .003) were significantly lower for the 2D fusion imaging group than for the control group. A subgroup analysis of complex (TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease C/D) lesions showed similar results. Stratification of the fusion imaging group into three subgroups, according to the procedure dates, showed no effect of a potential learning curve on the operative parameters. CONCLUSIONS: The results from the present study showed a significant reduction in the contrast volume and radiation dose for endovascular treatment of PAD when applying 2D fusion imaging technology. Overall, a reduction of >30% was observed for both operative parameters, without excessive training requirements, highlighting the potential benefits of using 2D fusion imaging when performing endovascular revascularization for PAD.

Image Navigation Surgery With the Fluorescent Ureteral Catheter of Recurrent Tumors in the Pelvic Cavity.

INTRODUCTION: Ureteral injury during pelvic surgery is a serious complication that requires special attention. The fluorescent ureteral catheter near-infrared ray catheter sets are 6.0F catheters containing fluorescent substances along their length that can be recognized by a laparoscopic indocyanine green camera. We present our experience using a near-infrared ray catheter in 6 consecutive patients who underwent surgery for recurrent pelvic tumors. TECHNIQUE: The near-infrared ray catheters were inserted into the bilateral ureters in all patients, with the exception of patient 5 (left unilateral), by urologists using a cystoscope with the same technique as that commonly used in placing ureteral stents under general anesthesia. A laparoscopic indocyanine green camera was adapted to identify the ureters. From February 2020 to July 2020, 6 consecutive patients with recurrent pelvic tumors underwent surgery using a near-infrared ray catheter. In 3 patients, recurrent tumors were detected in the pelvic cavity after surgery for colon cancer (1 patient each of peritoneal recurrence behind the seminal vesicles, lymph node metastasis on the residual superior rectal artery, and peritoneal recurrence at the peritoneal reflection). Two patients had postoperative local recurrences of rectal cancer. The last patient had a recurrence of cervical carcinoma invading the rectum. RESULTS: All patients underwent surgery under ureteral image navigation using near-infrared ray catheter not only for ureter preservation during the operation (4 patients) but also for the combined resection of the ureter with recurrent tumors (2 patients). One patient experienced postoperative ureteral stenosis on postoperative day 21 that required a ureteral double J-stent placement in the left ureter. CONCLUSION: Near-infrared ray catheter has the potential to reduce inadvertent periureteral dissection because the ureter can be identified before approaching it.

Bio-inspired multimodal 3D endoscope for image-guided and robotic surgery.

Image-guided and robotic surgery based on endoscopic imaging technologies can enhance cancer treatment by ideally removing all cancerous tissue and avoiding iatrogenic damage to healthy tissue. Surgeons evaluate the tumor margins at the cost of impeding surgical workflow or working with dimmed surgical illumination, since current endoscopic imaging systems cannot simultaneous and real-time color and near-infrared (NIR) fluorescence imaging under normal surgical illumination. To overcome this problem, a bio-inspired multimodal 3D endoscope combining the excellent characteristics of human eyes and compound eyes of mantis shrimp is proposed. This 3D endoscope, which achieves simultaneous and real-time imaging of three-dimensional stereoscopic, color, and NIR fluorescence, consists of three parts: a broad-band binocular optical system like as human eye, an optical relay system, and a multiband sensor inspired by the mantis shrimp's compound eye. By introducing an optical relay system, the two sub-images after the broad-band binocular optical system can be projected onto one and the same multiband sensor. A series of experiments demonstrate that this bio-inspired multimodal 3D endoscope not only provides surgeons with real-time feedback on the location of tumor tissue and lymph nodes but also creates an immersive experience for surgeons without impeding surgical workflow. Its excellent characteristics and good scalability can promote the further development and application of image-guided and robotic surgery.

Impact of Cusp-Overlap View for TAVR with Self-Expandable Valves on 30-Day Conduction Disturbances.

METHODS AND RESULTS: We retrospectively compared 257 consecutive patients undergoing TAVR with self-expandable valves using either CON (n = 101) or COVL (n = 156) in four intermediate/low volume centers. There were no significant differences in baseline characteristics between the groups. The 30-day incidence of new-onset LBBB (12.9% vs. 5.8%; p=0.05) and PPMI rate (17.8% vs. 6.4%; p=0.004) was significantly lower when using the COVL implantation view. There was no difference between the CON and COVL groups in 30-day incidence of death (4.9% vs. 2.6%), any stroke (0% vs. 0.6%), and the need for surgical aortic valve replacement (0% for both groups). CONCLUSION: Using the COVL view for implantation, we achieved a significant reduction of the LBBB and PPMI rate after TAVR in comparison with the traditional CON view, without compromising the TAVR outcomes when using self-expandable prostheses.