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TRANSCRIPT
Image Guided Surgery
Kazuhiro Yasufuku MD, PhD
Director of Endoscopy, University Health Network
Director, Interventional Thoracic Surgery Program
Associate Professor of Surgery, University of Toronto
Division of Thoracic Surgery, Toronto General Hospital
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2017 Duke Masters of Minimally Invasive Thoracic Surgery Sep 22-23rd, 2017
Disclosure
• Industry-sponsored grants• Educational and research
grants from Olympus Corporation
• Consultant• Olympus America Inc.
• Intuitive Surgical Inc.
• Medtronic
• Johnson and Johnson
• Auris Surgical Robotics
• Concordia Healthcare
• Research Collaboration• Siemens
• Novadaq Corp
• Veran Medical Technologies
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Image Guided Surgery (IGS) – Definition?
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Image Guided Surgery (IGS) – Definition?
• General term used for any surgical procedure wheresurgeons employs tracked surgical instruments inconjunction with preoperative or intraoperative images inorder to indirectly guide the procedure
• IGS was originally developed for treatment of brain tumors
• Various applications of navigations for neurosurgery havebeen widely used for almost two decades
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Image Guided Surgery (IGS) – in Thoracic Surgery
• Fluorescence Image Guided Surgery
• Virtual/Electromagnetic Navigation Guided Surgery
• Preoperative CT Guided Surgery
• Intraoperative Cone Beam CT Guided Surgery
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Fluorescence Image Guided Surgery
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ICG and Near Infrared (NIR) Imaging
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Surv Opthalmol, 2000
820-835nm
Mo
lar
exti
nct
ion
co
effi
cien
t (c
m-
1/M
)
M.W: 775
Indocyanine green NIR thoracoscope
PinPoint, Novadaq TechnologiesTM
ICG Fluorescence-Guided Surgery
• Sentinel LN Mapping
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J Thorac Cardiovasc Surg. 2013; 146: 562-70
• A-dose escalation phase 1 clinical trial
real-time NIR imaging after peritumoral
injection of 3.8 to 2500 μg
• 26 NIR(+) SLNs identified in 15 pts with 7
NIR(+) SLNs (6 pts) harboring metastatic
disease on histologic analysis
• Metastatic nodal disease never identified
in pts with a histologically negative NIR(+)
SLN
ICG Fluorescence-Guided Surgery
• NIR Thoracoscopic Segmental Resection
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J Thorac Cardiovasc Surg. 2012; 143: 1330-5
• ICG injection into the bronchus of target pulmonary segments under GA
• NIR Thoracoscopic identification of the target segments (Hamamatsu Photonics, Hamamatsu, Japan)
• Intersegmental lines and planes identified to allow segmental resection
ICG Fluorescence-Guided Surgery
• NIR Robotic Segmental Resection
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J Thorac Cardiovasc Surg. 2014; 148: 737-8
• iv injection of ICG after division of segment bronchus, vein and artery (2.5mg/10mL, 6-8mL bolus)
• Da Vinci Firefly fluorescence imaging for identification of the target segments
Virtual/Electromagnetic Navigation Guided Surgery
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Virtual assisted Lung Mapping
• VAL-MAP
• Bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection
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J Thorac Cardiovasc Surg. 2014; 147: 1813-9
Preoperative bronchoscopic marking
• CT Fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules
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CHEST 2004; 125:1747–1752
Preoperative ENB marking (fiducial, dye)
• ENB-guided VATS wedge resection of peripheral lung nodules
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Seminars in Thoracic and Cardiovascular Surgery, 22 , 2011J Community Hosp Intern Med Perspect. 2014; 4(1): 10
GTx (Guided Therapeutics) Program
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GTx OR at Toronto General Hospital
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GTx OR Capabilities
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Cone-Beam CT Dual Source- Dual Energy CT
MIS, Endoscopic Technology
Guided Therapeutics (GTx) Core
GTx OR Capabilities
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Cone-Beam CT
Guided Therapeutics (GTx) Core
Multi-Modality Surgical Guidance
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Optical Imaging
Surgical Tool TrackingIntraoperative CBCT
Surgical Planning
Pre-Operative Imaging
Intraoperative localization Image assistance during MIS/Robotic Surgery
Real time monitoring of minimally invasive thoracic
intervention
Optical Surgical Navigation
Surgical Tool TrackingIntraoperative CBCTPre-Operative Imaging
1. Preoperative CT imaging
2. Intraoperative CBCT Imaging
3. Image registration with
surgical navigation
Optical Surgical Navigation
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Chest Wall Tumor Resection
Guided Therapeutics (GTx) Core
GTx OR – VATS localization
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GTx OR – Image guided Transbronchial Interventions
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Ujiie et al, AATS 2016 abstract
CT-guided Microcoil Placement and ICG Injection
Ujiie et al, AATS 2016 abstract
Intraoperative NIR Localization
GTx OR – CBCT localization
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Summary
• Hybrid OR with capabilities of preoperative and intraoperative real-time radiologic imaging as well as advanced endoscopic procedures will assistsurgeons during Image Guided Surgery
• Advances in imaging technology will enable intraoperative localization of small peripheral nodule during minimally invasive surgery
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AcknowledgementLatner Thoracic Surgery LaboratoryYasufuku Laboratory
Hideki Ujiie
Kosuke Fujino
Chang Young Lee
Tomonari Kinoshita
Alex Gregor
Salma Hindy
Andrew Effat
Judy McConnell
Alexandria Grindlay
Kim Hudson
TECHNA Institute
David Jaffray
Robert Weersink
Jonathan Irish
Harley Chan
Michael Dunne
Jimmy Qiu
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Thank you
Division of Thoracic Surgery
Toronto General Hospital
University Health Network
Kazuhiro Yasufuku, MD, PhD, FCCP