Towards clinical implementation of ultrasound-based navigation for laparoscopic liver resection

Abstract

Liver cancer ranks seventh in global cancer prevalence and stands as the third leading cause of cancer-related deaths. Surgical resection is considered the gold standard for treatment of liver malignancies and has witnessed a shift toward minimally invasive techniques in recent decades. Surgeons rely on laparoscopic observations, preoperative imaging, and laparoscopic ultrasound for image guidance. However, these methods pose challenges in accurately representing the complex three-dimensional (3D) structure of the liver in a two-dimensional (2D) view. Surgical navigation devices aim to enhance this process by providing additional information for improved lesion localization and vascular structure visualization with respect to tracked surgical instruments. This study's objective was to establish an electromagnetically guided laparoscopic liver resection workflow at Netherlands Cancer Institute – Antoni van Leeuwenhoek (NKI-AvL) to be implemented into clinical practice.

A method was developed for tracking instruments in laparoscopic surgery, with a focus on the laparoscopic sealer/ divider. An adapter was developed with an embedded electromagnetic sensor to allow tracking. Calibration employed a dedicated device, followed by a comprehensive validation process encompassing usability, sterilizability, attachment reproducibility, and calibration accuracy. The adapter was produced from a non-ferromagnetic material, ensuring sterilizability and straightforward surgeon attachment, exhibiting positive results in reproducibility and virtual visualization. Nevertheless, the calibration accuracy, at 2.5 mm, could be enhanced, primarily through calibration method adjustments. Additionally, a fast calibration method for the laparoscopic ultrasound (LUS) probe adapter was developed, involving a dedicated calibration tool. Validation assessments to ascertain its reproducibility showed positive results. However, accuracy measurements can be further improved as ultrasound calibration method evaluation showed a root mean squared error (RMSE) of 3.6 mm. This is important as the navigation performance relies on the calibration accuracy of the tracked LUS probe. The workflow for navigated laparoscopic liver resection was tested using a liver phantom. It demonstrated the navigation system's capacity to register preoperative and intraoperative images with a mean target registration error (TRE) of 3.7 mm and showed promising augmented reality views. Additionally, this test led to workflow enhancements related to liver sensor placement and visualization techniques.

The developed navigation workflow for laparoscopic liver resection integrated Aurora EM tracking, tracked laparoscopic instruments, and software for intraoperative liver 3D model visualization. While feasible in an operating setting during phantom tests, further enhancements in visualization and accuracy are needed. A clinical study will be conducted to determine intraoperative feasibility, providing valuable experience to technical physicians and surgeons. In the near future, the presented navigation method may enhance laparoscopic resection accuracy and reduce disease recurrence. A clinical study at NKI-AvL will soon validate this navigation system for clinical use.