Liver planning software accurately predicts postoperative liver volume and measures early regeneration.

BACKGROUND: Postoperative or remnant liver volume (RLV) after hepatic resection is a critical predictor of perioperative outcomes. This study investigates whether the accuracy of liver surgical planning software for predicting postoperative RLV and assessing early regeneration. STUDY DESIGN: Patients eligible for hepatic resection were approached for participation in the study from June 2008 to 2010. All patients underwent cross-sectional imaging (CT or MRI) before and early after resection. Planned remnant liver volume (pRLV) (based on the planned resection on the preoperative scan) and postoperative actual remnant liver volume (aRLV) (determined from early postoperative scan) were measured using Scout Liver software (Pathfinder Therapeutics Inc.). Differences between pRLV and aRLV were analyzed, controlling for timing of postoperative imaging. Measured total liver volume (TLV) was compared with standard equations for calculating volume. RESULTS: Sixty-six patients were enrolled in the study from June 2008 to June 2010 at 3 treatment centers. Correlation was found between pRLV and aRLV (r = 0.941; p < 0.001), which improved when timing of postoperative imaging was considered (r = 0.953; p < 0.001). Relative volume deviation from pRLV to aRLV stratified cases according to timing of postoperative imaging showed evidence of measurable regeneration beginning 5 days after surgery, with stabilization at 8 days (p < 0.01). For patients at the upper and lower extremes of liver volumes, TLV was poorly estimated using standard equations (up to 50% in some cases). CONCLUSIONS: Preoperative virtual planning of future liver remnant accurately predicts postoperative volume after hepatic resection. Early postoperative liver regeneration is measureable on imaging beginning at 5 days after surgery. Measuring TLV directly from CT scans rather than calculating based on equations accounts for extremes in TLV.

Evaluation of a minimally invasive image-guided surgery system for hepatic ablation procedures.

BACKGROUND: The Explorer Minimally Invasive Liver (MIL) system uses imaging to create a 3-dimensional model of the liver. Intraoperatively, the system displays the position of instruments relative to the virtual liver. A prospective clinical study compared it with intraoperative ultrasound (iUS) in laparoscopic liver ablations. METHODS: Patients undergoing ablations were accrued from 2 clinical sites. During the procedures, probes were positioned in the standard fashion using iUS. The position was synchronously recorded using the Explorer system. The distances from the probe tip to the tumor boundary and center were measured on the ultrasound image and in the corresponding virtual image captured by the Explorer system. RESULTS: Data were obtained on the placement of 47 ablation probes during 27 procedures. The absolute difference between iUS and the Explorer system for the probe tip to tumor boundary distance was 5.5 ± 5.6 mm, not a statistically significant difference. The absolute difference for probe tip to tumor center distance was 8.6 ± 7.0 mm, not statistically different from 5 mm. DISCUSSION: The initial clinical experience with the Explorer MIL system shows a strong correlation with iUS for the positioning of ablation probes. The Explorer MIL system is a promising tool to provide supplemental guidance information during laparoscopic liver ablation procedures.

Evolution of image-guided liver surgery: transition from open to laparoscopic procedures.

INTRODUCTION: Indications for liver surgery to treat primary and secondary hepatic malignancies are broadening. Utilizing data from B-mode or 2-D intraoperative ultrasound, it is often challenging to replicate the findings from preoperative CT or MRI scans. Additional data from more recently developed image-guidance technology, which registers preoperative axial imaging to a 3-D real-time model, may be used to improve operative planning, locate difficult to find hepatic tumors, and guide ablations. METHODS: Laparoscopic liver procedures are often more challenging than their open counterparts. Image-guidance technology can assist in overcoming some of the obstacles to minimally invasive liver procedures by enhancing ultrasound findings and ablation guidance. This manuscript describes a protocol that evaluated an open image-guidance system, and a subsequent protocol that directly compared, for validation, a laparoscopic with an open image-guidance system. Both protocols were limited to ablations within the liver. DISCUSSION: The laparoscopic image-guidance system successfully creates a 3-D model at both 7 and 14 mm Hg that is similar to the open 3-D model. Ultimately, improving intraoperative image guidance can help expand the ability to perform both laparoscopic and open liver surgeries.

Image-guided liver surgery: intraoperative projection of computed tomography images utilizing tracked ultrasound.

BACKGROUND: Ultrasound (US) is the most commonly used form of image guidance during liver surgery. However, the use of navigation systems that incorporate instrument tracking and three-dimensional visualization of preoperative tomography is increasing. This report describes an initial experience using an image-guidance system with navigated US. METHODS: An image-guidance system was used in a total of 50 open liver procedures to aid in localization and targeting of liver lesions. An optical tracking system was employed to localize surgical instruments. Customized hardware and calibration of the US transducer were required. The results of three procedures are highlighted in order to illustrate specific navigation techniques that proved useful in the broader patient cohort. RESULTS: Over a 7-month span, the navigation system assisted in completing 21 (42%) of the procedures, and tracked US alone provided additional information required to perform resection or ablation in six procedures (12%). Average registration time during the three illustrative procedures was <1 min. Average set-up time was approximately 5 min per procedure. CONCLUSIONS: The Explorer™ Liver guidance system represents novel technology that continues to evolve. This initial experience indicates that image guidance is valuable in certain procedures, specifically in cases in which difficult anatomy or tumour location or echogenicity limit the usefulness of traditional guidance methods.

Experimental model for functional magnetic resonance imaging of somatic sensory cortex in the unanesthetized rat.

Functional magnetic resonance imaging (fMRI) has evolved into a method widely used to map neural activation in the human brain. fMRI is a method for recording blood oxygen level-dependent (BOLD) signals. These signals change with local cerebral blood flow coupled to neural activity. However, the relationship between BOLD signals and neural function is poorly understood and requires the development of animal models. Here we use an unanesthetized rat preparation to study BOLD responses to whisker stimulation in somatic sensory barrel cortex. Five rats were trained to tolerate restraint in a holder and fMRI noise with positive reinforcement. For maximal immobilization, the head was fastened to the holder with nuts screwed on threaded bolts attached to the head. On scanning day, residual stress was alleviated with injections of diazepam, and the rats were restrained in the holder and transferred into the scanner. After >75 min to allow the tranquilization to abate, structural images were acquired from three coronal brain slices. Subsequently, functional images were taken utilizing 4-min epochs without stimulation alternated with equivalent epochs during which the right caudal whiskers were stimulated with three air puffs/s. After 4 weeks, fMRI could be repeated in four rats. In seven of the nine functional runs, head motion was minimal and whisker stimulation resulted in a statistically significant (P

Optical imaging reveals retinotopic organization of dorsal V3 in New World owl monkeys.

Optical imaging of intrinsic responses to visual stimuli in extrastriate cortex of owl monkeys provided evidence for the dorsal half of the third visual area, V3. Visual stimuli were used to selectively activate locations in dorsolateral V2 and the rostrally adjoining presumptive V3. Consistent with the proposed retinotopies of dorsal V2 and dorsal V3, small bars of drifting gratings along the horizontal meridian of the contralateral hemifield activated cortex along the V2V3 border, whereas such stimuli along the vertical meridian activated cortex along the rostral border of V3. Stimuli in limited locations in the lower visual quadrant revealed mirror reversals of retinotopy in dorsal V2 and V3, whereas stimuli in the upper visual quadrant failed to activate either region. Brain sections processed for cytochrome oxidase from the same cases provided architectonic borders of V2 that matched those indicated by the optical imaging. The results support the concept that a narrow dorsal V3 exists in monkeys. V3d borders dorsal V2 and contains a smaller, mirror-image representation of the lower visual quadrant.

Design and implementation of a PC-based image-guided surgical system.

In interactive, image-guided surgery, current physical space position in the operating room is displayed on various sets of medical images used for surgical navigation. We have developed a PC-based surgical guidance system (ORION) which synchronously displays surgical position on up to four image sets and updates them in real time. There are three essential components which must be developed for this system: (1) accurately tracked instruments; (2) accurate registration techniques to map physical space to image space; and (3) methods to display and update the image sets on a computer monitor. For each of these components, we have developed a set of dynamic link libraries in MS Visual C++ 6.0 supporting various hardware tools and software techniques. Surgical instruments are tracked in physical space using an active optical tracking system. Several of the different registration algorithms were developed with a library of robust math kernel functions, and the accuracy of all registration techniques was thoroughly investigated. Our display was developed using the Win32 API for windows management and tomographic visualization, a frame grabber for live video capture, and OpenGL for visualization of surface renderings. We have begun to use this current implementation of our system for several surgical procedures, including open and minimally invasive liver surgery.