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46 Video-Based Training Apps andDeferred Live Surgery
483
Fig. 46.10 Video-in-Picture (VIP) image of capabilities of the dLive platform
vers, in addition to the method of communicating
Conclusion
the planes of dissection and aiding each other in
completing the excision and gastrointestinal
reconstruction. The dLiveMed group has been
able to also bookmark various procedural landmarks, allowing the presenter to focus on these
aspects, if asked by the audience, or to toggle
between different cases to demonstrate differences in, for example, lateral or anterior perineal
dissection planes in thin and obese patients.
Although there may be a persistent and important role for live surgery sessions, we propose
that the dLive concept is an additional tool to
demonstrate all aspects of a surgical procedure or
intervention in optimal quality, with the maintained advantages of live surgical broadcasts —
but also avoiding some of the discussed ethical
concerns that are being brought forth. It will form
As novel tools for surgical training are developing quickly, they will allow us to increase the
quality and accessibility of cognitive skills
training. Video teaching will play an important
role in advancing the teaching of MIS techniques. Furthermore, ease of access on mobile
devices will further increase the availability to
learners. Additionally, using multi-camera synchronized deferred recording, educating large
audiences about these surgical skills can be
made more easily available in a less controversial fashion, known as Deferred Live surgery
(dLive). These new training pathways hold signicant value and serve as important adjuncts
for the education of complex procedures such as
taTME.
a critical component of the cognitive training
pathway for trainees and practicing surgeons
alike, further improving the safety of introduction of new techniques such as taTME into
practice.
Acknowledgements We acknowledge Stephanie
Philippaerts and the iLappSurgery Foundation for the
illustrations and VIP-technology used in this manuscript.
Twitter: @iLappSurgery. Website: www.ilappsurgery.
com
484
J. Knol
Disclosures Joep Knol is co-founder of the
iLappSurgery Foundation, which is a non for
prot organization.
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Navigation forTransanal Total
Mesorectal Excision
LuisGustavoCapochinRomagnolo,
ArthurRandolphWijsmuller,
andArmandoGeraldoFranchiniMelani
47
Introduction
Functional and oncological outcome after multimodal treatment for rectal cancer could be
improved. This can be achieved with a better recognition of anatomical dissection planes, of anatomical landmarks, and of the dissection margin
to the tumor to optimize resection margins and to
minimize iatrogenic nerve damage. Recently, the
performance of stereotactic navigation for minimally invasive transanal rectal surgery has been
reported [1, 2]. Additionally, critical challenges
related to soft-tissue stereotactic pelvic navigation were assessed [3]. Surgical navigation systems could improve the quality of surgery for
rectal cancer as shown when used in other contexts. It is likely to improve the accuracy and efciency of pelvic surgical procedures in which it is
difcult or impossible to identify and dissect
along anatomical planes.
L. G. C. Romagnolo
IRCAD Latin America, Barretos, Brazil
Department of Surgery, Barretos Cancer Hospital,
Barretos, Brazil
A. R. Wijsmuller
Department of Surgery, University Medical Center
Groningen, Groningen, The Netherlands
A. G. F. Melani
IRCAD Latin America, Barretos, Brazil
Americas Medical City, Rio de Janeiro, Brazil
(*)
Functional and oncological outcome after
multimodal treatment for rectal cancer could be
improved. Long-term morbidity after multimodal
treatment for rectal cancer is reported in up to
one third of patients, and it is suggested to mainly
originate from nerve injury-related disorders
such as urogenital and bowel dysfunctions [4–6].
Additionally, a positive circumferential resection
margin (CRM) rate has been reported in a signicant number of laparoscopic rectal resections –
up to 12% (range 3–12)– being even higher in
case of low rectal cancers [7–11]. For this reason,
the transanal approach was developed for TME
(taTME) [12]. Potential benets of this approach
include a better oncological outcome via a
decrease in the positive CRM rate with a better
specimen quality and better quality of life through
increased sphincter and nerve preservation. On
the other hand, taTME is associated with new
challenges related to this bottom-up approach to
the pelvic anatomy, especially when performing
dissection anteriorly. Urethral injuries have been
described since the inception of taTME [13, 14].
Additionally, air embolisms were described,
probably resulting from venous lesions anterolaterally at the level of the neurovascular bundle of
Walsh [13].
The challenges associated with improved
oncological and functional outcomes have one
thing in common; namely, the importance of the
recognition of anatomical dissection planes, of
anatomical landmarks, and of the dissection
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_47
485
486
L. G. C. Romagnolo et al.
Fig. 47.1 A stereoscopic infrared emitting optical system
continuously tracks the patient and instrument by detecting infrared light which is reected by marker spheres
afxed to a patient tracker and an instrument tracker. On
margin to the tumor to optimize resection margins and to minimize iatrogenic damage.
Consequently, surgical navigation could improve
the quality of surgery for rectal cancer as shown
for stereotactic navigation, a type of surgical navigation, when used in other contexts.
Stereotactic navigation was developed by neurosurgeons who integrated medical imaging and
intraoperative stereotaxy [15]. Stereotactic navigation functions quite similarly to a navigation
system in a car. Both systems determine and track
the position of an instrument or a car in relation
to a patient or the earth, respectively. However,
the type of localization technology differs. A stereotactic navigation system does not localize via
triangulation similarly to a global positioning
system with the help of several satellites. It localizes and tracks reective marker spheres by
means of a stereoscopic infrared emitting camera. Subsequently, by means of a process that is
called registration, a point in patient space is
assigned to the corresponding anatomical point
in image space.
It is reported to increase safety and to minimize the invasiveness of surgical procedures by
acting as a real-time guidance tool during the
operation using tracked surgical instruments in
conjunction with preoperative images. It helps
the surgeon to identify anatomical structures,
which should be targeted or avoided. These systems are currently mainly used in the brain, skull
base, and vertebral surgery, and they have proven
to be an essential adjunct to surgical procedures
an additional screen which is connected to the navigation
platform, the location of the tip of the instrument is displayed in the image data set
where anatomical landmarks are obscured and
cannot be used for topographic orientation [16].
The rst reports of the performance of stereotactic navigation for minimally invasive transanal
rectal surgery were published by Atallah etal. in
2015 [1, 2]. The challenges associated with stereotactic pelvic navigation were recently assessed
by a study investigating the potential differences
in patient anatomy between intraoperative lithotomy and preoperative supine position for imaging [3]. It seems that when several aspects related
to patient setup are taken into account, pelvic stereotactic navigation can be performed with
accuracy.
Equipment andOperative Setup
The navigation systems which have been used for
stereotactic soft-tissue navigation during transanal rectal surgery rely on several major components (Fig.47.1):
• A stereoscopic infrared emitting optical
system – determines the position of an
instrument and the pelvis of the patient in
the operation room (OR) by detecting
infrared light which is reected by
marker spheres afxed to a patient tracker
and an instrument tracker (Fig.47.1).
47 Navigation forTransanal Total Mesorectal Excision
• A patient tracker– is xed to the patient
or operating table and has marker
spheres xed to it for continuous tracing
of the patient by means of the optical
system (Fig.47.2).
• An instrument tracker– is xed to an
instrument and has marker spheres xed
to it for continuous tracing by means of
the optical system (Fig.47.3).
• Skin ducials– at least four ducials are
xed to the skin of the patient during CT
scan just before the operation. Initially in
the OR, the position of the pelvis is determined by touching the center of these
ducials via a calibrated instrument with
marker spheres attached to it (Fig.47.2).
• A computer platform – matches the
three-dimensional position of the patient
to the CT scan by recognition of the
ducials. The position of the tip of the
instrument in the 3D image data set is
depicted on a separate screen.
• Merging software – merges an MRI or
CT scan which was performed well in
advance and which relevant anatomical
structures and tumor were segmented to
the most recent CT scan with ducials
which was used to determine the position of the patient.
487
In stereotactic navigation, it is essential to
obtain a perfect patient position registration in the
OR by means of the infrared optical system. To do
so, several skin reference points overlying the
area of anatomical interest are marked by means
of at least four radiopaque ducials during preoperative CT scanning, and these ducials are left in
place or changed for sterile ducials intraoperatively. In the studies, published 12 to 18 ducials
were placed on the skin anteriorly to the pelvic
area to optimize the registration process [1–3].
Subsequently, after uploading these preoperative
CT scan images to the navigation system, the
position of the patient in the operation room (OR)
can be determined via recognition and registration
of the position of the ducials by using a calibrated instrument of which the position of the tip
is recognized by the infrared optical system
(Fig. 47.2). This is the only registration option,
which has been described in the literature for stereotactic soft-tissue pelvic navigation [1–3]. After
this registration, the patient is tracked by means of
optical markers on a patient tracker, which is xed
to the operating table or the patient’s anterior
superior iliac spine by Kirschner wires or a screw
(Fig. 47.2). Surgical instruments are tracked by
means of an instrument tracker, which is xed to
the instrument allowing the position of the tip of
the instrument to be determined and visualized in
the navigation scans (Figs. 47.3 and 47.4). A
computerized process is used to match the
Fig. 47.2 Several ducials are placed on the skin anteriorly to the pelvic area. After a CT scan has been made just
preoperatively with these ducials in situ, this image data
set is uploaded to the navigation system. These sterile
ducials can then be changed for sterile skin markers after
marking. Subsequently, the position of the patient in the
OR can be determined via recognition and registration of
the position of the ducials/markers by using a calibrated
instrument (with marker spheres xed to it) of which the
position of the tip is recognized by the infrared optical
system. Additionally, the patient tracker (with marker
spheres xed to it) can be recognized which is xed to the
patient or OR table
488
Fig. 47.3 The tip of a surgical instrument can be tracked by means of an instrument tracker which is xed to the instrument. It can be attached to an energy device or a regular surgical instrument
L. G. C. Romagnolo et al.
abc
Fig. 47.4 The position of the tip of the surgical instrument is displayed in the image data set. Using an abdominal approach, the aortic bifurcation (a) and the left ureter
three-dimensional position of the patient in the
OR to the preoperative images which will be used
for navigation.
Three surgical infrared optical navigation platforms were reported to have been used for stereotactic soft-tissue pelvic navigation (StealthStation
®S7 Surgical Navigation System, Medtronic Inc.,
Louisville, USA; Stryker Navigation, Kalamazoo,
MI, USA; CURVE Navigation System, Brainlab,
Feldkirchen, Germany) [1, 3, 17]. All systems
rely on a stereoscopic camera emitting infrared
light, a computer platform, a patient tracker, and
an instrument tracker.
Specic Pelvic Surgery-Related
Challenges
Since anatomical structures at risk during rectal
surgery are xed retroperitoneally, they seem to
be less affected by pneumoperitoneum and respiratory movements as compared to upper abdomi-
are located (b). During a transanal endoscopic approach,
the border of the mesorectum is located (c)
nal organs. However, pelvic surgery is associated
with additional challenges as compared to surgical navigation in other contexts such as neurosurgery and orthopedic surgery. Rectal surgery is
performed in patients with variable degrees of
lithotomy, a position which is different from the
supine position used for acquisition of preoperative imaging. This positional change could alter
the patient anatomy and subsequently render stereotactic pelvic navigation using preoperative
imaging inaccurate. Additionally, the motion of
the skin reference points with their ducial markers by means of positional change may hamper
patient position registration in the operating room
(OR) to begin with. To assess these challenges, a
study was undertaken to determine the difference
in patient anatomy, sacral tilt, and ducial marker
position between these different patient positions
and to investigate the feasibility and optimal
setup for stereotactic pelvic navigation [3]. Four
consecutive human anatomical specimens were
submitted to repeated CT scans in a supine and
47 Navigation forTransanal Total Mesorectal Excision
489
several degrees of lithotomy position. Patient
anatomy, sacral tilt, and skin ducial position
were compared by means of an image computing
platform. In two specimens, a 10-degree wedge
was introduced to reduce the natural tilt of the
sacrum during the shift from a supine to a lithotomy position. A simulation of laparoscopic and
transanal surgical procedures was performed to
assess the accuracy of stereotactic navigation.
An up-to-supracentimetric change in patient
anatomy was noted between different patient
positions. This observation was minimized
through the application of a wedge. When switching from a supine to another position, sacral retroversion occurred irrespective of the use of a
wedge. There was considerable skin ducial
motion between different positions. Accurate stereotactic navigation was obtained with the least
registration error (1.9mm) when the position of
the anatomical specimen was registered in a
supine position with straight legs, without pneumoperitoneum, using a conventional CT scan
with an identical specimen positioning.
The authors concluded that the change in
patient anatomy is small during the sacral tilt
induced by positional changes when using a
10-degree wedge, allowing for an accurate stereotactic surgical navigation when certain prerequisites are taken into account. The following
aspects should be considered and included in the
protocol for an optimal setup of point-merge stereotactic navigation in pelvic surgery. Patient
position registration should be performed without pneumoperitoneum in a patient position
which is similar to the position during preoperative CT scanning with ducials. This is because a
changing patient position results in skin ducial
motion, which hampers accurate patient position
registration. A supine position with straight legs
is the preferred position. The patient tracker
should be xed into the anterior superior iliac
spine to integrate the change in the sacral tilt
angle into the surgical navigation system, since a
change is expected to occur when switching positions. Finally, a forced sacral tilt seems to minimize the change in patient anatomy.
Limitations related to stereotactic navigation
include the need for maintaining a direct line of
sight between the infrared camera of the navigation system and the patient and instrument
tracker. This line of sight can be hampered by the
patient’s legs which are placed in lithotomy and
the surgeon who is positioned between the
patient’s legs. Another limitation is that stereotactic navigation relies on preoperative images
for accurate navigation. As a result, real-time
geometric changes in pelvic anatomy caused by
tissue dissection and traction are known to affect
the accuracy of stereotactic navigation.
Other factors which should be considered
based on earlier studies on pelvic organ motion
are the following: rectal and bladder volume
should be equal during the scans which are used
for registration/ navigation, as well as intraoperatively. Consequently, the bladder should be emptied before scanning as well as intraoperatively
via the placement of a urinary catheter. The rectum should be emptied by means of an enema. In
case of transanal TME, the rectum should be emptied just before closing the purse string. The pelvic diaphragmatic muscle tension should be equal
during the scans, as well as intraoperatively.
Clinical Application
Stereotactic soft-tissue pelvic navigation has
reported to have been used invivo for laparoscopic
and transanal approaches for locally advanced and
recurrent rectal cancer cases [2, 17]. Atallah etal.
used image-guided real-time navigation in four
patients with anteriorly located locally advanced
rectal cancer [1, 2]. They used it during the transanal portion of the operation and reported radical
resections for all patients without any intraoperative complications. At a median follow-up of
18 months for three patients, there was no evidence of locoregional recurrence of distant metastatic disease [1]. Atallah etal. also used it during
a laparoscopic approach for a mixed cystic and
solid neoplasm in the left perirectal space of which
they performed a complete excision without any
perioperative complications [18]. Kawada et al.
reported the performance of stereotactic navigation during a laparoscopic Hartmann’s operation
with distal sacrectomy for a recurrent rectal cancer
490
L. G. C. Romagnolo et al.
[17]. A radical resection was performed without
any perioperative complications.
Future Directions inPelvic
Stereotactic Navigation
Stereotactic navigation would be more effective
when the tumor, relevant anatomical structures,
and resection margins are highlighted. MRI is currently the most accurate tool for the depiction of a
tumor, mesorectum, and the relationship of the
tumor to the surrounding structures. A recent study
in which pelvic nerves were manually delineated
in 20 volunteers who were scanned with a 3-Tesla
MRI reported that even pelvic nerves are usually
visible on high-resolution MRI with dedicated
scanning protocols (Fig.47.2) [19]. The advances
in medical software facilitating automatic threedimensional reconstruction from CT scans when
performed at an experienced radiological center
open the door to new promising opportunities
[20]. This is all the more true because the
StealthMerge software allows the surgeon to automerge the three- dimensional reconstructions with
a preoperative CT scan which is used for the registration of the position of the patient. Additionally,
it is expected that the combination of a surgical
navigation system with robotic-assisted surgery
might further improve the precision and accuracy
of the navigation system [21]. In sum, such
advancements are an important step forward
toward the development of digital surgery [22].
Conclusions
The application of stereotactic navigation during
rectal surgery opens new promising opportunities
to increase the precision and quality of surgery.
With improved recognition of anatomical dissection planes, anatomical landmarks, and of the
dissection margins to the tumor, these margins
can be optimized and iatrogenic injuries can be
minimized. In the appropriate context, this may
improve functional and oncological outcomes.
Additionally, it could shorten the learning curve
for a technically demanding surgical technique
such as taTME.The challenges related to optimal
patient setup combined with the navigation system need to be assessed in invivo studies.
Acknowledgments The authors want to thank Bernard
Dallemagne for his guidance during the projects leading
up to this chapter. We also thank Guy Temporal and Chris
Burel for their editorial assistance.
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Current Controversies and Challenges in Transanal Total Mesorectal Excision (taTME)
Shlomo Yellinek and Steven D. Wexner
48
Introduction
Total mesorectal excision (TME) is the requisite
method of surgical extirpation for optimizing
outcomes of rectal cancer surgery. Components
of TME include a complete or near-complete
rather than an incomplete mesorectal specimen,
tumor-free circumferential resection margins
(CRM), a tumor-free distal resection margin
(DRM), and the assessment of ≥12 lymph nodes.
Tumor-related characteristics may decrease the
potential of achieving these goals. Some adverse
prognostic factors noted on pre-treatment thin
slice rectal cancer protocol magnetic resonance
imaging (MRI) include a threatened CRM and
extramural vascular invasion (EMVI). Following
the American College of Surgeons (ACS),
Commission on Cancer (CoC), National
Accreditation Program for Rectal Cancer
(NAPRC) standards, all patients with newly diagnosed rectal cancer presenting to an NAPRC center should be discussed in the multidisciplinary
tumor (MDT) conference prior to the commence-
S. Yellinek
Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL, USA
S. D. Wexner (*)
Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL, USA
Digestive Disease Center, Weston, FL, USA
e-mail: wexners@ccf.org
ment of any treatment [1]. The standards require
MDT attendance by at least one member of each
of the following disciplines: surgery, pathology,
radiology, medical oncology, and radiation
oncology. This group might arrive at a consensus
opinion that preoperative neoadjuvant chemoradiotherapy is recommended to help mitigate
some of these adverse prognosticators and help
meet the surgical goals. However, there is a second set of less modiable factors that may challenge the surgeon to produce a complete or
near-complete TME specimen with tumor-free
CRMs and adequate DRM and lymph node extirpation. Such patient-related variables include
gender, body mass index (BMI), and prior radiation. Male gender and high BMI associated with
overweight, obese, and morbidly obese patients
are risk factors for less optimal surgical results
which, in turn, pose compromise to clinical outcomes. While robotic surgery was theorized to
improve upon these odds for optimal surgery,
unfortunately the recently published Robotic ver-
sus Laparoscopic Resection for Rectal Cancer
(ROLLAR trial) [2] showed that this postulate
failed. Thus open, laparoscopic, and robotic TME
all seem to offer equivalent results as discussed
below.
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_48
493