Update on three-dimensional image reconstruction for preoperative simulation in thoracic surgery

Abstract

Background: Three-dimensional computed tomography (3D-CT) technologies have been developed and refined over time. Recently, high-speed and high-quality 3D-CT technologies have also been introduced to the field of thoracic surgery. The purpose of this manuscript is to demonstrate several examples of these 3D-CT technologies in various scenarios in thoracic surgery.

Methods: A newly-developed high-speed and high-quality 3D image analysis software system was used in Kyoto University Hospital. Simulation and/or navigation were performed using this 3D-CT technology in various thoracic surgeries.

Results: Preoperative 3D-CT simulation was performed in most patients undergoing video-assisted thoracoscopic surgery (VATS). Anatomical variation was frequently detected preoperatively, which was useful in performing VATS procedures when using only a monitor for vision. In sublobar resection, 3D-CT simulation was more helpful. In small lung lesions, which were supposedly neither visible nor palpable, preoperative marking of the lesions was performed using 3D-CT simulation, and wedge resection or segmentectomy was successfully performed with confidence. This technique also enabled virtual-reality endobronchial ultrasonography (EBUS), which made the procedure more safe and reliable. Furthermore, in living-donor lobar lung transplantation (LDLLT), surgical procedures for donor lobectomy were simulated preoperatively by 3D-CT angiography, which also affected surgical procedures for recipient surgery. New surgical techniques such as right and left inverted LDLLT were also established using 3D models created with this technique.

Conclusions: After the introduction of 3D-CT technology to the field of thoracic surgery, preoperative simulation has been developed for various thoracic procedures. In the near future, this technique will become more common in thoracic surgery, and frequent use by thoracic surgeons will be seen in worldwide daily practice.

Keywords: Endobronchial ultrasonography (EBUS); living-donor lobar lung transplantation (LDLLT); thoracic surgery; three-dimensional computed tomography (3D-CT); video-assisted thoracoscopic surgery (VATS).

Figure 1

Chest CT of a 60-year-old man with a lung cancer in the right middle lobe (A). Preoperative 3D-CT images were created by the thoracic surgeons within 10 minutes (B and C). Surgical simulation also became feasible, resulting in the safe and reliable performance of VATS with complete thoracoscopic vision. CT, computed tomography; 3D-CT, three-dimensional CT; VATS, video-assisted thoracoscopic surgery.

Figure 2

Chest CT of a 30-year-old woman with three small pulmonary lesions (A). Preoperative marking of each lesion was performed using 3D-CT simulation. Then, wedge resection of the right middle lobe (B) and extended segmentectomy of the right lower lobe (C) were simulated preoperatively and finally performed with confidence. Pathological diagnosis revealed that all lesions were primary lung cancers. The dashed line indicates the surgical resection line. CT, computed tomography; 3D-CT, three-dimensional CT.

Figure 3

Virtual EBUS created by the 3D analyzer made it possible to show the image with (A) and without a transparent bronchial wall (B). EBUS, endobronchial ultrasonography; 3D, three-dimensional.

Figure 4

Comparison of the interlobar left pulmonary artery shown by 3D-CT and as seen in the operative view. Branches of the interlobar left pulmonary artery depicted by 3D-CT angiography were consistent with those seen in the actual operative field. 3D-CT, three-dimensional computed tomography.

Figure 5

3D models of the RLL donor graft and post-pneumonectomy left thorax of the patient. These models were created accurately based on individual CT data. The PA, Br, and PV aligned in the same order in the donor and recipient (red circle). 3D, three-dimensional; RLL, right lower lobe; CT, computed tomography; PA, pulmonary artery; Br, bronchus; PV, pulmonary vein.

Figure 6

Postoperative 3D-CT images in a bilateral t LDLLT with implantation of the inverted RLL in the left thorax. In this case, the donor pulmonary vein was sutured to the recipient’s left upper pulmonary vein as is usually performed in LDLLT (arrowheads). There were no complications involving the pulmonary arterial (arrows) and bronchial anastomoses (dashed arrow). 3D-CT, three-dimensional computed tomography; LDLLT, living-donor lobar lung transplantation; RLL, right lower lobe.