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Table of Contents
Year : 2018  |  Volume : 29  |  Issue : 3  |  Page : 156-160

Augmented reality-assisted single-incision laparoscopic adrenalectomy: Comparison with pure single incision laparoscopic technique

1 Department of Urology, Show Chwan Memorial Hospital; Asian Institute of Tele-Surgery; Department of Kinesiology Health Leisure Studies, Chienkuo Technology University, Changhua, Taiwan
2 Asian Institute of Tele-Surgery; Department of Surgery, Show Chwan Memorial Hospital, Changhua; Department of Surgery, Tri-Service General Hospital; National Defense Medical Center, Taipei, Taiwan
3 Asian Institute of Tele-Surgery, Changhua, Taiwan

Date of Web Publication27-Jun-2018

Correspondence Address:
Jungle Chi-Hsiang Wu
Division of Urology, Show Chwan Memorial Hospital, No. 542, Sec. 1, Chung-Shan Rd., Changhua 500
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_3_18

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Objective: The objective of this study was to evaluate augmented reality-assisted single-incision laparoscopic adrenalectomy (AR-SILA) and compare with pure SILA. Materials and Methods: Between January 2009 and March 2012, a total of 19 patients had received SILA. Eight cases were AR-SILA and the others were pure SILA. Results: Eight AR-SILA procedures and 11 SILA were successfully completed. There was no significant difference between the two groups in terms of age, body mass index, and tumor size. Operative times were shorter in the AR-SILA group (102.5 ± 12.8 vs. 150.9 ± 46.3, P = 0.005). The mean blood loss in the AR-SILA group was slightly less than that in the SILA group (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129). There was neither postoperative mortality nor morbidity at the time of discharge and during follow-up. Conclusion: AR-SILA provides important intraoperative information for surgeons to recognize where the pathological lesions and vessels are located beyond the surgeon's direct vision. It made SILA safer and easier.

Keywords: Adrenalectomy, augmented reality, single incision laparoscopic surgery

How to cite this article:
Lin MS, Wu JC, Wu HS, Liu JK. Augmented reality-assisted single-incision laparoscopic adrenalectomy: Comparison with pure single incision laparoscopic technique. Urol Sci 2018;29:156-60

How to cite this URL:
Lin MS, Wu JC, Wu HS, Liu JK. Augmented reality-assisted single-incision laparoscopic adrenalectomy: Comparison with pure single incision laparoscopic technique. Urol Sci [serial online] 2018 [cited 2022 Aug 13];29:156-60. Available from: https://www.e-urol-sci.com/text.asp?2018/29/3/156/229075

  Introduction Top

Since first described by Gagner et al. in 1992,[1] laparoscopic adrenalectomy (LA) has replaced open adrenalectomy as the first choice of treatment for most benign adrenal tumors [2],[3],[4] while conventional LA still requires several incisions. Each incision risks morbidity from bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis.[5] An alternative to conventional LA is single-incision LA (SILA). However, the SILA technique does not rely on triangulation, which is one of the core principles in conventional laparoscopic surgery, allowing adequate operative exposure while maintaining an ergonomic position for the surgeon and assistant.[6] Consequently, the inherent technical challenge that arises from the SILA technique or “in-line viewing” is that of a compromised view and locomotive field.

Augmented reality (AR) is a novel computer technology for image-guided surgery to display three-dimensional (3D) computer graphics of the surgical space; there are synchronized geometrically and superimposed onto the real laparoscopic surgical view, presenting 3D information of the surgical target beyond the surgical view. The adrenal gland is a relatively fixed organ, in which the 3D anatomical information of the tumor location and the major vasculature in preoperative computed tomography (CT) will provide the significant information to help the surgeon and potentially to reduce the problems caused by the visual limitation of SILA. This study evaluated and compared AR-assisted SILA (AR-SILA) and pure SILA.

  Materials and Methods Top


Between January 2009 and March 2012, 19 consecutive patients (11 females and eight males, aged 31–67 years) underwent SILA by a single surgeon in Show Chwan Memorial Hospital. Eight cases were AR-SILA and the others were pure SILA. Demographic, clinical, pathologic, intraoperative, postoperative, and follow-up data were prospectively collected and compared between the two groups. Informed consent was obtained from all patients before operation IRB No.: IRB1010308.

Patient position and placement of ports

All patients were accessed transperitoneally with the patient in the decubitus position with the side of the tumor facing up, allowing the abdominal contents retracted by gravity. A 3.0 cm incision on the midclavicular line two finger-breadths below the costal margin, SILS™ Port Multiple Instrument Access Device (Covidien/Autosuture, Hamilton HM FX, Bermuda) was used. On the right side, one additional 5 mm port for liver retraction [Figure 1] and [Figure 2].
Figure 1: Patient position and placement of ports, one additional 5 mm port for liver retraction

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Figure 2: The SILS™ Port Multiple Instrument Access Device (Covidien/Autosuture, Hamilton HM FX, Bermuda) was placed with three trocars (one 10 mm and two 5 mm)

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Surgical technique

Preoperative CT scan was done in the position similar to the operative position. Using CT scan images, a 3D reconstruction of the operating region is prepared. We use 3D virtual patient modeling (VPM) which is available under limited licensing from the Research Institute against Digestive Cancer, Strasbourg, for developing the 3D patient reconstruction. The AR software loads the 3D model, connects to the laparoscope to capture live video, and in real time merges the two views together (combined view). During the surgery, the surgeon can visualize the standard laparoscopic view on a conventional laparoscopic screen and the combined view on a second display [Figure 3]a and [Figure 3]b. The cost of AR is about US$100–150 per patient while the cost for the equipment of AR is around US$17,000.
Figure 3: (a) View of operating room with the endoscope on the right and the fused view on the left. (b) Software outline.

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On the right side, a rigid 10 mm, 30° laparoscope was inserted for inspection of the peritoneal cavity, after the triangular ligament and coronary ligament were freed; the liver was retracted cephalad with a retractor fixed by the holder instrument. Under the guidance by AR, the right kidney, adrenal tumor, adrenal vein, and inferior vena cava (IVC) were easily identified through a virtual transparency of the fat tissue without taking down the ascending colon or duodenum [Figure 4]. An incision in the posterior peritoneum allowed access into the retroperitoneal space directly at the junction of the right adrenal gland and IVC under the AR guidance [Figure 5]. The right adrenal vein was controlled with 5 mm hemoclips. Other multiple tiny branches were controlled with ultrasonic harmonic scalpel. The adrenal gland and tumor were removed en bloc with a retrieval bag through the port. On the left side, the same skin incision was made on the midclavicular line two finger-breadths below the costal margin. The spleen and pancreas were separated from their attachments to the parietal peritoneum with a hook cautery electrode, thereby exposing Gerota's fascia. Under the guidance by AR, the adrenal tumor and major vessels were identified [Figure 6]. Careful dissection was done from the medial or inferior side of the adrenal gland with the hook cautery electrode. The left adrenal vein was controlled with 5 mm hemoclips or Hem-o-lok clips (Weck); the tumor and adrenal gland were excised completely with ultrasonic harmonic scalpel and removed en bloc with a retrieval bag through the port.
Figure 4: Endoscope view fused with the three-dimensional model, adrenal tumor (green arrow), right main adrenal vein (red arrow), inferior vena cava (yellow arrow)

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Figure 5: The surgical view of right single-incision laparoscopic adrenalectomy is verified by the surgeon after dissection

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Figure 6: The surgical view of the left single-incision laparoscopic adrenalectomy is verified by the surgeon after dissection, left adrenal vein (red arrow)

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Demographic data and tumor size were determined preoperatively. Tumor size was evaluated in centimeter using the widest dimensions from preoperative CT or magnetic resonance imaging. Parameters included operative time, blood loss, postoperative hospital stay, and postoperative follow-up.

A typical augmented reality-based setup uses combination of a visualization module, a video capture module, an image-processing module, and a fusion module. The setup used in the current application followed a design similar to that shown in the figure.[7]

Statistical analysis

Statistical analysis was performed using the Mann–Whitney test, and data are expressed as mean ± SD. P < 0.05 was taken to represent a statistically significant difference between the two groups.

  Results Top

There were a total of 19 consecutive patients with adrenal tumor who underwent a SILA with a mean follow-up period of 11.05 ± 6.61 months. Eight of the patients underwent an AR-SILA and 11 patients underwent a SILA. [Table 1] summarizes the demographic data of the two groups. The mean patient age was 50.6 ± 6.7 years and 51.6 ± 11.4 years for AR-SILA group and SILA group, respectively; the mean BMI was 22.3 ± 1.9 and 24.0 ± 2.9 for AR-SILA group and SILA group, respectively; and the mean tumor size was 3.6 ± 0.7 cm and 3.7 ± 1.0 cm for AR-SILA group and SILA group, respectively. No significant differences in baseline characteristics, the mean patient age, the mean BMI, the mean tumor size, and postoperative hospital stay were noted between the two groups. All procedures were successfully completed without conversion cases. A significant correlation was noted in operative time between the two groups; the mean operative time was 102.5 ± 12.8 in the AR-SILA group and 150.9 ± 46.3 in the SILA group (P = 0.005). The mean blood loss in the AR-SILA group was slightly less than that in the SILA group (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129) [Table 2]. All patients began oral intake at 8–16 h postoperation. There were no perioperative complications in our series and no injuries related to the use of the 3D VPM for AR.
Table 1: Baseline characteristics of the two groups

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Table 2: Perioperative parameters

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  Discussion Top

Laparoscopy has changed the way physicians perceive and practice surgery. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, and shorter hospital stays and recovery time when compared to open surgery.[8] In open surgery, the surgeon can mentally combine the real-tissue morphology with tactile feedback to successfully achieve the surgical procedures. However, in laparoscopic approach, the sensory information available to the surgeons is much more limited than a corresponding open approach. The lack of direct contact and loss of 3D visualization increase the complexity of surgery and the learning curve of the surgeons. In addition, SILA is still technically demanding, comparing to conventional LA due to potential high risk of IVC nearby for the right side and pancreas injury for the left side,[9],[10],[11] especially for novice, in which resulting in the steep learning curve. To overcome these problems while minimizing the iatrogenic injury to the adjacent healthy tissues or major vessels, image-guided surgery becomes an essential technique during surgery.

AR is a computer-aided imaging-overlay system between the real endoscopic view and a reconstructed 3D surgical model of the targeted anatomy, which employs intraoperative surgical navigation to provide a 3D image superimposed onto the live surgical view, to display 3D anatomy beyond the surgical view, and thus, it can visually assist and direct the surgeon, as hidden anatomy such as vessels or tumors below the surface of an organ are revealed.

Marescaux et al.[12] first used AR for LA in 2004. The initial use of AR technology in clinical urology was demonstrated in live surgery for a case of laparoscopic partial nephrectomy in the World Congress of Endourology annual meeting in 2006, by Ukimura and Gill. They published the results in 2008 and concluded that imaging assistance beyond the endoscopic surgical view could increase the precision for and confidence of the surgeon, providing preoperative oncological data, and understanding of the surrounding vital anatomies.[13]

The results of our study revealed that AR-SILA was equivalent to SILA in terms of hospital stay and perioperative complications. However, operative time was shorter for AR-SILA than with SILA (102.5 ± 12.8 vs. 150.9 ± 46.3, respectively, P = 0.005). The mean blood loss was slightly less than that in the SILA group; however, it was not statistically significant (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129). All operations, including AR-SILA and SILA groups, were performed during the same period by a single surgeon. This minimized the variations caused by surgeon's experience. Despite a significant decrease in operative time in AR-SILA group, one of the patients in the AR-SILA group had a pheochromocytoma [Table 3], which we found during the dissection under the guidance by AR. The adrenal vein can more easily approach first with minimal manipulation of the tumor itself while the traditional laparoscopic approach has the risk of blood pressure elevation due to catecholamine effects during manipulation.[14],[15],[16] In our experience, AR provided good visualizing of anatomy and pathology intraoperatively; it can shorten the operative time, decreasing in blood loss, facilitating the exposure of the vital vessels, and resulting in the decrease of surgical morbidity. Recent use of AR in minimally invasive surgery has resulted in the creation of hybrid image-guided surgery using endoscopic and robotic video feeds. A dedicated institution has been developed around image-guided hybrid therapies.[17]
Table 3: Histologic results of the two groups

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However, there are still many issues to be resolved in the future. This including the surgical targets and surrounding anatomies may move or deform during surgery by heartbeat, lung deflation, respiratory motion, patient relocation, carbon dioxide insufflation, and surgical manipulations. According to the current application viewpoint, the registration is performed manually, with a trained technician assisting the surgeon. Automated registration and tracking of 3D mesh for an organ during the surgery is the future work toward integrating this feature into the current application.

  Conclusion Top

AR is one of the most significant advances in laparoscopic surgery. This technology enables the surgeon to follow the anatomical dissection in the operating room in real time. Difficult anatomic relationships can more easily be understood and treated with the assurance that the critical landmarks are secured.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gagner M, Lacroix A, Bolté E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med 1992;327:1033.  Back to cited text no. 1
Brunt LM, Doherty GM, Norton JA, Soper NJ, Quasebarth MA, Moley JF, et al. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg 1996;183:1-10.  Back to cited text no. 2
Brunt LM. Minimal access adrenal surgery. Surg Endosc 2006;20:351-61.  Back to cited text no. 3
Schell SR, Talamini MA, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: Improved safety, morbidity, and cost-effectiveness. Surg Endosc 1999;13:30-4.  Back to cited text no. 4
Raman JD, Cadeddu JA, Rao P, Rane A. Single-incision laparoscopic surgery: Initial urological experience and comparison with natural-orifice transluminal endoscopic surgery. BJU Int 2008;101:1493-6.  Back to cited text no. 5
Greaves N, Nicholson J. Single incision laparoscopic surgery in general surgery: A review. Ann R Coll Surg Engl 2011;93:437-40.  Back to cited text no. 6
Vemuri AS, Wu JC, Liu KC, Wu HS. Deformable three-dimensional model architecture for interactive augmented reality in minimally invasive surgery. Surg Endosc 2012;26:3655-62.  Back to cited text no. 7
Gumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab 2006;20:483-99.  Back to cited text no. 8
Venkatesh R, Lanman J. Laparoscopic complications: Gastrointestinal. In: Textbook of laparoscopic urology. Gill IS, editor. USA: 2006. p. 911-22.  Back to cited text no. 9
Karadag MA, Cecen K, Demir A, Bagcioglu M, Kocaaslan R, Kadioglu TC, et al. Gastrointestinal complications of laparoscopic/robot-assisted urologic surgery and a review of the literature. J Clin Med Res 2015;7:203-10.  Back to cited text no. 10
Meraney AM, Samee AA, Gill IS. Vascular and bowel complications during retroperitoneal laparoscopic surgery. J Urol 2002;168:1941-4.  Back to cited text no. 11
Marescaux J, Rubino F, Arenas M, Mutter D, Soler L. Augmented-reality-assisted laparoscopic adrenalectomy. JAMA 2004;292:2214-5.  Back to cited text no. 12
Ukimura O. Image-guided surgery in minimally invasive urology. Curr Opin Urol 2010;20:136-40.  Back to cited text no. 13
Matsuda T, Murota T, Oguchi N, Kawa G, Muguruma K. Laparoscopic adrenalectomy for pheochromocytoma: A literature review. Biomed Pharmacother 2002;56 Suppl 1:132s-8s.  Back to cited text no. 14
Kim AW, Quiros RM, Maxhimer JB, El-Ganzouri AR, Prinz RA. Outcome of laparoscopic adrenalectomy for pheochromocytomas vs. aldosteronomas. Arch Surg 2004;139:526-9.  Back to cited text no. 15
Kalady MF, McKinlay R, Olson JA Jr., Pinheiro J, Lagoo S, Park A, et al. Laparoscopic adrenalectomy for pheochromocytoma. A comparison to aldosteronoma and incidentaloma. Surg Endosc 2004;18:621-5.  Back to cited text no. 16
Marescaux J, Diana M. Next step in minimally invasive surgery: Hybrid image-guided surgery. J Pediatr Surg 2015;50:30-6.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3]


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