Advanced Visualization Makes the Cut: Adding a New Perspective to Surgery

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HIIT070604
A Segmentation, Analysis, and Tracking module is used to view images in their present state as well as over the course of time. Lesion area and volume are automatically calculated and displayed. Source: TeraRecon.
Although much of the focus on advanced visualization in medical imaging has been on its use in diagnostic interpretation, one of the technology’s strongest clinical roles may be its utilization by clinicians in planning interventional treatments. In addition to improving the quality of patient care, the applications foster even stronger collaboration between radiology services and surgical units.

Vijay K. Maker, MD, is an enthusiastic adopter of advanced visualization tools in his surgical practice. “The software I’m using now (Vitrea, Vital Images) has dramatically helped in planning complex surgery,” he says.

Maker, professor of surgery and family practice at Rush Medical School, chairman of the department of surgery at Illinois Masonic Hospital and program director of general surgery residency for the University of Illinois in Chicago, is a busy practitioner with a full clinical and didactic schedule. The use of advanced visualization software enables him to more efficiently, and effectively, plan surgeries.

“The use of 3D visualization preoperatively helps plan the surgery,” he says. “I can literally simulate the entire surgical procedure preoperatively.”

He finds that the ability to see pathology, in addition to the information from a radiologist’s diagnostic report, enables him to fine tune his surgical plan.

“Being able to see the diagnosis with my own eyes in 3D, rather than just reading it from a radiologist’s report, has helped in my surgical planning,” he says. “Radiologists are trained to take three separate images [coronal, axial and sagittal slices] and put them together in their head. Other clinicians don’t have that training, so looking at images in 3D really helps us.”

Maker says he has used advanced visualization reformations in almost all aspects of his practice as a general surgeon. He notes that it is particularly helpful in complex vascular interventions as well as in oncologic surgery in the liver and pancreas as well as sarcomas.

Interventional radiology may just as easily be called “image-guided surgery.” Although the practitioners of interventional radiology are comfortable and confident at delivering reports from diagnostic images, they are equally as skilled at conducting image-guided interventional procedures.

Constantino S. Peña, MD, interventional radiologist and the medical director of vascular imaging at the Baptist Cardiac & Vascular Institute in Miami, says that advanced visualization technology is a well-used tool in his practice, too.

“I think it aids what we do everyday,” he says. “Before we start our day, we get together and review all the different cases that we will handle. We discuss the clinical information, and then we go over the imaging that’s available. Advanced imaging technologies (iNtuition, TeraRecon) give us a better feel for how we’re going to treat our patients. Often, we’ll display those reformations in the procedure suite.”

Peña says that advanced visualization tools are helpful in all the different types of procedures performed in his practice. “Where we really find the value is in complex procedures,” he says. “Although it’s important and useful for placing a G-Tube—which is a non-vascular interventional procedure—it’s also helpful to evaluate liver segments for a possible portal vein or hepatic vein embolization.”

Peña says he tailors his image reformations to the type of patient procedure he will be performing. “The volume-rendered images are very pretty, very nice pictures. A lot of times, those can give you a global evaluation of what is going on [with a particular pathology]. With our vascular work, we rely on a lot of MIPS [maximum intensity projections] to help us evaluate things such as the amount of calcium and lumen of a vessel and curved-planar reformations to help us evaluate the length of a stenosis or length of an artery.”

Another great seaport up the coast from Miami is home to the practice of interventional radiologist Neil J. Halin, DO. Halin, an assistant professor at Tufts University School of Medicine in Boston, and its chief of cardiovascular and interventional radiology, says that advanced visualization technology is used every day in his department. “We use it [Visage CS, Visage Imaging] for everything from routine analysis and review of CTA, CTV, MRA and MRV, all the way up to cardiac CT,” he says.

For demonstrating pathology found in diagnostic imaging, standard orthogonal slices are sent to the PACS where they can be viewed, along with the radiology report, by the referring clinician. For treatment planning purposes, Halin employs advanced visualization tools.

“The routine stuff that comes off the scanners is strictly for show and tell,” he notes. “When a physician comes down to our department and asks to review a patient’s CT study, one of the first things I’ll normally do is throw the exam into a 3D visualization package for him or her. Our clinicians really appreciate that we’ll do that for them.”

Although advanced visualization applications are of tremendous value in preparing and planning interventional procedures that Halin performs, he finds the tools to be of equal value in his role as consultant to other medical specialties.

“Advanced visualization really comes into play when we’re consulting. For example, a cardiothoracic surgeon may order a CTA of the chest, abdomen and pelvis. But the question he really wants answered is: Do I have enough room to put my clamp here? Essentially, he wants to know what it’s going to look like in the operating room. He wants a specific angle and he wants to see where he can put his clamp in or if he can get behind a rib.”

Luis A. Fernandez, MD, assistant professor of transplantation at the University of Wisconsin School of Medicine and Public Health in Madison, is an avid user of advanced visualization technology in his oncology and transplant surgery practice.

“The advanced imaging [Ziostation, Ziosoft] application allows us to more thoroughly evaluate the liver in patients who need resection, say for a hepatocellular carcinoma,” Fernandez says. “The operative planning using only two-dimensional CT images, unfortunately, results in a potentially larger amount of devascularized liver tissue of about 20 to 40 percent of the future liver remnant. The 3D allows us to calculate each potential area that needs to be revascularized. This allows for better planning so that we can preserve more of the remnant liver that otherwise would be resected.”

The use of image reformations in his surgical planning has allowed Fernandez to be much more aggressive in his interventional technique for liver resection. “The use of 3D reconstructions has permitted us to be lot more aggressive in terms of curative resections than if we were to have only a two-dimensional CT image set from which to plan our procedure. The reconstructions allow us to completely visualize the hepatic vascular anatomy, which allows me to plan monosegmentectomies—removing one of the eight liver segments—as opposed to a right hepatic lobectomy, which is the classic, standard operation.”

In addition to allowing for a higher quality of patient care, Fernandez says that employing advanced visualization technology in his surgical practice has strengthened his collaboration with the university’s imaging services department.

“Developing and refining protocols for surgical planning image reformations with our radiologists has resulted in a greater appreciation for the expertise in each of our specialties,” he says. “The result is a better level of patient care.”