Navigated hepatic tumor resection using intraoperative ultrasound imaging

Purpose: This proof-of-concept study evaluates feasibility and accuracy of an ultrasound-based navigation system for open liver surgery. Unlike most conventional systems that rely on registration to preoperative imaging, the proposed system provides navigation-guided resection using 3D models generated from intraoperative ultrasound. Methods: A pilot study was conducted in 25 patients undergoing resection of liver metastases. The first five cases served to optimize the workflow. Intraoperatively, an electromagnetic sensor compensated for organ motion, after which an ultrasound volume was acquired. Vasculature was segmented automatically and tumors semi-automatically using region-growing (n=15) or a deep learning algorithm (n=5). The resulting 3D model was visualized alongside tracked surgical instruments. Accuracy was assessed by comparing the distance between surgical clips and tumors in the navigation software with the same distance on a postoperative CT of the resected specimen. Results: Navigation was successfully established in all 20 patients. However, four cases were excluded from accuracy assessment due to intraoperative sensor detachment (n=3) or incorrect data recording (n=1). The complete navigation workflow was operational within 5-10 minutes. In 16 evaluable patients, 78 clip-to-tumor distances were analyzed. The median navigation accuracy was 3.2 mm [IQR: 2.8-4.8 mm], and an R0 resection was achieved in 15/16 (93.8%) patients and one patient had an R1 vascular resection. Conclusion: Navigation based solely on intra-operative ultrasound is feasible and accurate for liver surgery. This registration-free approach paves the way for simpler and more accurate image guidance systems.

PIVOTS: Aligning unseen Structures using Preoperative to Intraoperative Volume-To-Surface Registration for Liver Navigation

Non-rigid registration is essential for Augmented Reality guided laparoscopic liver surgery by fusing preoperative information, such as tumor location and vascular structures, into the limited intraoperative view, thereby enhancing surgical navigation. A prerequisite is the accurate prediction of intraoperative liver deformation which remains highly challenging due to factors such as large deformation caused by pneumoperitoneum, respiration and tool interaction as well as noisy intraoperative data, and limited field of view due to occlusion and constrained camera movement. To address these challenges, we introduce PIVOTS, a Preoperative to Intraoperative VOlume-To-Surface registration neural network that directly takes point clouds as input for deformation prediction. The geometric feature extraction encoder allows multi-resolution feature extraction, and the decoder, comprising novel deformation aware cross attention modules, enables pre- and intraoperative information interaction and accurate multi-level displacement prediction. We train the neural network on synthetic data simulated from a biomechanical simulation pipeline and validate its performance on both synthetic and real datasets. Results demonstrate superior registration performance of our method compared to baseline methods, exhibiting strong robustness against high amounts of noise, large deformation, and various levels of intraoperative visibility. We publish the training and test sets as evaluation benchmarks and call for a fair comparison of liver registration methods with volume-to-surface data. Code and datasets are available here https://github.com/pengliu-nct/PIVOTS.