Disclosure. Industry-sponsored grants. Research Collaboration. Consultant. Educational and research grants from Olympus Corporation

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1 Image Guided Surgery Kazuhiro Yasufuku MD, PhD Director of Endoscopy, University Health Network Director, Interventional Thoracic Surgery Program Associate Professor of Surgery, University of Toronto Division of Thoracic Surgery, Toronto General Hospital 2017 Duke Masters of Minimally Invasive Thoracic Surgery Sep rd,

2 Disclosure Industry-sponsored grants Educational and research grants from Olympus Corporation Research Collaboration Siemens Novadaq Corp Veran Medical Technologies Consultant Olympus America Inc. Intuitive Surgical Inc. Medtronic Johnson and Johnson Auris Surgical Robotics Concordia Healthcare 2

3 Image Guided Surgery (IGS) Definition? 3

4 Image Guided Surgery (IGS) Definition? General term used for any surgical procedure where surgeons employs tracked surgical instruments in conjunction with preoperative or intraoperative images in order to indirectly guide the procedure IGS was originally developed for treatment of brain tumors Various applications of navigations for neurosurgery have been widely used for almost two decades 4

5 Image Guided Surgery (IGS) in Thoracic Surgery Fluorescence Image Guided Surgery Virtual/Electromagnetic Navigation Guided Surgery Preoperative CT Guided Surgery Intraoperative Cone Beam CT Guided Surgery 5

6 6 Fluorescence Image Guided Surgery

7 Molar extinction coefficient (cm- 1/M) ICG and Near Infrared (NIR) Imaging Indocyanine green NIR thoracoscope M.W: nm Surv Opthalmol, 2000 PinPoint, Novadaq Technologies TM 7

8 ICG Fluorescence-Guided Surgery Sentinel LN Mapping A-dose escalation phase 1 clinical trial real-time NIR imaging after peritumoral injection of 3.8 to 2500 μg 26 NIR(+) SLNs identified in 15 pts with 7 NIR(+) SLNs (6 pts) harboring metastatic disease on histologic analysis Metastatic nodal disease never identified in pts with a histologically negative NIR(+) SLN J Thorac Cardiovasc Surg. 2013; 146:

9 ICG Fluorescence-Guided Surgery NIR Thoracoscopic Segmental Resection ICG injection into the bronchus of target pulmonary segments under GA NIR Thoracoscopic identification of the target segments (Hamamatsu Photonics, Hamamatsu, Japan) Intersegmental lines and planes identified to allow segmental resection J Thorac Cardiovasc Surg. 2012; 143:

10 ICG Fluorescence-Guided Surgery NIR Robotic Segmental Resection iv injection of ICG after division of segment bronchus, vein and artery (2.5mg/10mL, 6-8mL bolus) Da Vinci Firefly fluorescence imaging for identification of the target segments J Thorac Cardiovasc Surg. 2014; 148:

11 Virtual/Electromagnetic Navigation Guided Surgery 11

12 Virtual assisted Lung Mapping VAL-MAP Bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection J Thorac Cardiovasc Surg. 2014; 147:

13 Preoperative bronchoscopic marking CT Fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules CHEST 2004; 125:

14 Preoperative ENB marking (fiducial, dye) ENB-guided VATS wedge resection of peripheral lung nodules Seminars in Thoracic and Cardiovascular Surgery, 22, 2011 J Community Hosp Intern Med Perspect. 2014; 4(1): 10 14

15 15 GTx (Guided Therapeutics) Program

16 GTx OR at Toronto General Hospital 16

17 GTx OR Capabilities Cone-Beam CT Dual Source- Dual Energy CT MIS, Endoscopic Technology 17 Guided Therapeutics (GTx) Core

18 GTx OR Capabilities Cone-Beam CT 18 Guided Therapeutics (GTx) Core

19 Multi-Modality Surgical Guidance Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking Surgical Planning Optical Imaging Intraoperative localization Image assistance during MIS/Robotic Surgery Real time monitoring of minimally invasive thoracic intervention 19

20 Optical Surgical Navigation 1. Preoperative CT imaging 2. Intraoperative CBCT Imaging 3. Image registration with surgical navigation Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking

21 Optical Surgical Navigation Chest Wall Tumor Resection 21 Guided Therapeutics (GTx) Core

22 GTx OR VATS localization 22

23 GTx OR Image guided Transbronchial Interventions 23

24 CT-guided Microcoil Placement and ICG Injection Ujiie et al, AATS 2016 abstract

25 Intraoperative NIR Localization Ujiie et al, AATS 2016 abstract

26 GTx OR CBCT localization 26

27 Summary Hybrid OR with capabilities of preoperative and intraoperative real-time radiologic imaging as well as advanced endoscopic procedures will assist surgeons during Image Guided Surgery Advances in imaging technology will enable intraoperative localization of small peripheral nodule during minimally invasive surgery 27

28 Acknowledgement Latner Thoracic Surgery Laboratory Yasufuku Laboratory Hideki Ujiie Kosuke Fujino Chang Young Lee Tomonari Kinoshita Alex Gregor Salma Hindy Andrew Effat Judy McConnell Alexandria Grindlay Kim Hudson TECHNA Institute David Jaffray Robert Weersink Jonathan Irish Harley Chan Michael Dunne Jimmy Qiu 28

29 Division of Thoracic Surgery Toronto General Hospital University Health Network Kazuhiro Yasufuku, MD, PhD, FCCP Thank you 29