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Page 208 Stott et al. Art Int Surg 2023;3:207-16 https://dx.doi.org/10.20517/ais.2022.42

and it is the involvement of these structures that technically limits surgical resection with curative intent for
PDAC. It is possible to resect venous and arterial structures involved in cancer to increase options for
patients for whom surgery was previously thought to not be possible, but this is best performed in high-
[4]
volume pancreatic surgery centres . Resectability varies according to international classification but is
currently based on anatomical definitions derived from radiographic imaging, mainly computed
tomography. Unresectable pancreatic cancer, as defined by the National Comprehensive Cancer Network,
encompasses tumours that exhibit distant metastasis, encasement of the superior mesenteric (SMA) or
coeliac artery by more than 180 degrees, aortic encasement, or the inability to reconstruct the superior
mesenteric (SMV)-portal vein (PV) complex after resection .
[5]

Key to successful pancreatic surgery is the delineation of relationships between vascular structures, the
tumour, and the pancreas itself. This is particularly important in pancreas surgery due to the variant and
aberrant anatomy common in this area. 3D visualisation and navigation surgery are techniques that have
been developed mainly in diagnostic radiology technology and applied to hepatobiliary surgery, although
less frequently reported in pancreatic surgery. The aim of this systematic review was to examine the role
that 3D visualisation and navigation surgery have in pancreatic surgery.

METHODS
A search of MEDLINE, Embase, and Scopus databases was performed to identify relevant studies relating to
the use of 3D visualisation and virtual simulation in pancreatic surgery. Search terms included: “3D
visualisation”, “virtual simulation”, “3D reconstruction”, “navigation surgery”, “pancreas”, “pancreas
surgery”, “pancreatic surgery”, and “pancreatic cancer”. Articles were included if they were written in
English and related to pancreatic surgery only. Articles relating to hepatobiliary surgery alone and reviews
were excluded. After removing duplicates, titles and abstracts were screened and full-text articles and
references were reviewed by the authors. If an agreement was not reached, this was achieved by discussion.

RESULTS
The literature search identified 67 articles after removing duplicates. Following abstract screening, 51
articles were excluded and 16 were taken forward for this systematic review [Figure 1]. Twelve of the studies
were from either China or Japan. Two randomised trials were identified, while the others were case series,
case reports, or pilot studies. A summary of articles included in this review is provided in Table 1.

DISCUSSION
Role of 3D visualisation in preoperative planning, evaluation of resectability, and surgical training
Computed tomography (CT) and magnetic resonance (MR) based imaging modalities are the traditional
methods of radiological assessment of pancreatic tumours and provide imaging that surgeons can use to
guide preoperative planning, particularly with regard to relationships between key anatomical structures.
These modalities are limited as they provide only a 2D representation. 3D visualisation is a process whereby
2D imaging is transformed through computer processing to provide a 3D reconstruction. Zhang et al.
(2022) studied the role that 3D visualisation may have in changing preoperative planning in patients
undergoing pancreaticoduodenectomy . Patients underwent conventional CT of the abdomen in the
[6]
pancreas protocol. 2D imaging was then imported into a medical image 3D visualisation system (MI-3DVS)
which enabled 3D volumetric reconstructions, measurements, and rendering of discrete anatomical and
pathological aspects such as tumour, lymph nodes, surrounding organs, and vasculature. Surgical planning
was based on 2D and then 3D rendered imaging by the operating surgeon. Of 47 cases, surgical plans varied
in 20% of cases, mainly because vascular involvement was more apparent in 3D rendered cases and this
allowed the surgeon to plan for vascular resection. The surgical approach also changed after reviewing the