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Lin et al. (2018) looked at the role of 3D visualisation in residency training in pancreaticoduodenectomy .
The aim was to assess if 3D visualisation improved residents’ ability to determine resectability using 3D
visualisation imaging. Eighty-eight surgical residents underwent training on evaluating resectability using
conventional 2D imaging utilising the NCCN clinical practice guidelines. They were then randomised to
evaluate the same imaging in 3D or continue using the 2D images. Residents were then evaluated on two
further cases and asked questions regarding recognition of anatomy, tumour staging, and surgical planning.
Those residents who underwent 3D visualisation training had an improved understanding of tumour
staging and spatial relationships between tumours and adjacent structures, as well as surgical planning of
complex tumours.

Use of virtual simulation and augmented reality navigation for arterial assessment during
pancreaticoduodenectomy
While 3D visualisation of its various forms allows better preoperative assessment, planning and assessment
of resectability of pancreatic lesions, 3D visualisation techniques can be applied intraoperatively to allow
augmented reality navigation-guided surgery to be a possibility. Developed over the last 20 years, its
application to pancreatic surgery is relatively new, perhaps due to the ease of application to minimally
invasive surgery compared to open techniques.

Marzano et al. (2013) describe the use of augmented reality navigation-guided surgery to improve the ability
to perform the “artery first” approach to pancreaticoduodenectomy . They suggest that it is important to
[13]
dissect the retroperitoneal margin close to the SMA to determine resectability before commitment to formal
resection. The authors describe a method where a 3D virtual anatomical model was obtained from
conventional CT imaging (in this case, using VR-RENDER, IRCAD). Preoperatively, the imaging was used
to plan the operation and a virtual surgical exploration was performed to delineate the tumour, the
pancreas, and the vascular anatomy. Intraoperatively, the surgical field was viewed with an exoscopic
camera, and the live feed was sent in real time to a computer scientist in a separate video room where the
previous 3D reconstruction was superimposed onto the real-world view by using fixed landmarks such as
the inferior vena cava, the left renal vein, and the aorta. This imaging was relayed to the operating theatre in
real time to delineate structures, further augmented by venous structures being displayed in blue and
arterial structures in red. The authors then describe how the path of the SMA could be easily identified and
dissected from the surrounding tissues along the hanging plane and the hanging manoeuvre could be
utilised to allow the completion of the dissection. The authors suggest that using this Augmented reality
(AR)-guided navigation allows easier identification of the SMA and easier dissection in challenging
situations such as obesity and when the uncinate process is close to vascular structures. They also suggest
this will have an important role in the era of neoadjuvant chemotherapy for pancreatic ductal
adenocarcinoma (PDAC), as local inflammatory reactions may make the assessment of vascular
involvement more difficult.

Onda et al. (2013) used an augmented reality-navigation system to allow early identification of the inferior
pancreaticoduodenal artery (IPDA) during pancreaticoduodenectomy in an attempt to minimise blood loss
during the operation, which it is suggested occurs if the IPDA is divided after the efferent draining veins as
this leads to congestion of the pancreatic head . They studied this in a small proof of concept study of
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seven non-consecutive patients undergoing pancreaticoduodenectomy matched to those undergoing non-
navigation surgery and compared operating time and intraoperative blood loss. Similar to the system
described by Marzano et al., it involved the reconstruction of 3D visualised imaging from preoperative CT
[13]
scans and this was projected over the operating field intraoperatively . They specifically displayed the origin
of the SMA, jejunal artery and IPMA on the reconstructed images. In this case series, after determining
resectability with the “artery first” approach to the SMA, they then either divided the IPDA at its origin, or if