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Stott et al. Art Int Surg 2023;3:207-16 https://dx.doi.org/10.20517/ais.2022.42 Page 215

developed allows an ability to accurately locate the main blood vessels required to safely undertake major
pancreatic surgery laparoscopically. They suggest that by overlaying the 3D reconstruction of the vessels
and tumour onto the laparoscopic images in real time, it provides navigation to reduce the learning curve
and allow less experienced surgeons to complete the procedure as safely and efficiently as experienced
operators.

Müller et al. (2021) take this concept further and have evaluated computer-assisted navigation in
endopancreatic surgery, such as performing pancreatic resection from inside the pancreatic duct in surgery
[19]
for chronic pancreatitis as opposed to duodenum-preserving pancreatic head resection . Here, a rigid
endoscopy is introduced via the pancreatic papilla into the pancreatic duct. They suggest that image-guided
navigation here may be useful to display critical structures relative to the view from inside the pancreatic
duct, which can guide the extent of resection. The evaluation was based on an artificial pancreas silicone
model in this proof-of-concept study, although this was relatively high fidelity with surrounding duodenum,
SMA, SMV, and aorta. It included lesions that were not visible from inside the pancreatic duct. 3D
reconstructions were then made through CT of the model and were transferred to the CAS-One navigation
system (CAScination AG, Bern, Switzerland). Tracking landmarks were identified as the duodenal papilla
and the aorta. The study showed that, for the first time, minimally invasive endopancreatic surgery could be
combined with an image-guided, computer-assisted navigation system and that it was possible to accurately
locate lesions that were invisible from the endoscopic view using the navigation system. They also found
there to be minimal registration errors, i.e., the accuracy of image fusion from the virtual to the real world.
They suggest this could be applied to the clinical setting and allow endopancreatic surgery to be performed
instead of radical open surgery for chronic pancreatitis.

CONCLUSION
3D visualisation, cinematic rendering, and navigation surgery have a role in the preoperative evaluation of
resectability of pancreatic cancer, including the evaluation of arterial and venous involvement. It has been
suggested that 3D visualisation may improve the accuracy of determination of resectability, which may
become more important if there is a move to neoadjuvant chemotherapy for both borderline and resectable
pancreatic cancer. There is evidence that these technologies can enhance the operative performance of
major pancreatic surgery and in the training of future pancreatic surgeons, especially as techniques evolve
and surgery is considered for a more complex patient cohort. The role of navigation technology to augment
novel surgical techniques such as endopancreatic surgery is in its infancy. Most of this evidence, however, is
case series or case reports of single-centre experiences with such technology outlining its feasibility and
applicability. Moreover, evidence is lacking that these technologies improve oncological and patient-centred
outcomes in pancreatic surgery, and this will require further evaluation.

DECLARATIONS
Authors’ contributions
Concept and design of the paper, collection of data, and authorship: Stott M, Kausar A

Availability of data and materials
Not applicable.