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Page 4 of 12 Pecoraro et al. Mini-invasive Surg 2024;8:25 https://dx.doi.org/10.20517/2574-1225.2023.134

them to fine-tune the patient’s 3D model, much like an artisan perfects a finished product.

5. Refinement of the 3D Model: The segmented areas are refined to accurately represent the patient’s
anatomy. The expertise of the engineer or clinician plays a significant role in ensuring the model is
anatomically accurate.

6. Exporting the 3D Model: The final 3D model is exported in .stl (Standard Triangulation Language)
format, a common format used in 3D printing and further modeling. This virtual model can then be
reviewed, modified, or transferred for other purposes, such as surgical planning or patient consultation.

3D models: four different platforms
This interaction between the surgeon and the model can be utilized in different scenarios :
[17]
• Virtual Reality: The 3D model is rendered within a fully immersive virtual setting.
• Mixed Reality: Through head-mounted display systems, both the virtual 3D model and the physical
environment can exist and interact simultaneously.
• AR: The 3D model is projected onto the real world using a dedicated platform, such as Tilepro with the Da
[18]
Vinci surgical console , enhancing the features of the real environment.

[17]
In the beginning, the superimposition of the images on the operative field was manual and static .
Subsequently, AR begins to incorporate the simulation of tissue deformation using nonlinear parametric
techniques . Finally, using a specific computer software vision algorithm, after injection of ICG, the
[6]
primary reference point for superimposition is identified: the green image of the kidney, set against a dark
surgical field . After a registration time of ten seconds, an automatic AR driven-surgical navigation
[12]
becomes possible . However, extreme movements of the kidney (for example, kidney rotations) and
[12]
posterior tumors still represent an obstacle for this technology.

Additionally, since 2022, a specific platform for 3D models, named ICON3DTM (Intraoperative Cognitive
Navigation), has been available at https://www.medics3d.com. The ICON3D platform allows surgeons to
TM
independently access and manage 3D models via the cloud for use in robotic and laparoscopic surgeries.
The platform supports preoperative planning, intraoperative navigation, and even AR surgical procedures,
offering a bridge between traditional methods and advanced technologies such as AR and robotics .
[18]

Surgeons can access 3D models online, ensuring easy and fast retrieval regardless of location, and the
minimally invasive modality used (laparoscopic or robotic). Surgeons can use 3D models for planning
before surgery, allowing for an understanding of the patient’s anatomy in great detail. Moreover, during
surgery, surgeons can navigate through the virtual models for real-time guidance and decision-making;
otherwise, the platform also supports AR-based procedures, overlaying virtual models on real surgical
views.

Several studies [8,19-23] have examined the effectiveness of 3D imaging models in the education of medical
students, urology residents, and fellows. Rai et al. found that medical students using the interactive 3D
virtual reality simulator (dV-Trainer) along with standard 2D images were better at identifying renal masses
in 3D physical models compared to those who only used 2D planar images . Additionally, two studies [20,21]
[22]
assessed how well medical students could characterize renal tumors using the RENAL nephrometry scoring
system, in comparison to a reference standard created by experienced surgeons. Both studies indicated that
students were more precise in locating renal tumors with the 3D renal models than with 2D imaging alone.