Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Abstract

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures

“…Preoperative VR head-mounted display navigation in adults is reported to allow surgical strategy changes in almost 40% of the cases as a modality to prevent errors [ 1 , 6 ]. The application of VR in children seems to allow preoperative prevention and management of surgical risks in complex malformations, renal tumors requiring a tissue-sparing approach, and combined laparoscopic-endoscopic techniques such as biliary tree exploration congenital malformations [ 7 , 8 ].…”

“…Micro-instruments, the use of natural orifices, single incisions, or remotely controlled robot-assisted procedures promise to increase the benefits of surgical indications in the pediatric field [ 1 , 4 , 6 ]. Moreover, virtual reality (VR) and augmented reality (AR) are also seen as added technological advances to help manage complex malformations, tumors, and lesions requiring a tissue-sparing approach [ 1 , 6 , 7 , 8 ].…”

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of “New Technologies”

“…Although our experience is limited, recent technological and educational innovations promise to extend treatment options for children with complex GB pathologies. Three-dimension models used for preoperative surgical simulations help understand the anatomy's complexity [15]. ICG fluorescent cholangiography is a real-time surgical aid to target the anatomy, quickly obtaining the "critical view of safety" [28,37].…”

“…The radiological images were elaborated to obtain 3D models that were zoomable and viewable from many viewpoints and hidden or shown in transparency, allowing focus on specific structures. Free, opensource software was used for image segmentation (https://www.slicer.org, accessed on 23 August 2022) and 3D models were loaded into an HMD (head-mounted display) (Oculus Quest v.1-META Inc., Menlo Park, CA, USA) [15,16].…”

Teachers’ learning driven by “multi-subject needs”: Implication, mode and strategies

“…Activities are composed of different behaviors and operations. The tools people rely on in activities include not only material appliances and equipment, but also language, social customs, theories and other symbols [22], [23]. It can be seen that people interact with society and cultural situations through tools, symbolic intermediaries and cultural connotations to promote social development and knowledge generation.…”