Table 3 Open in new tab Studies included...

Table 3

Studies included assessing the intraoperative use of VR/AR in thoracic surgery

Study	Year	Study characteristics	Population number	Simulation technique employed	Main reported outcomes
Itano et al.*	2010	NR, NM, P	15	Patients included: suspected or proven lung tumours. 3D-rendered, dynamic virtual PET/CT mediastinoscopic images were reconstructed in the tracheobronchial- and vessel-modes. Then standard mediastinoscopic nodal biopsies were performed; afterwards the clinical benefits of the 3D PET/CT virtual movies over the standard 2D tomographic images were assessed.	The technique enhances understanding of spatial and positional relationship between the FDG-avid nodes and the anatomy of the mediastinum. Offers a more detailed virtual depiction of anatomy leading to improved selection of subsequent operative procedures.
Akiba et al.*	2011	NR, M, P	11	Twelve operations in 11 patients who had chemotherapy before pulmonary metastasectomy (lobectomy or segmentectomy): 1 segmentectomy, 10 lobectomies and 1 wedge bronchoplasty upper lobectomy, 10 had VATS. Tailor-made virtual lungs were synthesised using 3D multidetector computed tomography (CT) before operation.	Duration tailor-made virtual lung = approx. 10 min The tailor-made virtual lung enhanced the understanding of the patient’s individual anatomy for VATS. Makes it possible to measure distance and angles among pulmonary arteries, veins and bronchi and examining the locations of vessels and bronchi preoperatively.
Sato et al.	2013	NR, NM, NP	41	Patients included: lung tumours. Virtual endobronchial ultrasound for transbronchial needle aspiration: Aquarius Thin Client Viewer (TeraRecon, Inc, Tokyo, Japan) was employed to create 3D virtual bronchoscopy images and a computer-based simulation of EBUS-TBNA with input from thin-slice CT images. Virtual EBUS images and videos were used as reference aids during the EBUS-TBNA procedure.	Virtual EBUS was useful particularly when potential target was outside of the typical mediastinal lymph node. May enhance TBNA procedure performance at difficult and high angles. Offers US confirmation of virtual images and real-time monitoring of operational procedure.
Sato et al.	2014	NR, NM, P	30	Patients included: hardly palpable lung tumours. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, is used preoperatively to determine reference points. Post-VAL-MAP a 3D reconstruction of the lung is performed using fluoroscopy and CT, which aids before and during the VATS operation.	Duration VAL-MAP: 20–60 min, 55 ± 14 min and 21 ± 6 min for single wedge resection (n = 7) and 190 ± 43 and 119 ± 35 min for single segmentectomy (n = 20). Of 95 marking attempts, 91 visible during the operation (95.7%), 100% success rate for surgical resections using VAL-MAP. 0 adverse events.
Sardari Nia et al.*	2019	NR, NM, P	25	25 patients referred for anatomic pulmonary resections were included. 3D reconstruction of the pulmonary anatomy was constructed by inputting CT scans from a dual-source CT scanner into dedicated rendering software (Fujifilm Synapse Vincent system). An interactive 3D reconstruction with virtual resection was created, in which individual structures could be selected and targeted preoperatively. The reconstruction also aided in intraoperative guiding during 3D VATS.	All patients had complete resections; post-interventional complications were grade ≤2 in 96.2% of patients. The preoperative 3D reconstructions of pulmonary vessels and intraoperative guiding were equal to intraoperative findings in 100% of cases. In 15.4% patients, anatomic variations were revealed upon preoperative 3D reconstructions that were confirmed intraoperatively.
Sato et al.*	2019	NR, NM, NP	28	Treatment group: 4 patients with 4 lesions, control group: 3 patients with 5 lesions; afterward trial of electromagnetic navigation bronchoscopy (ENB) VAL-MAP in 19 patients. In treatment group: Planned lung markings on CT images are transferred to an ENB system and a portable radiology workstation intraoperatively to create 3D VAL-MAP images including resection markings. Intraoperatively lung markings are evaluated by a single surgeon, also 3D ENB-VAL-MAP is used to make intraoperative adjustments. In control group, conventional VAL-MAP is used, and markings are also evaluated intraoperatively, but no re-adjustments are made.	No significant difference in the success rate regarding intraoperative navigation between the no-adjustment and adjustment groups (36.3% vs 40.0%, P = 0.86). However, looking at the markings placed with no successful navigation, the control group had a significantly lower accuracy grade than the treatment group (2.6 ± 0.5 vs 4.5 ± 0.8). Total time: ENB VAL-MAP = 41 ± 14 min vs VAL-MAP = 43 ± 4.9 min.
Yang et al.	2019	NR, NM, P	24	24 patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen of those patients also received preoperative CT-guided percutaneous localization post-VAL-MAP; 15 patients received CT-guided localization with dye and microcoil, and 4 patients received only dye. Virtual bronchoscopy is used for VAL-MAP; after VAL-MAP, a microcoil is placed near the lesion through the CT-guided needle localization; then blue dye is injected to set the marking; at the end, a confirmatory CT scan was performed pre-operation. The contribution of VAL-MAP to the respective surgery is evaluated by the performing surgeon.	Of 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No complications occurred after the treatment. After training and video demonstration, the successful total marking rate was 85.7%. Median time from VAL-MAP to CT room was 36 min, VAL-MAP to operating room was 61 min.

Study	Year	Study characteristics	Population number	Simulation technique employed	Main reported outcomes
Itano et al.*	2010	NR, NM, P	15	Patients included: suspected or proven lung tumours. 3D-rendered, dynamic virtual PET/CT mediastinoscopic images were reconstructed in the tracheobronchial- and vessel-modes. Then standard mediastinoscopic nodal biopsies were performed; afterwards the clinical benefits of the 3D PET/CT virtual movies over the standard 2D tomographic images were assessed.	The technique enhances understanding of spatial and positional relationship between the FDG-avid nodes and the anatomy of the mediastinum. Offers a more detailed virtual depiction of anatomy leading to improved selection of subsequent operative procedures.
Akiba et al.*	2011	NR, M, P	11	Twelve operations in 11 patients who had chemotherapy before pulmonary metastasectomy (lobectomy or segmentectomy): 1 segmentectomy, 10 lobectomies and 1 wedge bronchoplasty upper lobectomy, 10 had VATS. Tailor-made virtual lungs were synthesised using 3D multidetector computed tomography (CT) before operation.	Duration tailor-made virtual lung = approx. 10 min The tailor-made virtual lung enhanced the understanding of the patient’s individual anatomy for VATS. Makes it possible to measure distance and angles among pulmonary arteries, veins and bronchi and examining the locations of vessels and bronchi preoperatively.
Sato et al.	2013	NR, NM, NP	41	Patients included: lung tumours. Virtual endobronchial ultrasound for transbronchial needle aspiration: Aquarius Thin Client Viewer (TeraRecon, Inc, Tokyo, Japan) was employed to create 3D virtual bronchoscopy images and a computer-based simulation of EBUS-TBNA with input from thin-slice CT images. Virtual EBUS images and videos were used as reference aids during the EBUS-TBNA procedure.	Virtual EBUS was useful particularly when potential target was outside of the typical mediastinal lymph node. May enhance TBNA procedure performance at difficult and high angles. Offers US confirmation of virtual images and real-time monitoring of operational procedure.
Sato et al.	2014	NR, NM, P	30	Patients included: hardly palpable lung tumours. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, is used preoperatively to determine reference points. Post-VAL-MAP a 3D reconstruction of the lung is performed using fluoroscopy and CT, which aids before and during the VATS operation.	Duration VAL-MAP: 20–60 min, 55 ± 14 min and 21 ± 6 min for single wedge resection (n = 7) and 190 ± 43 and 119 ± 35 min for single segmentectomy (n = 20). Of 95 marking attempts, 91 visible during the operation (95.7%), 100% success rate for surgical resections using VAL-MAP. 0 adverse events.
Sardari Nia et al.*	2019	NR, NM, P	25	25 patients referred for anatomic pulmonary resections were included. 3D reconstruction of the pulmonary anatomy was constructed by inputting CT scans from a dual-source CT scanner into dedicated rendering software (Fujifilm Synapse Vincent system). An interactive 3D reconstruction with virtual resection was created, in which individual structures could be selected and targeted preoperatively. The reconstruction also aided in intraoperative guiding during 3D VATS.	All patients had complete resections; post-interventional complications were grade ≤2 in 96.2% of patients. The preoperative 3D reconstructions of pulmonary vessels and intraoperative guiding were equal to intraoperative findings in 100% of cases. In 15.4% patients, anatomic variations were revealed upon preoperative 3D reconstructions that were confirmed intraoperatively.
Sato et al.*	2019	NR, NM, NP	28	Treatment group: 4 patients with 4 lesions, control group: 3 patients with 5 lesions; afterward trial of electromagnetic navigation bronchoscopy (ENB) VAL-MAP in 19 patients. In treatment group: Planned lung markings on CT images are transferred to an ENB system and a portable radiology workstation intraoperatively to create 3D VAL-MAP images including resection markings. Intraoperatively lung markings are evaluated by a single surgeon, also 3D ENB-VAL-MAP is used to make intraoperative adjustments. In control group, conventional VAL-MAP is used, and markings are also evaluated intraoperatively, but no re-adjustments are made.	No significant difference in the success rate regarding intraoperative navigation between the no-adjustment and adjustment groups (36.3% vs 40.0%, P = 0.86). However, looking at the markings placed with no successful navigation, the control group had a significantly lower accuracy grade than the treatment group (2.6 ± 0.5 vs 4.5 ± 0.8). Total time: ENB VAL-MAP = 41 ± 14 min vs VAL-MAP = 43 ± 4.9 min.
Yang et al.	2019	NR, NM, P	24	24 patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen of those patients also received preoperative CT-guided percutaneous localization post-VAL-MAP; 15 patients received CT-guided localization with dye and microcoil, and 4 patients received only dye. Virtual bronchoscopy is used for VAL-MAP; after VAL-MAP, a microcoil is placed near the lesion through the CT-guided needle localization; then blue dye is injected to set the marking; at the end, a confirmatory CT scan was performed pre-operation. The contribution of VAL-MAP to the respective surgery is evaluated by the performing surgeon.	Of 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No complications occurred after the treatment. After training and video demonstration, the successful total marking rate was 85.7%. Median time from VAL-MAP to CT room was 36 min, VAL-MAP to operating room was 61 min.

AR: augmented reality; CT: computed tomography; M: multicentre; NM: non-multicentre; NP: non-prospective; NR: non-randomized; P: prospective; PET-CT: positron emission tomography–computed tomography; R: randomized; VAL-MAP: virtual-assisted lung mapping; VATS: video-assisted thoracic surgery; VR: virtual reality. * Articles reporting on both the preoperative and the intraoperative use of VR/AR in thoracic surgery.

Table 3

Open in new tab

Studies included assessing the intraoperative use of VR/AR in thoracic surgery

Study	Year	Study characteristics	Population number	Simulation technique employed	Main reported outcomes
Itano et al.*	2010	NR, NM, P	15	Patients included: suspected or proven lung tumours. 3D-rendered, dynamic virtual PET/CT mediastinoscopic images were reconstructed in the tracheobronchial- and vessel-modes. Then standard mediastinoscopic nodal biopsies were performed; afterwards the clinical benefits of the 3D PET/CT virtual movies over the standard 2D tomographic images were assessed.	The technique enhances understanding of spatial and positional relationship between the FDG-avid nodes and the anatomy of the mediastinum. Offers a more detailed virtual depiction of anatomy leading to improved selection of subsequent operative procedures.
Akiba et al.*	2011	NR, M, P	11	Twelve operations in 11 patients who had chemotherapy before pulmonary metastasectomy (lobectomy or segmentectomy): 1 segmentectomy, 10 lobectomies and 1 wedge bronchoplasty upper lobectomy, 10 had VATS. Tailor-made virtual lungs were synthesised using 3D multidetector computed tomography (CT) before operation.	Duration tailor-made virtual lung = approx. 10 min The tailor-made virtual lung enhanced the understanding of the patient’s individual anatomy for VATS. Makes it possible to measure distance and angles among pulmonary arteries, veins and bronchi and examining the locations of vessels and bronchi preoperatively.
Sato et al.	2013	NR, NM, NP	41	Patients included: lung tumours. Virtual endobronchial ultrasound for transbronchial needle aspiration: Aquarius Thin Client Viewer (TeraRecon, Inc, Tokyo, Japan) was employed to create 3D virtual bronchoscopy images and a computer-based simulation of EBUS-TBNA with input from thin-slice CT images. Virtual EBUS images and videos were used as reference aids during the EBUS-TBNA procedure.	Virtual EBUS was useful particularly when potential target was outside of the typical mediastinal lymph node. May enhance TBNA procedure performance at difficult and high angles. Offers US confirmation of virtual images and real-time monitoring of operational procedure.
Sato et al.	2014	NR, NM, P	30	Patients included: hardly palpable lung tumours. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, is used preoperatively to determine reference points. Post-VAL-MAP a 3D reconstruction of the lung is performed using fluoroscopy and CT, which aids before and during the VATS operation.	Duration VAL-MAP: 20–60 min, 55 ± 14 min and 21 ± 6 min for single wedge resection (n = 7) and 190 ± 43 and 119 ± 35 min for single segmentectomy (n = 20). Of 95 marking attempts, 91 visible during the operation (95.7%), 100% success rate for surgical resections using VAL-MAP. 0 adverse events.
Sardari Nia et al.*	2019	NR, NM, P	25	25 patients referred for anatomic pulmonary resections were included. 3D reconstruction of the pulmonary anatomy was constructed by inputting CT scans from a dual-source CT scanner into dedicated rendering software (Fujifilm Synapse Vincent system). An interactive 3D reconstruction with virtual resection was created, in which individual structures could be selected and targeted preoperatively. The reconstruction also aided in intraoperative guiding during 3D VATS.	All patients had complete resections; post-interventional complications were grade ≤2 in 96.2% of patients. The preoperative 3D reconstructions of pulmonary vessels and intraoperative guiding were equal to intraoperative findings in 100% of cases. In 15.4% patients, anatomic variations were revealed upon preoperative 3D reconstructions that were confirmed intraoperatively.
Sato et al.*	2019	NR, NM, NP	28	Treatment group: 4 patients with 4 lesions, control group: 3 patients with 5 lesions; afterward trial of electromagnetic navigation bronchoscopy (ENB) VAL-MAP in 19 patients. In treatment group: Planned lung markings on CT images are transferred to an ENB system and a portable radiology workstation intraoperatively to create 3D VAL-MAP images including resection markings. Intraoperatively lung markings are evaluated by a single surgeon, also 3D ENB-VAL-MAP is used to make intraoperative adjustments. In control group, conventional VAL-MAP is used, and markings are also evaluated intraoperatively, but no re-adjustments are made.	No significant difference in the success rate regarding intraoperative navigation between the no-adjustment and adjustment groups (36.3% vs 40.0%, P = 0.86). However, looking at the markings placed with no successful navigation, the control group had a significantly lower accuracy grade than the treatment group (2.6 ± 0.5 vs 4.5 ± 0.8). Total time: ENB VAL-MAP = 41 ± 14 min vs VAL-MAP = 43 ± 4.9 min.
Yang et al.	2019	NR, NM, P	24	24 patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen of those patients also received preoperative CT-guided percutaneous localization post-VAL-MAP; 15 patients received CT-guided localization with dye and microcoil, and 4 patients received only dye. Virtual bronchoscopy is used for VAL-MAP; after VAL-MAP, a microcoil is placed near the lesion through the CT-guided needle localization; then blue dye is injected to set the marking; at the end, a confirmatory CT scan was performed pre-operation. The contribution of VAL-MAP to the respective surgery is evaluated by the performing surgeon.	Of 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No complications occurred after the treatment. After training and video demonstration, the successful total marking rate was 85.7%. Median time from VAL-MAP to CT room was 36 min, VAL-MAP to operating room was 61 min.

Study	Year	Study characteristics	Population number	Simulation technique employed	Main reported outcomes
Itano et al.*	2010	NR, NM, P	15	Patients included: suspected or proven lung tumours. 3D-rendered, dynamic virtual PET/CT mediastinoscopic images were reconstructed in the tracheobronchial- and vessel-modes. Then standard mediastinoscopic nodal biopsies were performed; afterwards the clinical benefits of the 3D PET/CT virtual movies over the standard 2D tomographic images were assessed.	The technique enhances understanding of spatial and positional relationship between the FDG-avid nodes and the anatomy of the mediastinum. Offers a more detailed virtual depiction of anatomy leading to improved selection of subsequent operative procedures.
Akiba et al.*	2011	NR, M, P	11	Twelve operations in 11 patients who had chemotherapy before pulmonary metastasectomy (lobectomy or segmentectomy): 1 segmentectomy, 10 lobectomies and 1 wedge bronchoplasty upper lobectomy, 10 had VATS. Tailor-made virtual lungs were synthesised using 3D multidetector computed tomography (CT) before operation.	Duration tailor-made virtual lung = approx. 10 min The tailor-made virtual lung enhanced the understanding of the patient’s individual anatomy for VATS. Makes it possible to measure distance and angles among pulmonary arteries, veins and bronchi and examining the locations of vessels and bronchi preoperatively.
Sato et al.	2013	NR, NM, NP	41	Patients included: lung tumours. Virtual endobronchial ultrasound for transbronchial needle aspiration: Aquarius Thin Client Viewer (TeraRecon, Inc, Tokyo, Japan) was employed to create 3D virtual bronchoscopy images and a computer-based simulation of EBUS-TBNA with input from thin-slice CT images. Virtual EBUS images and videos were used as reference aids during the EBUS-TBNA procedure.	Virtual EBUS was useful particularly when potential target was outside of the typical mediastinal lymph node. May enhance TBNA procedure performance at difficult and high angles. Offers US confirmation of virtual images and real-time monitoring of operational procedure.
Sato et al.	2014	NR, NM, P	30	Patients included: hardly palpable lung tumours. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, is used preoperatively to determine reference points. Post-VAL-MAP a 3D reconstruction of the lung is performed using fluoroscopy and CT, which aids before and during the VATS operation.	Duration VAL-MAP: 20–60 min, 55 ± 14 min and 21 ± 6 min for single wedge resection (n = 7) and 190 ± 43 and 119 ± 35 min for single segmentectomy (n = 20). Of 95 marking attempts, 91 visible during the operation (95.7%), 100% success rate for surgical resections using VAL-MAP. 0 adverse events.
Sardari Nia et al.*	2019	NR, NM, P	25	25 patients referred for anatomic pulmonary resections were included. 3D reconstruction of the pulmonary anatomy was constructed by inputting CT scans from a dual-source CT scanner into dedicated rendering software (Fujifilm Synapse Vincent system). An interactive 3D reconstruction with virtual resection was created, in which individual structures could be selected and targeted preoperatively. The reconstruction also aided in intraoperative guiding during 3D VATS.	All patients had complete resections; post-interventional complications were grade ≤2 in 96.2% of patients. The preoperative 3D reconstructions of pulmonary vessels and intraoperative guiding were equal to intraoperative findings in 100% of cases. In 15.4% patients, anatomic variations were revealed upon preoperative 3D reconstructions that were confirmed intraoperatively.
Sato et al.*	2019	NR, NM, NP	28	Treatment group: 4 patients with 4 lesions, control group: 3 patients with 5 lesions; afterward trial of electromagnetic navigation bronchoscopy (ENB) VAL-MAP in 19 patients. In treatment group: Planned lung markings on CT images are transferred to an ENB system and a portable radiology workstation intraoperatively to create 3D VAL-MAP images including resection markings. Intraoperatively lung markings are evaluated by a single surgeon, also 3D ENB-VAL-MAP is used to make intraoperative adjustments. In control group, conventional VAL-MAP is used, and markings are also evaluated intraoperatively, but no re-adjustments are made.	No significant difference in the success rate regarding intraoperative navigation between the no-adjustment and adjustment groups (36.3% vs 40.0%, P = 0.86). However, looking at the markings placed with no successful navigation, the control group had a significantly lower accuracy grade than the treatment group (2.6 ± 0.5 vs 4.5 ± 0.8). Total time: ENB VAL-MAP = 41 ± 14 min vs VAL-MAP = 43 ± 4.9 min.
Yang et al.	2019	NR, NM, P	24	24 patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen of those patients also received preoperative CT-guided percutaneous localization post-VAL-MAP; 15 patients received CT-guided localization with dye and microcoil, and 4 patients received only dye. Virtual bronchoscopy is used for VAL-MAP; after VAL-MAP, a microcoil is placed near the lesion through the CT-guided needle localization; then blue dye is injected to set the marking; at the end, a confirmatory CT scan was performed pre-operation. The contribution of VAL-MAP to the respective surgery is evaluated by the performing surgeon.	Of 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No complications occurred after the treatment. After training and video demonstration, the successful total marking rate was 85.7%. Median time from VAL-MAP to CT room was 36 min, VAL-MAP to operating room was 61 min.

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