You will hear about an advancement for imaging during endoscopic surgery. The endoscopic system design and image acquisition method could provide low-cost and real-time surgical navigation capability with optimized sensitivity and functionality.

1. LLNL-PRES-647318
This work was performed under the auspices of the
U.S. Department of Energy by Lawrence Livermore
National Laboratory under contract DE-AC52-07NA27344.
Lawrence Livermore National Security, LLC
Stavros Demos

2. • Detect locations of disease
• Verify complete removal
after surgery
• Detect and preserve
anatomical features of
importance
Lawrence Livermore National Laboratory
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Intraoperative imaging using targeting fluorescing contrast
agents has been shown to be an effective navigation tool

3. Lawrence Livermore National Laboratory
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…and is adaptable to any conventional endoscope system

4. Lawrence Livermore National Laboratory
Key advantages of our system
• It is easy to handle (low weight, compact)
• Simultaneous image acquisition
• Optimal sensitivity
• It can be multiplexed to use multiple contrast
agents
• It can be adapted to any endoscope type
system for multi-purpose use in the OR
• It is relatively inexpensive to manufacture
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Hamamatsu system, Aoki et.Al., J Hepatobiliary Pancreat Sci., 2010
Intuitive Surgical system, Robotic system, Spinoglio et. Al. Surg Endosc, Dec 2012

5. Lawrence Livermore National Laboratory
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Competition: One camera acquires alternately color and spectral images
Our approach: Separate image-coupled cameras acquire images in parallel
Our approach provides orders of magnitude higher sensitivity

6. Enhancing the visualization of the biliary
system during laparoscopic surgery • 750,000 patients undergo laparoscopic
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Biliary System
cholecystectomy/year USA
• Common Bile Duct (CBD) injury occurs in 1/200
operations (4000/yr)
• Multiple reconstructive operations and procedures,
increased mortality, and lifelong disability
• Liability/Medical costs: $250k-$1M per occurrence
• Most significant injury occurs when surgeon
misidentifies CBD as cystic duct and cuts this
structure
The concepts are directly applicable to other clinical
needs such as cancer detection and the vascular system
visualization

7. • Cannulation of the cystic duct and associated
complications (which can include: Infection, bleeding,
pancreas inflammation, damage to the common bile duct)
• 10-20 minutes of OR time
• Exposure to radiation
• Live image is not available during the dissection phase
• Anatomy is not directly overlaid onto the surgical field
• Operator dependent interpretation
• Cost/benefit questionable as a routine procedure
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• 97% of errors due to visual perceptual illusion
• Faults in technical skill only 3% of injuries

8. • ICG is administered intravenously before surgery
• ICG is nearly exclusively eliminated by the liver
into the bile
• Intraoperative fluorescent cholangiography
using ICG was first demonstrated in 2009 by
Ishizawa et. Al., J Am Coll Surg. 208 (see left,
open surgery)
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LLNL-PRES-647318
• A large number of publications have been
produced in the last 4 years on this topic,
highlighting the clinical importance of this
method
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9. ICG emission image RGB conventional image
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Imaging the gallbladder and bile ducts using ICG
Ex vivo images using animal model

10. ICG image of tube Conventional image ICG emission image
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3 mm plastic tube
containing ICG solution
5-mm thick bovine
muscle tissue covering
the tube
ICG fluorescence image
through the 5-mm tissue

11. Lawrence Livermore National Laboratory
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Conventional image ICG fluorescence image Composite image
Bile duct covered by two
layers of intestinal wall
ICG image visualize
subsurface bile duct
Image superposition can
assist real time navigation

12. Lawrence Livermore National Laboratory
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13.  Our system design offers optimized sensitivity and
functionality for endoscopic/laparoscopic NIR fluorescent
subsurface imaging
 This design could provide low-cost and real-time surgical
navigation capability for minimally invasive surgery
• Common bile duct
• Blood vessels
• Cancer (Sentinel lymph node biopsy)
• Any application with a fluorescent contrast agent
Lawrence Livermore National Laboratory
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14. Lawrence Livermore National Laboratory
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Genaro Mempin
mempin1@llnl.gov