Augmented Reality with Diffusion Tensor Imaging (DTI) and Tractography during laparoscopic myomectomies.

Augmented reality (AR) is a technology that allows a surgeon to see key hidden subsurface structures in an endoscopic video in real time. This works by overlaying information obtained from pre-operative imaging, and fusing it in real time with the endoscopic image. MR-DTI and fiber tractography are known to provide additional information to standard structural MRI. Here we report the first two cases of real-time augmented reality during laparoscopic myomectomies with visualization of uterine muscle fibers after DTI tractography-MRI, to help the surgeon to decide the starting point incision. First case: A 31 years-old patient underwent a laparoscopic surgery for a 6cm FIGO 5 myoma. Second case: a 38 years-old patient also underwent a laparoscopic myomectomy, for a unique 6cm myoma FIGO 6. Signed consents were obtained for all the patients, which included clauses of no modification of the surgery. Before surgery, MRI were realized. The external surface of the uterus, the uterine cavity, and the surface of the myomas were delimited according to the preoperative MRI. A fiber tracking algorithm was used to extrapolate the uterine muscle fibers architecture. The aligned models were blended with each video frame to give the feeling that the uterus is almost transparent, and so the surgeon can localize exactly the myomas, and the uterine cavity. We displayed also the uterine muscle fibers, and the visualization of them helped us to decide the starting incision point for the myomectomies. Then, the myomectomies were performed using a classic laparoscopic technique. Those case-reports shows that AR and DTI fiber tracking in fibroid uterus is possible, providing fiber direction, helping the surgeon to visualize and decide the starting incision point, for laparoscopic myomectomy. Respecting the fibers orientation could improve the quality of the scar, and decrease the architectural disorganization of the uterus.