This study was funded by the National Natural Science Foundation Cultivation Program of The Third Affiliated Hospital of Sun Yat-sen University (2023GZRPYMS08) and funding by Science and Technology Projects in Guangzhou (SL2023A03J01216).&#160;The authors would also like to acknowledge the joint funding project of&#160;the Third Affiliated Hospital of Sun Yat-sen University and Chaozhou Central Hospital.

The protocol follows the guidelines of the human research ethics committee of Sun Yat-Sen University. No specific ethics approval is required since this treatment was performed in routine clinical care.
1. 3D reconstruction
<ol>
	<li>Import DICOM data from neck-enhanced CT scans into 3DSlicer10, utilizing a window width of 350 Hounsfield units (HU) and a window level of 40 HU.</li>
	<li>Segment and reconstruct the neck 3D model using a semi-automatic approach.
	<ol>
		<li>Segment and reconstruct the skin using the Threshold and Hollow functions. First, create a segmentation for CT values greater than -250 HU with the Threshold function. Then, utilize the Hollow function to remove the interior of this segmentation.</li>
		<li>Segment and reconstruct the thyroid, lesion, trachea, and esophagus using the Grow from seeds function based on either arterial or venous phase images. Manually delineate seeds within the target structures across cross-sectional, sagittal, and coronal images. Following this, automatically generate the target segmentation using the Grow from seeds function.</li>
		<li>Segment and reconstruct the bone using the Threshold function based on plain scanning images. Create this segmentation for CT values exceeding 200 HU.</li>
		<li>Segment and reconstruct arteries using the Local threshold function based on arterial phase images. Manually delineate seeds within the arteries in the coronal images. Subsequently, create a segmentation with a CT value range consistent with the seeds using the Local threshold function, and repeat the procedure to gradually expand the segmentation.</li>
		<li>Segment and reconstruct veins using the Local threshold function based on venous phase images. Use the specific operations identical to those described in the previous step.</li>
	</ol>
	</li>
	<li>Automatically reconstruct the neck 3D model using volume rendering.
	<ol>
		<li>Select either arterial phase images or venous phase images within the volume rendering module.</li>
		<li>Opt for an optimal automatic reconstruction protocol, typically the coronary enhanced CT reconstruction protocol, emphasizing visualizing the superior and inferior thyroid vessels.</li>
		<li>Minimize unnecessary reconstruction by precisely adjusting the region of interest.</li>
	</ol>
	</li>
</ol>
2. Constructing the neck virtual hologram
<ol>
	<li>Export the semi-automatically reconstructed neck 3D model from 3DSlicer as an OBJ file.</li>
	<li>Create a new project in Unity3D utilizing the Mixed Reality Toolkit (MRTK) and configure the necessary components.
	<ol>
		<li>Add a control border by utilizing the Box collider component.</li>
		<li>Implement a movable cursor using the Cursor Context Object Manipulator component.</li>
		<li>Add movement, scaling, and rotation functions through the Object manipulator, Near interaction Grabbable, and Min Max Scale Constraint components.</li>
		<li>Enable transparency control by utilizing the Slider Transparency Controller component.</li>
	</ol>
	</li>
	<li>Import the OBJ file into the project and associate the aforementioned components with the neck 3D model.</li>
	<li>Debug the neck virtual hologram on the MR head-mounted device (HMD) using the Holographic Remoting program, followed by packaging and exporting the project from Unity3D11.</li>
	<li>Install the neck virtual hologram onto the MR HMD using the Visual Studio program.</li>
</ol>
3. MR device manipulation
<ol>
	<li>Wear the MR HMD before surgery or have circulating nurses assist in wearing the HMD during surgery.</li>
	<li>Use MR HMD to manipulate the neck virtual holograms.
	<ol>
		<li>Control the movement, scaling, and rotation of the neck virtual hologram using a Grab gesture.</li>
		<li>Adjust the transparency of the neck virtual hologram by dragging the corresponding virtual slider.</li>
		<li>Align the neck virtual hologram with the patient&#39;s position, ensuring proper alignment of anatomical markers such as the mandible and clavicle.</li>
	</ol>
	</li>
	<li>Import clinical data such as neck CT images, ultrasonography and laboratory examination results into the MR HMD to access this information at any time during surgery.</li>
	<li>Control the HMD to capture MR images and videos through voice commands.</li>
	<li>Share the first-person perspective through the MR HMD via a Wi-Fi connection.</li>
</ol>
4. Preoperative stage
<ol>
	<li>Inclusion criteria
	<ol>
		<li>Include patients with papillary thyroid carcinoma (PTC) with a maximum diameter &#8804; 3 cm.</li>
		<li>Include patients who express a requirement for beauty.</li>
	</ol>
	</li>
	<li>Exclusion criteria
	<ol>
		<li>Exclude patients who are unable to tolerate surgery or general anesthesia.</li>
		<li>Exclude patients exhibiting extrathyroidal invasion or distant metastasis of PTC.</li>
		<li>Exclude patients with a history of thyroid surgery, ablation, or radioactive iodine treatment.</li>
		<li>Exclude patients with chest or clavicle deformities.</li>
		<li>Exclude patients with hypoparathyroidism or vocal cord dysfunction.</li>
	</ol>
	</li>
	<li>Auxiliary examination
	<ol>
		<li>Conduct neck-enhanced CT and ultrasonography to assess the PTC and its surrounding anatomy.</li>
		<li>Conduct chest radiography, electrocardiogram, complete blood count, liver and kidney function tests, and coagulation tests to exclude any absolute surgical contraindications.</li>
		<li>Conduct thyroid and parathyroid function tests, along with thyroglobulin levels.</li>
		<li>Conduct fiberoptic laryngoscopy to evaluate vocal cord function.</li>
	</ol>
	</li>
	<li>Preoperative preparation
	<ol>
		<li>Fast patients for 10 h and administer intravenous glucose saline or Ringer&#39;s solution.</li>
		<li>Administer midazolam, propofol, sufentanil, and atracurium intravenously to induce general anesthesia, followed by transoral tracheal intubation. Avoid using muscle relaxants during the maintenance phase of anesthesia.</li>
		<li>Perform urethral catheterization.</li>
		<li>Connect the intraoperative neuromonitoring (IONM) device.</li>
		<li>Position the patient in a split-leg configuration and extend their neck by tilting their head back. Position the endoscope system at the front of the patient&#39;s head.</li>
	</ol>
	</li>
</ol>
5. Surgical procedure (breast approach)
<ol>
	<li>Disinfect the surgical field, lay down the aseptic operating towels, and connect the endoscope, electrocoagulation hook, suction unit, and ultrasound knife.</li>
	<li>Identify the observation hole located 2 cm to the right of the midpoint of the line connecting the bilateral nipples. Inject expansion fluid subcutaneously and dissect using a stripping rod.</li>
	<li>Place a 10 mm Trocar and introduce carbon dioxide to establish an operating space with internal pressure maintained at less than 6 mmHg.</li>
	<li>Use the upper edge of both areolas as the operating channel. Dissect the subcutaneous cavities on both sides with two 5 mm or 10 mm Trocar needles under 30&#176; laparoscopic visualization. Insert the ultrasonic knife and scatheless forceps, and extend the subcutaneous space towards the front of the neck.</li>
	<li>Separate the cervical white line to free the thyroid gland. Suspend the ribbon muscles with sutures to extend the field of view.</li>
	<li>Inject carbon nanoparticles into the thyroid gland to stain it and the cervical lymph nodes.</li>
	<li>Disconnect the isthmus of the thyroid to expose the trachea and detach the suspensory ligament of the thyroid.</li>
	<li>Utilize the ultrasonic knife to coagulate the superior thyroid artery and vein, inferior thyroid artery, and middle thyroid vein. Secure the larger blood vessels with absorbable clamps.</li>
	<li>Perform auto-transplantation of PGs into the homolateral sternocleidomastoid muscle if the PG is removed or its blood supply is destroyed.</li>
	<li>Identify the RLN and superior laryngeal nerve using the IONM probe. Protect the nerves with wet gauze to prevent thermal injury.</li>
	<li>Carefully separate and excise the lesional thyroid gland, ensuring it is completely retrieved using a specimen bag.</li>
	<li>Perform homolateral lymphadenectomy in the cervical central region. If indicated, proceed with contralateral thyroidectomy and lymphadenectomy.</li>
	<li>Ensure all bleeding is thoroughly controlled, and rinse the surgical field with sterile distilled water. Insert a drainage tube in the operating channel and suture the incision layer by layer.</li>
</ol>
6. Postoperative management
<ol>
	<li>Provide electrocardiogram monitoring and oxygen therapy as patients return to the ward. Subsequently, administer treatments that include fluid replacement, intravenous calcium, pain relief, inhalation drug therapy, and phlegm clearance. If required, administer hemostatic drugs and initiate physical therapy.</li>
	<li>On the first postoperative day, discontinue electrocardiogram monitoring and oxygen therapy and remove the urinary catheter. Patients may resume a full diet and take daily oral doses of levothyroxine and calcium.</li>
	<li>On the second or third postoperative day, remove the drainage tube and prepare for patient discharge.</li>
	<li>Instruct the patient to visit the outpatient department for follow-up during the first week after surgery, as well as at 1 month, 3 months, 6 months, and 12 months postoperatively. Routinely review thyroid function and thyroglobulin levels, and perform neck ultrasonography.</li>
</ol>

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The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

MR is a cutting-edge AI technology based on various algorithmic models and sensing devices. The purpose of this protocol is to utilize MR to assist in radical ET. Moreover, the key procedure is the construction of the neck 3D model and virtual hologram. Subjective scales indicate positive results, demonstrating that MR is benefitial for surgeons in performing radical ET with ease. Additionally, MR exhibits potential advantages in preventing complications associated with ET. However, the small sample size limits the significance of the differences observed in all surgical outcomes.
MR is employed as a real-time presentation method for the neck 3D model. This protocol incorporates two 3D reconstruction methods12: volume rendering, which effectively displays thyroid blood vessels, and semi-automatic reconstruction, which accurately presents small structures such as lesions and lymph nodes. The 3D reconstruction of neck-enhanced CT images can be completed within one hour, while the production of the neck virtual hologram takes only 15 min. Consequently, the preparation phase of this protocol is simple and can be implemented in routine clinical settings.
MR can significantly enhance the clinical utility of tomographic imaging in surgical settings. On the one hand, the MR HMD works wirelessly and incorporates various innovative human-computer interaction techniques, making it particularly suitable for sterile environments such as operating rooms10. Surgeons can interact with the virtual hologram at any time during surgery. On the other hand, MR offers greater convenience and efficacy compared to other visualization methods, including 3D printing. It significantly enhances the visualization capabilities of 3D models, which can accurately and in real-time depict the spatial distribution of critical structures, such as target organs, lymph nodes, and blood vessels8. Consequently, surgeons can optimize surgical protocols promptly before and during operations, thereby increasing their confidence. To date, MR has been utilized in various surgical disciplines, including orthopedics, neurosurgery, urology, and hepatobiliary surgery. The existing studies on MR-assisted surgery are summarized in Table 413,14,15,16,17,18,19,20,21. It can be seen that MR-assisted ET is realized for the first time in this protocol. Furthermore, many of these studies utilized subjective rating scales.
However, MR-assisted surgery is not without its limitations. Firstly, the intense lighting in operating rooms may compromise the MR device&#39;s ability to accurately recognize and analyze the surrounding environment, thereby diminishing the quality of the virtual hologram presentation22. Secondly, this protocol requires manual alignment of the virtual hologram with the patient for effective localization and navigation. Nevertheless, every alignment method has inherent errors. As a result, MR should be regarded as an auxiliary tool for perioperative assessment rather than a standalone basis for modifying surgical plans without anatomical exposure23. Additionally, in contrast to other surgical procedures, the approach and field of radical ET are relatively fixed, limiting the potential for optimization through MR.
MR holds significant promise for surgical applications, as it can be integrated with various visual, auditory, and tactile sensors to assist surgeons in conducting realistic preoperative simulation exercises24. Additionally, MR can be combined with deep learning-based image recognition technology to develop an intraoperative navigation system. This enables surgeons to more efficiently and accurately discern the relationship between lesions and surrounding anatomical structures25. MR HMD can present not only virtual 3D models in real-time but also integrate endoscopic system data to display virtual split screens from any position and angle26. During surgery, surgeons can access clinical data such as patient history and auxiliary examination results at any time through the MR HMD and share their first-person perspective with others to facilitate bedside teaching and telemedicine.
In summary, investigating the surgical applications of MR is of considerable importance. The advancement of AI technology is anticipated to promote a transformative shift in surgical procedures in the future. In the context of radical ET, MR has the potential to enhance the surgeon&#39;s intraoperative experience, reduce the surgical threshold, and possibly improve safety. However, a large-scale, prospective, multi-center clinical study is necessary to further assess the impact of MR on the efficacy and safety of ET.

Over the past decade, the global incidence of thyroid nodules has risen to 29.29%, reflecting an increase of 7.76% compared to the previous decade. This trend positions thyroid nodules as one of the most prevalent diseases1. Concurrently, the incidence of thyroid cancer has reached 20/100,000, ranking it seventh among all cancers and third among females. Radical surgery remains the preferred treatment approach2.
Thyroidectomy can be categorized into open, endoscopic, and robotic surgeries. Endoscopic thyroidectomy (ET) is a form of cosmetic surgery that employs the length of endoscopic instruments to create subcutaneous tunnels through incisions made in the areola, axilla, oral cavity, and other concealed areas, thereby facilitating a scarless appearance in the neck. This approach is particularly appealing to women, who constitute the majority of thyroid cancer patients3. However, ET still requires further optimization from a surgical perspective. Firstly, ET is challenged by limited surgical space and a lack of tactile feedback, which complicates the operation and contributes to a prolonged learning curve4. Secondly, the thyroid possesses special physiological functions and complex local anatomy, making ET susceptible to serious complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) injury5. Additionally, thyroid cancer often presents with occult lymphatic metastasis, and incomplete cervical lymph node dissection may further elevate the risk of postoperative lymphatic recurrence6, leading to the necessity for secondary or even multiple surgeries in some patients.
Artificial intelligence (AI) is an emerging field that seeks to simulate and enhance human intelligence through computer algorithms. Extended reality (XR) is a category of AI techniques that can deliver highly realistic audiovisual information in real-time, particularly suited for surgical applications7. Mixed reality (MR), a subset of XR, integrates virtual holograms with real-world entities, enabling users to interact seamlessly between reality and virtual environments8. Three-dimensional (3D) reconstruction is a computer graphics technique that transforms two-dimensional (2D) images composed of pixels into 3D models made up of voxels. The presentation of 3D models is crucial, and the primary application of MR in surgery involves displaying 3D models constructed from tomographic images, such as computed tomography (CT) and magnetic resonance imaging (MRI).
In this study, MR was utilized to assist in radical ETwith the aim of enhancing its efficacy and safety while reducing surgical complexity. Patients diagnosed with thyroid cancer who met specified inclusion and exclusion criteria were randomly assigned to either the experimental group or the control group. Those in the experimental group underwent MR-assisted radical ET. A comparative analysis of the surgical outcomes between the two groups was conducted. Furthermore, the National Aeronautics and Space Administration Task Load Index Scale (NASA-TLX) and the Likert Subjective Rating Scale were employed to assess the impact of MR-assisted ET on the surgeons. NASA-TLX is recognized as the gold standard for subjective workload assessment and comprises six dimensions: mental demand (MD), physical demand (PD), temporal demand (TF), own performance (OP), effort (EF), and frustration (FR)9. Each dimension is rated independently on a scale of 0 to 100. The Likert Subjective Rating Scale includes a series of questions with five response levels ranging from very satisfied (5 points) to very dissatisfied (1 point), with the intermediate levels being satisfied (4 points), acceptable (3 points), and dissatisfied (2 points).

<table><tbody><tr><td>3DSlicer</td><td>Slicer</td><td></td><td>https://www.slicer.org/</td></tr><tr><td>HoloLens2</td><td>Microsoft</td><td></td><td>a type of mixed reality helmet mounted display&lt;br/&gt; https://www.microsoft.com/en-us/hololens/hardware#document-experiences</td></tr></tbody></table>

mixed reality assisted radical endoscopic thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, the thyroid&#39;s unique physiological functions and intricate surrounding anatomy may result in various surgical complications. Mixed reality (MR), a real-time holographic visualization technology, enables the creation of highly realistic 3D models in the real world and facilitates multiple human-computer interactions. MR can be utilized for both preoperative evaluation and intraoperative navigation. First, semi-automatic 3D reconstruction of the neck from enhanced computed tomography images is performed using 3Dslicer. Next, the 3D model is imported into Unity3D to create a virtual hologram that can be displayed on an MR helmet-mounted display (HMD). During surgery, surgeons can wear the MR HMD to locate lesions and surrounding anatomy through the virtual hologram. In this study, patients requiring radical ET were randomly assigned to either the experimental group or the control group. Surgeons performed MR-assisted radical ET in the experimental group. A comparative analysis of surgical outcomes and the results of scales was conducted.&#160;This study successfully developed the neck 3D model and the virtual hologram. According to the NASA Task Load Index Scale, the experimental group exhibited significantly higher scores in &#39;Own Performance&#39; and lower scores in &#39;Effort&#39; compared to the control group (p = 0.002). Additionally, on the Likert Subjective Evaluation Scale, the mean scores for all questions exceeded 3. Although the incidence of surgical complications was lower in the experimental group than in the control group, the differences in surgical outcomes were not statistically significant.MR is beneficial for enhancing performance and alleviating the burden of surgeons during the perioperative period. Furthermore, MR has demonstrated the potential to enhance the safety of ET. Therefore, it is essential to further investigate the surgical applications of MR.

This study successfully constructed the neck 3D model of patients with PTC (Figure 1) and performed 14 cases of MR-assisted radical ET (Figure 2).
A total of 32 ETs were performed by a senior surgeon, who completed the NASA-TLX and the Likert Subjective Rating Scale (Table 1 and Table 2) following the surgeries. In the NASA-TLX, the experimental group exhibited a significantly higher OP score and lower EF score compared to the control group (p = 0.002), indicating that the surgeon felt it easier to achieve better performance in MR-assisted radical ET. In the Likert Subjective Rating Scale, the average score for all questions exceeded 3 points, suggesting that the surgeon regarded the protocol as feasible and effective.
The clinical results of this study are summarized in Table 3. None of the patients experienced recurrence. Although the incidence of surgical complications in the experimental group was lower than in the control group, this difference was not statistically significant (p = 0.426). As a preliminary study, the differences in all surgical outcomes were not statistically significant due to the small sample size.
In summary, MR is beneficial for enhancing the intraoperative experience and alleviating the subjective burden on surgeons during the perioperative period. Furthermore, MR has demonstrated potential for improving the safety of ET.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67522/67522fig01.jpg" /> 
Figure 1: 3D reconstruction of the neck using enhanced CT imaging. (A) Semi-automated segmentation and reconstruction of the neck 3D model. (B) Automated reconstruction of the neck 3D model through volume rendering. <a href="https://www.jove.com/files/ftp_upload/67522/67522fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/67522/67522fig02.jpg" /> 
Figure 2: Manipulation of the MR HMD during surgery. (A,B) The surgeon utilized the MR HMD to access the neck CT images. (C,D) The surgeon employed the MR HMD to present the virtual hologram of the neck. <a href="https://www.jove.com/files/ftp_upload/67522/67522fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2">NASA-TLX</td>
			<td>Experimental group</td>
			<td>Control group</td>
			<td rowspan="2">P</td>
		</tr>
		<tr>
			<td>(n = 14)</td>
			<td>(n = 18)</td>
		</tr>
		<tr>
			<td>Mental demand (MD)</td>
			<td>73.21 &#177; 6.68</td>
			<td>77.50 &#177; 10.18</td>
			<td>0.18</td>
		</tr>
		<tr>
			<td>Physical demand (PD)</td>
			<td>73.93 &#177; 7.12</td>
			<td>78.33 &#177; 10.00</td>
			<td>0.071</td>
		</tr>
		<tr>
			<td>Temporal demand (TF)</td>
			<td>72.86 &#177; 9.35</td>
			<td>78.33 &#177; 10.00</td>
			<td>0.124</td>
		</tr>
		<tr>
			<td>Own performance (OP)</td>
			<td>85.00 &#177; 6.20</td>
			<td>74.44 &#177; 9.84</td>
			<td>0.002</td>
		</tr>
		<tr>
			<td>Effort (EF)</td>
			<td>73.21 &#177; 8.90</td>
			<td>82.50 &#177; 3.93</td>
			<td>0.002</td>
		</tr>
		<tr>
			<td>Frustration (FR)</td>
			<td>30.36 &#177; 25.23</td>
			<td>40.56 &#177; 19.01</td>
			<td>0.168</td>
		</tr>
	</tbody>
</table>
Table 1: Results of the NASA-TLX for this protocol.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Dimension</td>
			<td>Question</td>
			<td>Score (M&#177;SD)</td>
		</tr>
		<tr>
			<td>Operational</td>
			<td>Q1: This protocol is easy to implement</td>
			<td>3.57 &#177; 0.85</td>
		</tr>
		<tr>
			<td>Comfortable</td>
			<td>Q2: This protocol didn&#8217;t cause obvious discomfort or adverse reactions</td>
			<td>3.93 &#177; 0.62</td>
		</tr>
		<tr>
			<td rowspan="2">Preoperative</td>
			<td>Q3: This protocol is helpful for surgical planning</td>
			<td>4.21 &#177; 0.89</td>
		</tr>
		<tr>
			<td>Q4: This protocol is helpful for understanding the anatomy of the surgical field</td>
			<td>4.07 &#177; 0.83</td>
		</tr>
		<tr>
			<td rowspan="2">Postoperative</td>
			<td>Q5: This protocol is helpful for surgical manipulations</td>
			<td>4.14 &#177; 0.54</td>
		</tr>
		<tr>
			<td>Q6: This protocol is helpful for locating important anatomical structures</td>
			<td>4.29 &#177; 0.83</td>
		</tr>
	</tbody>
</table>
Table 2: Questions and scores from the Likert Subjective Rating Scale for this protocol.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2">Surgical outcomes</td>
			<td>Experimental group</td>
			<td>Control group</td>
			<td rowspan="2">P</td>
		</tr>
		<tr>
			<td>(n = 14)</td>
			<td>(n = 18)</td>
		</tr>
		<tr>
			<td>Complications</td>
			<td>2 (14.3%)</td>
			<td>5 (27.8%)</td>
			<td>0.426</td>
		</tr>
		<tr>
			<td>Hypoparathyroidism</td>
			<td>2 (14.3%)</td>
			<td>3 (16.7%)</td>
			<td>1</td>
		</tr>
		<tr>
			<td>RLN injury</td>
			<td>0 (0.0%)</td>
			<td>1 (5.6%)</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Postoperative bleeding</td>
			<td>0 (0.0%)</td>
			<td>1 (5.6%)</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Recurrence</td>
			<td>0</td>
			<td>0</td>
			<td>-</td>
		</tr>
		<tr>
			<td>Operation beeding (mL)</td>
			<td>21.43 &#177; 23.16</td>
			<td>15.56 &#177; 5.11</td>
			<td>0.808</td>
		</tr>
		<tr>
			<td>Operation duration (min)</td>
			<td>211.57 &#177; 85.04</td>
			<td>181.89 &#177; 92.83</td>
			<td>0.36</td>
		</tr>
		<tr>
			<td>Operation cost (yuan)</td>
			<td>17458.73 &#177; 4616.30</td>
			<td>16606.24 &#177; 2276.29</td>
			<td>0.779</td>
		</tr>
		<tr>
			<td>Drainage duration (day)</td>
			<td>3.57 &#177; 0.94</td>
			<td>3.76 &#177; 0.90</td>
			<td>0.493</td>
		</tr>
		<tr>
			<td>Drainage volume (mL)</td>
			<td>180.14 &#177; 93.16</td>
			<td>161.24 &#177; 88.08</td>
			<td>0.739</td>
		</tr>
		<tr>
			<td>Hospitalization duration (day)</td>
			<td>7.43 &#177; 3.57</td>
			<td>7.06 &#177; 3.02</td>
			<td>0.779</td>
		</tr>
		<tr>
			<td>Hospitalization cost (yuan)</td>
			<td>27783.56 &#177; 10772.23</td>
			<td>24569.34 &#177; 3478.90</td>
			<td>0.808</td>
		</tr>
	</tbody>
</table>
Table 3: Comparative analysis of surgical outcomes between the experimental group and the control group.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Studies</td>
			<td>Publication time (Year. Month)</td>
			<td>Region</td>
			<td>Surgery</td>
			<td>Sample size</td>
			<td>Methods</td>
		</tr>
		<tr>
			<td>Liu et al.13</td>
			<td>2021.02</td>
			<td>China</td>
			<td>Transforaminal Percutaneous Endoscopic Lumbar Discectomy</td>
			<td>44</td>
			<td>Retrospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Wierzbicki et al.14</td>
			<td>2022.01</td>
			<td>Poland</td>
			<td>Laparoscopic liver metastasis ablation</td>
			<td>8</td>
			<td>Retrospective analysis</td>
		</tr>
		<tr>
			<td>Kitagawa et al.15</td>
			<td>2022.04</td>
			<td>Japan</td>
			<td>Laparoscopic cholecystectomy</td>
			<td>9</td>
			<td>prospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Zhou et al.16</td>
			<td>2022.04</td>
			<td>China</td>
			<td>Glioma resection</td>
			<td>16</td>
			<td>Retrospective analysis</td>
		</tr>
		<tr>
			<td>Wang et al.17</td>
			<td>2022.08</td>
			<td>China</td>
			<td>Percutaneous nephrolithotomy</td>
			<td>21</td>
			<td>prospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Van Gestel et al.18</td>
			<td>2023.03</td>
			<td>Belgium</td>
			<td>Intracranial tumor resection</td>
			<td>20</td>
			<td>prospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Costa et al.19</td>
			<td>2023.03</td>
			<td>America</td>
			<td>Cerebrovascular Neurosurgical Procedures</td>
			<td>33</td>
			<td>Retrospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Wong et al.20</td>
			<td>2023.07</td>
			<td>China</td>
			<td>Bone tumor resection</td>
			<td>9</td>
			<td>Retrospective analysis; Scale survey</td>
		</tr>
		<tr>
			<td>Saadya et al.21</td>
			<td>2023.07</td>
			<td>England</td>
			<td>Parotid surgery</td>
			<td>20</td>
			<td>Retrospective analysis</td>
		</tr>
	</tbody>
</table>
Table 4: Existing clinical studies on MR-assisted surgery.

Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, ...

mixed-reality-assisted-radical-endoscopic-thyroidectomy

Nanyang Technological University

Research

JoVE Journal

Medicine

221 Views.  The Third Affiliated Hospital of Sun Yat-Sen University. Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Video: Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Accuracy in Dental Medicine, A New Way to Measure Trueness and Precision

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base for dental restorations. The current limitation of many reference scanners is the lack of accuracy scanning large objects like full dental arches, or the limited possibility to assess detailed tooth surfaces. A new reference scanner, based on focus variation scanning technique, was evaluated with regards to highest local and general accuracy. A specific scanning protocol was tested to scan original tooth surface from dental impressions. Also, different model materials were verified. The results showed a high scanning accuracy of the reference scanner with a mean deviation of 5.3 &#177; 1.1 &#181;m for trueness and 1.6 &#177; 0.6 &#181;m for precision in case of full arch scans. Current dental impression methods showed much higher deviations (trueness: 20.4 &#177; 2.2 &#181;m, precision: 12.5 &#177; 2.5 &#181;m) than the internal scanning accuracy of the reference scanner. Smaller objects like single tooth surface can be scanned with an even higher accuracy, enabling the system to assess erosive and abrasive tooth surface loss. The reference scanner can be used to measure differences for a lot of dental research fields. The different magnification levels combined with a high local and general accuracy can be used to assess changes of single teeth or restorations up to full arch changes.

Accuracy is a major demand in dental medicine. To verify accuracy, reference scanners are needed. This article presents a new reference scanner with an adjusted scanning method to acquire a broad variety of dental morphologies with high trueness and precision.

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure.
The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection.
To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day.
Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter&#39;s size and mediastinal positioning.

Here, we present a protocol for retrosternal thyroid goiter resection using a thoracoscopic-assisted transcervical approach.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic ...

Augmented Reality-Based Visualization of a Resected Tumor Specimen

In this research protocol, we expand upon our previously described three-dimensional (3D) scanning protocol with the addition of augmented reality (AR) technology. Surgical margin status remains one of the most important prognostic features in cancers of the head and neck and is one of the few factors under the control of the head and neck surgeon1,2,3. The complex 3D anatomy of the head and neck often creates difficulty for surgeons attempting to relocate a positive or close margin, and prior studies have demonstrated that accuracy in relocating margins following initial resection is suboptimal4,5,6. As a result, oncologic outcomes following re-resection remain poor2,3. This protocol investigates the feasibility and accuracy of AR to guide the re-resection of initial positive or close margins in head and neck oncologic surgery. This technology allows surgeons to replace a 3D scanned virtual hologram of the resected cancer specimen back into the resection bed to improve visualization of re-resection location to adequately clear an initial positive or close margin.&#160;
ETHICS DISCLAIMER:
This protocol includes the use of cadavers with approval from the Vanderbilt University Medical Center&#8217;s Center for Experiential Learning and Assessment. This protocol was performed in compliance with Vanderbilt University Medical Center guidelines for human subjects research under IRB #221733.

NOTE: A schematic detailing the protocol workflow can be seen in Figure 1.
1. 3D Scanning

	Obtain a 3D Scan of an oncologic resection specimen per the ...

Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Summary

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