Exploring Three-dimensional Digital Imaging and Communications in Medicine Image Reconstruction with the Anatomage Table in Pediatric Surgery: Our Experience

Managing a case as a surgeon involves three key steps: Interpreting investigations to establish a diagnosis, choosing between operative and conservative management, and, if surgery is decided, meticulously planning the intraoperative course. Besides the general examination and routine blood work, a reliable interpretation of the disease process through imaging modalities such as ultrasound (a noninvasive initial mode) and more objective modes such as computed tomography (CT) and magnetic resonance imaging (MRI) has thoroughly helped a surgeon. We explored a few of our cases by feeding their radiological images into the Anatomage table available for three-dimensional (3D) reconstruction and described its role in our intraoperative assistance. The Anatomage Table is the state-of-the-art, real-human-based 3D anatomy and medical education system, which offers digitized imprinted human cadavers, masterful medical learning aids, and representational 3D anatomy images, remodeling medical education and training Figure 1a. Some of the factors which has an edge over other traditional ways of learning, as quoted by the pioneers of Anatomage Table, include the following: Real frozen cadaveric slices, intricate vascular systems, various Cadavers (male, female, geriatric, and pregnant cadavers), high-visualization, annotated structures, real Anatomy and physiology, real-tissue simulation, and comprehensive physiology.Figure 1: The Anatomage Table and the various modes available in volume rendering and Ultra High Quality Rendering. (a) The Table in horizontal position with the computed tomography loaded image displayed on its screen and projected on the wall screen connected for teaching purposes. (b) The names and appearance of the various modes available in the volume rendering menuHIGH RESOLUTION DIGITAL IMAGING AND COMMUNICATIONS IN MEDICINE IMAGE RENDERING THREE-DIMENSIONAL RECONSTRUCTION This has been one feature that has been able to give surgeons realistic 3D graphic representations of the patient’s digital imaging and communications in medicine images that have been loaded onto the Anatomage Table. Two separate software tools for rendering of the patients’ radiological images have been made – Volume rendering and Ultra High Quality rendering, one each for CT and MRI Figure 1b. This technology permits detailed exploration of anatomy, including both soft and hard tissues. The options available are listed in the Figure below, wherein the decision to use each will depend on the tissue of interest – radiopaque structures such as bones and medical devices; soft tissues such as skin, muscles, blood vessels, and tissues containing air such as respiratory sinus, lungs, and gastrointestinal tract. The brightness and contrast for better visualization of structures can be adjusted using the slider bars. We used the Anatomage Table in a few of our cases, and below are the descriptions of the cases with the relevant images. Case 1: Ewing’s sarcoma of the right first rib A 16-year-old male had presented with superior vena cava (SVC) Syndrome, and after initial management in the Pediatric Intensive Care Unit, including detailed evaluation, a diagnosis of Ewing’s Sarcoma was made. He underwent neoadjuvant chemotherapy, and after size reduction, he was planned for surgical excision. We utilized the Anatomage Table for the 3D Reconstruction with volume rendering of his CT scan to get a spatial understanding of the same. The Citrine mode showed the residual tumor, which was initially more than 50% of the right hemithorax, was seen localized to the first rib, just touching the second rib Figure 2a. The lesion was seen to be extending to the lateral chest wall with very little space to enter the thoracic cavity Figure 2b. Medially, it was compressing and adhering to the main vessels, including the SVC Figure 2b. The posterior view gave a perspective about how the tumor looked in the thoracic cavity and its relation to the second rib. Furthermore, the Internal Thoracic vessel seemed to pass through the tumor Figure 2c. Intraoperatively, the lesion was pretty much a reflection of the preoperative Anatomage Table visualization, with the lesion extending as mentioned above. Our preoperative plan of dissection and excision of the residual tumor with the first rib, along with some margin on either side, preserving the second rib and clavicle, and shaving it off gently from the great vessels medially, was carried out.Figure 2: The computed tomography image and the three-dimensional reconstructed images on the Anatomage table. (a) The 1st rib reduced lesion after the chemotherapy (white solid arrow); (b) The image as seen in the Citrine mode showing the tumor (white star), the 1st rib (yellow arrow), the lateral extent of the tumor (white sold arrow) and the superior vena cava compressed medially (green arrowhead); (c) The posterior view in the citrine mode showing the tumor (white star) and the Internal Mammary vessel going through the tumor (white solid arrow)Case 2: Gallstone-induced pancreatitis – Pseudopancreatic cyst A 16-year-old female was suffering recurrent episodes of gallstone-induced pancreatitis. She even developed Acute respiratory distress syndrome and was admitted in the Pediatric ICU for 2 weeks. She gradually improved but went on to develop a pseudopancreatic cyst, which did not resolve and instead persisted to cause her recurrent pain and early satiety. A CT scan done showed a pancreatic pseudocyst of size 11 cm × 6.5 cm × 5.5 cm with a wall thickness of 5.5 mms; and multiple gallstones largest measuring 1 cm. She was planned for a cystogastrostomy. We did a 3D Reconstruction with volume rendering of her CT scan to get a spatial understanding of the stomach Figure 3a and the pseudocyst. The Citrine mode showed the cyst was lying behind the stomach along its length in the orientation of the stomach itself Figure 3b. The images gave us a good idea with regard to what our findings may be intraoperatively and how to plan the incision along the stomach, as well as an understanding that the incision anywhere along the posterior wall of the stomach will lead us to the cyst. Intraoperatively, the surgery proceeded with an incision in the anterior wall of the stomach, assessing the stomach wall posteriorly, and we were able to proceed with the procedure of doing a cystogastrostomy and a cholecystectomy.Figure 3: The three-dimensional reconstructed Coronal images of the computed tomography abdomen in Citrine mode (a) Image showing the stomach (white star); (b) The location and extent of the pancreatic pseudocyst (white arrowhead) and the fundus of the stomach (white star)Case 3: Hydatid cyst left lung A 14-year-old male presented to the emergency with hemoptysis for a few months, off and on coughing, fever with mild chest pain. He was evaluated and found to have a large cyst in the left hemithorax. The CT scan showed a large cyst of a size suggestive of a hydatid cyst. Hydatid serology was negative. The CT Thorax of this boy was uploaded in the Anatomage Table, and 3D Reconstruction with volume rendering was done. The cyst was seen well compressing on the left lung in Transparent soft-tissue mode Figure 4a and in Citrine mode Figure 4b. Our area of interest was the relation of the blood vessels with the cyst wall and also the bronchial communication, since the radiologists could not find evidence of any connections. The Opaque soft and hard modes showed the relation of the left lower segmental brochus being stretched over the superior wall of the cyst Figure 4c. The Citrine mode showed the left bronchial vessels stretched at the superior surface of the cyst Figure 4d. Intraoperatively, the findings were a cyst severely adherent to the posterior wall of the chest with features of a hydatid cyst: clear fluid, a white membrane-cyst wall had multiple bronchial communications, which were repaired on the table; some generalized oozing was present, which was controlled.Figure 4: The three dimensional reconstructed images of the computed tomography thorax (a) The Transparent soft tissue mode showing the relation of the cyst (black star) with the left lung; (b) The Citrine mode showing the relation of the cyst (white star) with the lung (in blue); (c) The Transparent soft-tissue mode showing the left lower bronchus (white arrow) adjacent to the superomedial wall of the cyst (white star); (d) The Opaque soft and hard mode showing the stretching of the left bronchial vessels over the cyst wall superiorly (white solid arrows)Case 4: Solid pseudopapillary epithelial neoplasm of the pancreas A 17-year-old girl presented with an acute onset of moderate to severe abdominal pain associated with hematemesis. She was diagnosed case of Solid Pseudopapillary Epithelial Neoplasm (SPEN) of the pancreas in 2021, for which she had taken alternative medications for several years. Contrast-enhanced CT (CECT) abdomen and endoscopic evaluation revealed a large lesion (7.4 cm × 8.3 cm × 8.6 cm) arising from the body and tail of the pancreas, with multiple varices and features suggestive of portal hypertension. She underwent 3D reconstruction of her CT abdomen using the Anatomage Table to aid in surgical planning. Volume rendering helped delineate the tumor’s relationship to surrounding organs, especially its close approximation to the splenic hilum, stomach, and jejunal loops. The reconstruction highlighted how the lesion encased the splenic vein (~180° contact) and was abutting the splenic artery, emphasizing the need for splenectomy Figure 5a. The Anatomage table helped clearly delineate the lesion’s spatial relationships and highlighted prominent gastric varices – features often difficult to appreciate on standard axial CT images Figure 5b. She subsequently underwent a distal pancreatectomy with splenectomy. Intraoperative findings correlated well with the reconstructed images, reinforcing the value of Anatomage in evaluating vascular anatomy in complex pancreatic cases.Figure 5: The three dimensional Reconstructed Coronal images of the computed tomography Abdomen of solid pseudopapillary epithelial neoplasm patient (a) Citrine Mode showing the large tumor (white star) seen in relation to the splenic artery superior to the mass (white arrowhead), the Superior Mesenteric vessels medially; (b) The Opaque soft and hard mode showing the gastric varices (white arrowhead) and the tumor seen below the stomach (white star)We tried a few cases of MRI, but due to the larger cuts (5–7 mm) of the images, the reconstruction was not satisfactory. MRI with smaller cuts (<2 mm cuts) will be preferable for good reconstructions in urological cases with Magnetic resonance urography, for MRI of abdomen and pelvis for complex cases like cloaca, for neurological anomalies, etc. Case 5: Ewing sarcoma of the left 10th rib An 11-year-old girl presented with progressive left lumbar pain and swelling over the left lower chest wall for 3 months, which later became painful and was associated with significant weight loss. Examination revealed hepatosplenomegaly, decreased air entry on the left side, and tracheal shift. The CECT chest and abdomen demonstrated a large, heterogeneously enhancing mass measuring 13 cm × 12.4 cm × 10.9 cm, centered on the left 10th rib with rib destruction, pleural effusion, complete left lung collapse, and mediastinal shift. FNAC suggested a small round cell neoplasm, and immunohistochemistry confirmed Ewing sarcoma. She received neoadjuvant multi-agent chemotherapy (VAC/IE regimen) with clinical and radiological improvement (reduced to 8.8 cm × 5.2 cm). For surgical planning, the CT images were reconstructed on the Anatomage Table using the volume rendering and transparent soft tissue mode. The 3D reconstruction clearly defined the tumor’s margins, its relation to the 10th rib and intercostal space, and proximity to the diaphragm and pleural cavity Figure 6a. The visualization showed diaphragmatic thinning with doubtful involvement. The extent of 10th rib erosion was well visualized in the anterior and posterior views Figures 6b and c.Figure 6: The three dimensional Reconstructed Coronal images of the computed tomography Chest and upper abdomen of the Ewing’s Sarcoma patient. (a). Citrine mode showing the tumor seen arising from the 10th rib at a distance of 2 cms lateral to the costovertebral junction of the left side 10th rib (white arrow). (b) Turquoise Mode Anterior view showing the eroded 10th rib (white arrow head) (c) Turquoise mode Posterior view showing the eroded 10th ribShe underwent wide local excision of the 10th rib with en bloc resection of the tumor. The posteromedial part of the diaphragm was removed in toto with the tumor (about 5 cm × 4 cm defect) and was repaired with 2-0 prolene. No pleural breach or tumor spillage occurred. Intraoperative findings closely matched the 3D reconstruction. The postoperative course was uneventful, with minimal intercostal drainage, early return to oral feeds, and discharge on post-operative day 4 in stable condition. DISCUSSION The Anatomage Table is changing the way we learn and understand anatomy by combining traditional teaching with modern digital technology. Conventionally, cadaver dissection has been the foundation of anatomy education, but it comes with challenges: Limited access, ethical concerns, and the difficulty of preserving specimens. The Anatomage Table helps overcome many of these problems by offering a full-size, 3D, virtual body that users can interact with – rotating, dissecting, and exploring in ways that are not possible with a physical cadaver.1,2 Medical and allied health students have responded positively to this technology. According to Kavvadia et al., most students found it helpful for understanding complex anatomical relationships.2 The ability to zoom in, view from different angles, and work in a clean, safe environment made learning more enjoyable and effective. This tool also proved especially valuable during the COVID-19 pandemic, when many institutions had to suspend traditional dissection sessions. For clinicians, including anesthesiologists and surgeons, the Anatomage Table has practical implications. Gupta et al. described how it can assist in preoperative planning, particularly for regional anesthesia or airway management.1 In situations like difficult intubation or complex spinal blocks, being able to visualize the anatomy beforehand can help guide the approach more precisely. The table also allows exploration of rare anatomical variations with high fidelity. Strantzias et al. reported finding a rare variation in the course of the facial nerve using the table – something that could be crucial during facial surgery.3 Unlike traditional dissection, the table allows users to “undo” mistakes and repeatedly explore structures, which supports safer learning and surgical preparation. Beyond education and planning, the table also shows promise in diagnosis. In a small pilot study, Tirelli et al. used the Anatomage Table to detect the spread of cancer beyond the lymph nodes in patients with head and neck cancer.4 Impressively, for larger lymph nodes, the table matched the accuracy of biopsy results and outperformed regular CT and MRI scans. Although it was less effective for smaller nodes, this early data suggests it could play a future role in improving cancer staging and treatment planning. There is a continued need to explore more cases using the Anatomage Table to fully understand its potential, which calls for detailed and focused research. Surgeons can make effective use of this tool to better prepare for surgery, especially when collaborating closely with radiologists, helping to overcome some of the logistical challenges typically faced. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.