Seeing the Invisible: Mixed Reality–Guided Anatomical Segmentectomy for Ground-Glass Nodules

Mixed reality–guided anatomical segmentectomy represents an emerging strategy to improve intraoperative spatial understanding during sublobar lung resection. Accurate identification of segmental anatomy is critical in segmentectomy, particularly for ground-glass nodules, where lesion localization and margin assessment can be challenging. Conventional imaging review and intraoperative visualization may be insufficient to fully translate complex three-dimensional anatomy into the surgical field. Recent advances in three-dimensional reconstruction and augmented visualization technologies have enabled improved preoperative planning and intraoperative navigation in thoracic surgery.
This video demonstrates the use of mixed reality to guide a uniportal video-assisted thoracoscopic (VATS) left apicoposterior (S1+2) segmentectomy.

The case presents a 59-year-old female, who never-smoked, with an incidental pulmonary finding on computed tomography. Imaging revealed a 13 mm subsolid nodule located in the left apicoposterior segment, with a solid component measuring 0.9 × 0.5 cm and no evidence of lymphadenopathy. Interval imaging demonstrated an increase in the solid component, and surgical resection was indicated.

Preoperative planning included high-resolution computed tomography followed by three-dimensional reconstruction of the pulmonary anatomy. Segmental arteries, veins, and bronchial structures were identified, and the spatial relationship between the lesion and segmental boundaries was defined. Mixed reality visualization was performed using an untethered, self-contained augmented reality (AR) and mixed reality (MR) headset, which allowed for an interactive assessment of patient-specific anatomy prior to surgery. Previous studies have demonstrated that three-dimensional reconstruction improves anatomical understanding and may reduce intraoperative uncertainty during segmentectomy, particularly in cases with complex or variant anatomy.

A uniportal VATS approach was performed. After entry into the pleural cavity and lung mobilization, mixed reality guidance was used intraoperatively to assist in correlating the three-dimensional reconstruction with the surgical field. The segmental arterial branch to S1+2 was identified and divided, followed by bronchial isolation and division. Venous structures were preserved or divided according to anatomical boundaries. The intersegmental plane was defined and divided using staplers.

Mixed reality facilitated intraoperative recognition of vascular and bronchial anatomy and supported the accurate identification of the segmental plane. Emerging evidence suggests that augmented and mixed reality technologies may enhance surgical precision, improve orientation, and support decision-making during minimally invasive procedures. These tools may be particularly relevant in sublobar resections, where precise anatomical delineation is required to ensure oncologic adequacy while preserving lung parenchyma.

The lesion was included within the resected specimen with adequate margins. No intraoperative complications occurred. The patient had an uneventful postoperative course and was discharged without complications.

This approach demonstrates that mixed reality can be integrated into minimally invasive thoracic surgery to enhance anatomical orientation and may represent a useful adjunct in segmentectomy for subsolid nodules.

This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.  

References

1. Ujiie H, Kato T, Hu HP, et al. Three-dimensional imaging and navigation in thoracic surgery. J Thorac Cardiovasc Surg. 2022;164(3):1020–1028.
2. Zhang L, Li M, Yang Y, et al. Application of mixed reality technology in thoracic surgery: a systematic review. Ann Thorac Surg. 2023;116(2):512–520.
3. Liu Z, Zhang Y, Chen X, et al. Clinical application of augmented and mixed reality in thoracic surgery: current status and future perspectives. Eur J Cardiothorac Surg. 2024;65(1):ezad365.
4. Chen-Yoshikawa TF. Virtual-assisted lung mapping: a review of navigation techniques for thoracic surgery. J Thorac Dis. 2020;12(6):3277–3284.

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