Development of a web-based preoperative planner for right vertical infra-axillary thoracotomy.

Abstract

Right Vertical Infra-Axillary Thoracotomy (RVIAT) offers superior cosmetic outcomes but presents challenges due to restricted access. In pediatric patients, the 'crowded thorax' necessitates simultaneous visualization of intracardiac defects and central cannulation sites. Therefore, the choice of the intercostal incision can significantly affect the surgical field. To address this, we propose a patient-specific, geometry-driven framework to objectively optimize surgical corridors. A web-based surgical planner was developed to simulate incision strategies using patient-specific computed tomography data. The system utilizes ray-casting algorithms to compute a quantitative 'Visibility Score' for multiple anatomical targets. The framework was validated through a complex dual-pathology case and a multi-parametric sensitivity analysis involving varying chest wall thicknesses and instrument constraints. The system was successfully implemented as a platform-independent web application capable of real-time, client-side processing. In the dual-pathology validation, the simulation revealed that the standard 4th intercostal space (ICS) provided limited visibility for the secondary target (Patent Ductus Arteriosus, PDA: 72%). The optimizer identified the 3rd ICS as the superior vector, increasing PDA visibility to 86% without compromising primary Ventricular septal defect exposure (100%). Sensitivity analysis further indicated that while deep intracardiac targets maintained robust visibility across varying anatomical conditions, the exposure of cannulation sites was reduced. The proposed framework provides a deterministic method to evaluate surgical corridors preoperatively. By objectively quantifying exposure for both intracardiac defects and obligatory cannulation sites, the system assists surgeons in selecting the optimal incision level to ensure comprehensive procedural safety.