Use of augmented reality with image fusion to facilitate surgical stoma creation: an IDEAL stage 2A case series

Introduction: Augmented reality (AR) has been increasingly applied to surgical procedures in fixed anatomical organs like brain, bones, aorta and kidneys, enabling image-guided precision, but sparingly to mobile organs such as the intestines. We report our initial experience with AR-guided intestinal stoma creation using an “image-guided” minimally invasive approach.

Methods: Adult patients requiring elective or urgent stoma creation for colonic decompression or diversion were included. Patient-specific 3D reconstructions of the relevant portion of the GI tract and reference organs (skin, bones, vessels) from a preoperative CT were co-registered intraoperatively via a head-mounted Augmented reality device (HoloLens2) onto the patient’s body using surface landmarks visible such as the umbilicus, bones, and prior surgical scars. A trajectory to the target bowel loop based on AR was marked on the skin, and stoma creation was performed at this site. Targeting of the correct bowel loop was confirmed with intraoperation fluoroscopy using intralumenal contrast injection. Technical success was defined as completion at the targeted site without open surgery.

Results: Fourteen patients underwent AR-guided stoma creation (9 colostomies, 5 ileostomies). Indications were bowel obstruction (n = 6), fistula (n = 5), anastomotic leak (n = 1), perforation (n = 1) and gastrointestinal bleeding (n = 1). Median age was 76 years, median BMI 23.8 kg/m². The median (range) number of prior abdominal surgeries was 2 (0–11). The median operative time was 131 min (interquartile range [IQR]: 96–143). The approach was either cut down directly over the stoma site (n = 11) or laparoscopic assisted (n = 3). AR permitted precise identification of the bowel loop required for stoma creation in all cases and help to avoid need for standard open surgery. Median postoperative stay was 7 days (interquartile range: 3–10). No Clavien-Dindo grade III or IV complications, reoperations, or unplanned readmissions were observed. Two postoperative deaths occurred in ASA 4 patients, both due to the underlying malignancy and multiorgan failure preoperatively, unrelated to the surgical procedure.

Conclusion: This early experience suggests AR methods may identify and target a loop of bowel, play a useful role in intestinal stoma creation, with potential to avoid need for laparoscopy or extensive open surgery. Further clinical application and refinement are warranted.

Introduction

Augmented reality (AR) in surgery is an emerging technology that integrates digital three-dimensional (3D) models or images directly onto the surgeon’s real-time view, theoretically enhancing intraoperative visualization and decision-making. Microsoft HoloLens 2, Meta Quest 3, and Apple Vision Pro are some of the AR headsets that may have the capabilities to do all of this (Birlo et al., 2022; Jiang et al., 2025). Originally developed for engineering and military applications, AR has rapidly expanded into medicine, with demonstrated utility in medical education and surgical training, as well as intraoperative guidance across specialties including neurosurgery, vascular surgery, orthopedics, and maxillofacial surgery (Chidambaram et al., 2021; Taghian et al., 2023). Most successful clinical applications have involved procedures on relatively immobile, solid organs, where accurate registration between preoperative imaging and intraoperative anatomy is feasible. In contrast, AR guidance for mobile organs such as the bowel remains challenging due to organ deformation, peristalsis, and shifting anatomical relationships, which complicate real-time alignment and visualization (Nicolau et al., 2011; Okamoto et al., 2015).

In the United States, more than one million individuals currently live with a stoma, with over 150,000 new ileostomy or colostomy procedures performed each year (Sheetz et al., 2014; Krishnamurty et al., 2017; Babakhanlou et al., 2022). In the United Kingdom, the population with a stoma exceeds 200,000 (MacDonald et al., 2023; Shehu et al., 2025). Intestinal stomas may involve the small bowel (e.g., ileostomy, jejunostomy) or the colon (colostomy), and can be temporary or permanent depending on the clinical indication (Sinicrope, 2022). Stomas are commonly fashioned via open or laparoscopic techniques, with less frequent use of single-incision laparoscopic surgery (SILS) or single-incision open methods (Hayashi et al., 2017). Laparoscopy facilitates visualization of the abdominal cavity without need for a large incision, in cases with substantial bowel dilation or adhesions from prior surgery, open approaches may provide superior access and surgical control (Scheidbach et al., 2009; Hayashi et al., 2017). However, the presence of severe adhesions, prior surgeries, or a “hostile abdomen” can significantly complicate these traditional surgical approaches.

The development and use of an AR overlay have the potential to be a transformative tool in this space. By integrating preoperative imaging with procedural planning, AR overlay systems allow for precise anatomical targeting, helping surgeons identify optimal stoma sites while minimizing dissection and avoiding major incisions (Ratti et al., 2024; Baashar et al., 2023; Ribeiro et al., 2024). In this report, we outline our initial clinical experience of this technique in a small but complex patient cohort. AR was used to identify the “target loop” needed for intestinal diversion, and we attempt to highlight both technical feasibility and clinical outcomes associated with AR-guided stoma creation.

Materials and methods

Study design

This was a longitudinal, prospective observational study conducted under an IRB-approved protocol at a quaternary care center on the Eastern Coast of the United States.

Patient selection

Adults (≥18 years) requiring elective or urgent stoma creation in the setting of bowel obstruction or diversion for colonic malignancy were eligible. All patients underwent preoperative abdominal CT imaging that was used to create the 3D intestinal model. Patients were excluded if they declined consent, lacked appropriate imaging, required concomitant procedures that precluded pre-operative virtual surgical planning and intraoperative AR-guided incision and surgical guidance.

Informed consent

The consent process included a detailed discussion of the novel AR visualization and navigation technique. Risks and benefits were reviewed, including the potential for a more targeted approach, reduced incision size, avoidance of pneumoperitoneum, expedited recovery, and decreased postoperative pain. Patients were also counseled on standard surgical risks—including bleeding, iatrogenic injury, infection, delayed recovery—and the possibility of conversion to open surgery. The operators’ experience level with the AR platform was disclosed during consent. We emphasized that “standard surgical measures”, both laparoscopic and open, were available and would be used as needed to conduct the stoma formation, and that confirmation of the correct segment of bowel to be exteriorized (the stoma) would be carried out using fluoroscopy and contrast injection into the bowel to confirm that the correct bowel loop was chosen.

Preoperative 3D segmentation

For preoperative planning and intraoperative guidance, we used a custom-optimized imaging workflow built on institutional platform (ImagineHIVE, DNAHIVE Inc., California, United States) (Simonyan et al., 2016). ImagineHIVE provides a secure web-based interface with user authentication, patient management, and seamless PACS integration for rapid image retrieval, streamlining the entire workflow from segmentation to AR deployment. Specifically, the platform integrates a customized image processing and visualization software (3D Slicer 5.9.0, Harvard Medical School, Massachusetts, United States) and segmentation software (TotalSegmentator 2.9.0, University Hospital Basel, Basel, Switzerland) to perform automatic and manual 3D segmentation of the anatomy from preoperative CT scans (Fedorov et al., 2012; Wasserthal et al., 2023). The segmented models included target bowel loops, soft tissues, major vessels, abdominal wall, bones, and skin contours (Figure 1). The finalized 3D models were prepared by software engineers working in concert with experienced surgeons who were performing the procedures and stored for intraoperative AR visualization.

Figure 1

Figure 1. (A–C) Axial, coronal and sagittal CT scan of a patient with malignant bowel obstruction showing the target bowel loop for stoma creation (star). (D) 3D-model generated based on the CT scan showing the target anatomy (star).

Procedural setting

Procedures were performed in major surgical operating rooms of a quaternary care facility. A mobile fluoroscopy system (OEC 9900 Elite, GE Healthcare, Illinois, United States) was prepared for all procedures. The operative team included board-certified colorectal surgeons, interventional radiologists, surgical fellows or residents, scrub technicians, circulating nurses, radiologic technologists, and research personnel.

Surgical technique

A laptop computer (Razer Blade 15, Razer Inc., California, United States), wireless router (AX5400, ASUSTeK Computer Inc., Taipei, Taiwan), and the ImagineHIVE system were used to support wireless AR streaming and visualization (Figure 2A). Following induction of general anesthesia, the lead surgeon donned an AR headset (HoloLens2, Microsoft Corporation, Washington, United States) (Figure 2B). The pre-segmented 3D models were superimposed onto the patient’s body using real-time AR overlay (Figure 2C). Using key anatomical landmarks—the rib margins, bilateral anterior superior iliac spines, pubic symphysis, xiphoid process, umbilicus, and pre-existing scars on the patient’s abdomen—the 3D imaging model was co-registered with the patient. Co-registration was performed by “manual registration”, in which the 3D image was guided and aligned to the patient’s body on the operating table. With the patient in the supine position, the floating or unlocked 3D image was directly overlaid while palpating the superficially palpable landmarks. Once proper alignment was accomplished, the image was fixed in place with a verbal command: “Lock body”. A pre-marked trajectory line representing the target bowel loop was aligned and transferred to the skin using a sterile marker. This location was confirmed intraoperatively by placing a radiopaque instrument (e.g., artery forceps) over the mark and performing an intra-operative fluoroscopy (Figure 2D). To enhance target loop visibility, carbon dioxide insufflation transanally via colonoscopy was employed in cases where complete obstruction was not present.

Figure 2

Figure 2. (A) Setup of the real-time AR overlay. (B) Image showing surgeon using the Microsoft HoloLens 2 in the operating room to register the virtual digital 3D model of the CT scan onto the patient’s abdomen using surface markings. (C) Camera view from the HoloLens 2 showing the 3D model being registered over the patient’s abdomen. (D) Intraoperative fluoroscopic image used to confirm the location and orientation of the target bowel loop. (E) Colostomy made using targeted surgery at the pre-planned location, with multiple incisions noted over the abdominal wall.

After surgical preparation, a targeted incision was made at the marked location to identify the bowel loop. The loop was exteriorized and a small enterotomy was performed and a 16 Fr red rubber catheter was inserted intra-luminally (Figure 2E). In all cases, Intraoperative fluoroscopy was then used to confirm that the correct loop by injection of a 50% diluted nonionic iodinated contrast agent (Omnipaque 300, GE Healthcare, Illinois, United States). Upon confirmation, the stoma was constructed. If dense adhesions or anatomical complexity prevented safe identification, the stoma site incision was extended or a small parallel incision was created for improved mobilization. Postoperatively, patients were managed according to the institution’s Enhanced Recovery After Surgery (ERAS) protocol.

Safety monitoring

Patient safety was monitored via standard intraoperative and postoperative protocols, including real-time imaging feedback, surgical visualization safeguards, and adherence to ERAS pathways. Any deviations from planned care were documented.

Outcome measures

Primary outcome was technical success, defined as correct identification of the target loop using AR, and completion of stoma creation without the need for exploratory laparotomy. Secondary outcomes included procedural complications, need for additional incisions, and length of hospital stay.

Results

A total of fourteen patients underwent stoma creation who had the AR overlay system used. All patients additionally had conventional image guidance utilized including fluoroscopy or cone beam CT. Patient characteristics are in Table 1. The clinical indications for stoma creation included large bowel obstruction in six cases, fistula formation in five cases, postoperative anastomotic leakage in one case, perforation from stoma loop in one case and gastrointestinal bleeding in one case. The median number of prior abdominal surgeries was 2 (range, 0–11). Three were classified as ASA physical status grade 4, reflecting significant preoperative morbidity. One of these was a 100-year-old patient with advanced rectal cancer, while the other two were undergoing intensive care unit (ICU) management for sepsis at the time of stoma creation.

Table 1

Table 1. Patient demographics and baseline characteristics.

The median operative time was 131 min (interquartile range [IQR]: 96–143) (Table 2). The length of time for the co-registration of the preoperative 3D images with the patient’s body was not formally recorded, but the process took less than 5 min. The AR headset was used preoperatively to assist in determining the optimal stoma site and bowel loop, but it was removed prior to stoma creation to avoid interfering with the surgeon’s field of view. In three cases, laparoscopic assistance was employed for stoma creation. These cases involved surgeons who were still in the learning phase of the AR-guided stoma creation technique and utilized laparoscopy as an intermediate step in their skill acquisition process. The bowel segments used for stoma creation included the transverse colon in six cases, the sigmoid colon in three cases, and the ileum in five cases. The median diameter of the skin incision used for stoma creation was 3.3 cm (IQR: 3.0–4.0).

Table 2

Table 2. Operative details.

All procedures were completed as planned without deviation from the intended stoma site as predicted by the AR model. Confirmation of using the correct bowel loop was obtained using fluoroscopy with intralumenal contrast injection. A secondary small incision was required for adhesiolysis in three cases, successful stoma creation was achieved in all patients. The median length of postoperative hospital stay was 7 days (IQR: 3–10) (Table 3). There were no intraoperative or postoperative complications classified as Clavien-Dindo grade Ⅲ–IV. Two patients died in the early postop period (Clavien-Dindo grade V complications), these were due to the underlying advanced malignancy and multiorgan failure present at time of stoma formation. No patient required unplanned readmission or reoperation during the 30-day follow-up period.

Table 3

Table 3. Postoperative outcomes.

Discussion

AR technology is expanding ins its applications in surgery but has been used sparingly in intestinal fields. It permits real-time visualization of patient-specific internal anatomy by registering 3D models from readily available preoperative imaging such as CT and MRI onto the patient’s body, thus enhancing spatial understanding and procedural planning (Hachach-Haram and Miskovic, 2021; Wang et al., 2024; Sheriff et al., 2024). While AR has been increasingly applied to surgeries involving fixed structures such as bones, solid organs, and blood vessels, its use in procedures involving the bowel has remained limited due to its mobility and variable intraoperative presentations (Chidambaram et al., 2021; Ryu et al., 2023). This study represents an initial novel application of AR technology to the bowel, chosen because a highly focused “target” could be identified, surgically pulled up to the skin through a limited incision, and verification was confirmed using fluoroscopy.

In our study, AR-guided stoma creation was performed in fourteen patients with diverse clinical indications, including bowel obstruction, fistula formation, anastomotic leakage, and gastrointestinal bleeding. Of the 14 patients, only three had no prior abdominal surgeries, while the remaining 11 had a history of multiple prior abdominal surgeries. Despite varied surgical histories and the presence of physiologically compromised conditions in several cases, reliable preoperative segmentation of the bowel and peritoneal cavity using the AR system enabled accurate selection of the optimal bowel loop and incision site, allowing all procedures to be executed safely and as planned. In co-registration, we selected as landmarks the rib margins, the umbilicus, symphysis pubis, and the anterior superior iliac spines and surgical scars visible on the 3D reconstructed CT scan. The landmarks were easily accessible and reachable with the patient lying supine on the operating table, and with palpation while co-registering the image using the 3D image while floating or “unlocked” in space, we then made fine manual adjustments and were assured that landmarks on patient were completely lined up with the 3D hologram (Supplementary Video). Intraoperative fluoroscopy was employed to confirm anatomical alignment at the intended stoma site and assess bowel loop orientation, thereby confirming surgical precision. In three cases, 1-2 additional ports were placed and laparoscopy was used to confirm location of the target loop of bowel with a laparoscopic camera and grasper through these extra ports by surgeons who were new to usage of AR. Laparoscopy served as an intermediate step, allowing them to assess the real-time condition of intra-abdominal organs and to compare intraoperative findings with AR-based 3D reconstructions. This step helped the surgeons recognize the utility of preoperative AR information and increased their confidence in transitioning to the cut-down technique. AR identified the correct location of the target loop of bowel and in all cases we were able to carry out the preplanned surgical approach.

The length of postoperative hospital stay exceeded 10 days in four patients. In two of these cases, ongoing treatment for sepsis at the time of surgery contributed to delayed postoperative recovery. The other two had advanced malignancies; although their postoperative courses were favorable, hospitalization was prolonged to accommodate subsequent chemotherapy. While no Clavien-Dindo grade Ⅲ–Ⅳ complications were observed, two patients experienced Clavien-Dindo grade Ⅴ complications corresponding to postoperative mortality. These patients had terminal malignancies and/or multiple organ failure prior to surgery. Although their prognoses were poor, the procedures were performed with the aim of improving their general condition and quality of life through stoma creation. Despite successful completion of the procedures as planned, the progression of their underlying diseases could not be prevented. Nevertheless, the fact that AR-guided stoma creation was safely performed even in such physiologically compromised patients suggests the procedural safety of this technique. These findings support both the technical feasibility and the early safety of AR-assisted stoma creation across a spectrum of complex clinical scenarios.

To our knowledge, this is the first report of AR technology being used as an image-guided supplement to stoma creation and the precise identification of a “target loop”. Although the bowel has traditionally been considered unsuitable for image-guided surgery due to its mobility and variable intraoperative presentation, in cases with adhesions or chronic obstructions, its mobility may be reduced, and the bowel loop may be quite easy to identify based on preoperative imaging. In such contexts, AR may achieve sufficient accuracy to support real-time procedural planning (Okabayashi et al., 2014). As for the wider application of AR in abdominal surgery, prior studies have reported its use in laparoscopic liver resection, colorectal cancer surgery, and hepatectomy, primarily focusing on intraoperative navigation and tumor localization or vascular structures (Ryu et al., 2023; Wang et al., 2024). However, the use of AR for soft-tissue incision planning and loop identification in bowel surgery remains underexplored. In our preliminary concept, we assumed that a safety tolerance of approximately 2–3 cm would be acceptable when localizing the bowel loop for stoma creation, since minor variations could be adjusted under direct visualization once the incision was made. However, our intraoperative observations demonstrated that the difference between the AR-predicted site and the actual bowel position was consistently less than 1 cm, suggesting that the AR overlay provided a high degree of spatial reliability for this procedure. Although in some cases, carbon dioxide insufflation through the rectum using a colonoscope was performed to distend the colon, serving as a “contrast medium” to enhance visualization, surprisingly, this maneuver did not appear to cause noticeable spatial discrepancies between the AR-projected colon and the actual anatomical structures, indicating that the AR registration remained stable even under conditions of moderate bowel distension. This initial experience highlights the potential of AR in soft tissue surgery, demonstrating that it is not only technically feasible despite anatomical variability and mobility, but may also help reduce operative complexity and post-procedural morbidity.

The software we used in this study was based on 3D Slicer, the opensource medical visualization and analysis platform. Duration of the preoperative planning process in this study ranged between 15–45 min, depending on the complexity of the imaging and segmentation process. Although 3D reconstruction of the relevant intestinal segments is not easily replicated at all medical centers at this point, we believe this could be expanded, just like 3D platforms in vascular surgery (e.g., TeraRecon). Our iterative development method for ImagineHIVE is expected to allow a surgeon to plan a colostomy case with ease, minimal training, and in less than 15 min without external help in the near future. Since the AR headset used in this study was a wireless, hands-free device that does not contact the surgical field, and all 3D interactions were performed through touchless gesture or voice commands, there was no evidence of contamination or infection related to AR use in our cases. However there remains a theoretical risk of infection if strict sterile protocols are not followed, future innovations such as voice-activated visors, cameras, and hands-free control systems will likely be required to ensure sterility and enable wider application of AR technology in the operative environment. At the present stage, our system does not function as a standalone intraoperative guidance tool. It provides additional visualized spatial information that complements existing imaging modalities, and confirmatory fluoroscopy remains essential to ensure procedural accuracy. In the future, integration of multiple imaging sources—such as endoscopy, CT, ultrasonography, and fluoroscopy—within a unified AR environment could allow for an independent and fully interactive intraoperative imaging platform directly operable within the surgical field.

We believe that this technique can progress toward IDEAL Stage 2b, where its reproducibility and safety can be evaluated in a prospective, multi-center format. Clinical indications may include patients such as those in this study, with complex surgical histories, high risk of adhesions, or limited access windows where conventional stoma marking is insufficient. The potential to avoid unnecessary intra-abdominal dissection, reduce operative complexity and post-procedural morbidity supports the significance of further development and validation.

There are several limitations to our study. The small sample size and single-center design limit generalizability of our findings. Additionally, we did not acquire quantitative data regarding preoperative planning duration. Our ongoing efforts aim to develop objective metrics of time efficiency in AR-guided stoma creation. Another important limitation is that alignment accuracy in this study was assessed manually on the skin surface. Although the difference between the AR-predicted site and the intraoperative findings was less than 1 cm, such surface-based evaluation does not fully capture potential depth-related alignment errors. In cases with higher soft-tissue mobility, visually appropriate alignment in a single plane may still result in three-dimensional discrepancies. Moreover, the relatively low bowel mobility in our cohort—likely due to prior surgeries and adhesions—may have contributed to the favorable apparent accuracy. While these early results are encouraging and may hold promise for broader application in the future, generalizability cannot yet be confirmed, underscoring the need for rigorous, quantitative three-dimensional accuracy validation in subsequent studies. This also required a lot of technical support by a strong team of software engineers, imaging specialists, and combined efforts of colorectal surgeons, interventional radiologists, and data scientists on our team, all who contributed to developing this method. Although the AR headset proved valuable for preoperative planning, it had to be removed prior to stoma creation due to limited visibility and ergonomic constraints. The visor of a HoloLens somewhat obstructs direct vision during surgery. This highlights a key limitation of current head-mounted AR devices, which are not yet suitable for continuous use. Technological improvements—such as lighter, more ergonomic designs and enhanced transparency during use—will be essential for extending applicability of AR beyond pre-incision planning. Moreover, the evaluation of AR usability was subjective, and the absence of a control group limits the objectivity of the data. Nevertheless, the completion of all procedures as planned with minimal need for conversion to open exploration and without major complications provides preliminary evidence supporting the feasibility and safety of this approach. Continued clinical experience is expected to further refine the AR-guided procedure and enhance the clinical evidence.

Conclusion

This early experience suggests AR methods may identify and target a loop of bowel and play a useful role in intestinal stoma creation. Future development of AR in intestinal surgery seems warranted. As surgical planning increasingly incorporates digital tools, AR platforms will likely play a role in improving procedural safety, personalization, and overall patient experience.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Weill Cornell Medicine Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

BP: Writing – original draft, Formal Analysis, Resources, Visualization, Project administration, Methodology, Supervision, Data curation, Conceptualization, Writing – review and editing, Investigation, Validation. SU: Writing – review and editing, Formal Analysis, Methodology, Writing – original draft, Investigation, Visualization, Data curation, Validation, Conceptualization. AC: Investigation, Conceptualization, Writing – review and editing, Data curation, Writing – original draft, Validation. AZ: Methodology, Software, Writing – review and editing, Resources. MD: Resources, Methodology, Software, Writing – review and editing. DP: Methodology, Visualization, Investigation, Validation, Writing – review and editing, Software, Resources, Formal Analysis. AL: Methodology, Software, Writing – review and editing, Resources, Visualization. AS: Writing – review and editing. JM: Formal Analysis, Validation, Writing – review and editing, Methodology, Conceptualization, Data curation, Supervision, Project administration, Software, Investigation, Resources, Visualization, Funding acquisition.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

Authors MD, DP, and AL were employed by DNA-HIVE Inc.

The remaining author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frvir.2025.1709269/full#supplementary-material

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