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  • 1. Computer-Assisted Surgery Medical Robotics Medical Image Processing LECTURE 1 1. What‘s in a surgery 2. Technical tools in CS 3. CAS systems
  • 2. PAST: Cut, then see
  • 3. PRESENT: See, then cut
  • 4. FUTURE: Combine, see, minimally cut
  • 5. How do surgeries proceed? • Diagnosis – based on physical exams, images, lab tests • Preoperative planning – determine the surgical approach – elaborate intraoperative plan (path, tools, implants) • Surgery – prepare patient and assess condition – acquire intraoperative images, adapt and execute plan • Postoperative follow-up – exams, lab tests, images to be corroborated
  • 6. Treatment procedures • Invasive – neurosurgery: tumor removal – hear surgery: clogged arteries, transplants – orthopaedic surgery: spine, hip replacement, knee, fractures – gall bladder removal, prostate, various cancers • Non-invasive – radiation therapy – kidney stone pulverization
  • 7. Medical imaging modalities • Preoperative – Film X-rays, Digital X-rays, Ultrasound, Angiography, Doppler, …. – Computed Tomography (CT), Magnetic Resonance (MR), Nuclear Medicine (PET, SPECT, …) • Intraoperative – X-ray fluoroscopy, ultrasound – video images (laparoscopy, arthorscopy) – Open MR
  • 8. Medical imaging modalities: X-rays Film or Digital X-ray X-ray Fluoroscopy
  • 9. Medical imaging modalities: continuous X-ray angiography
  • 10. Medical imaging modalities: Ultrasound
  • 11. Medical imaging modalities: CT Single slice Series of parallel slices 2mm apart
  • 12. Medical imaging modalities: MRI Good imaging of soft tissue
  • 13. Medical imaging modalities: Nuclear medicine (PET, SPECT, NMR) Functional imaging: colors indicate electrical activity
  • 14. Medical imaging modalities: video TV quality image from small camera (laparoscope or endoscope)
  • 15. Surgical approaches • Open surgery – area of interest directly exposed by cutting – direct sight and touch of anatomy by surgeon – direct access but causes additional damage • Closed surgery not always feasible – indirect access to anatomical area of interest – no direct visual sight or tactile feel – catheterization, biopsies – intraoperative imaging is often required – require more skills: lengthier, more difficult • Diagnostic surgery
  • 16. Minimally invasive surgery • Provides treatment through small incisions • Uses imaging equipment for seeing and instruments for touching • Advantages: less damage, faster recovery • Disadvantages: hand/eye coordination, time • Examples: – brain tumor removal, laparoscopic surgery
  • 17. Laparoscopic surgery
  • 18. Brain surgery
  • 19. Total Hip replacement -- principle
  • 20. Total hip replacement procedure
  • 21. What is required to perform surgery? • Knowledge intensive task – anatomy, procedures, cases – experience, skills, customization and generalization • Manual and cognitive skills – dexterity, precision, strength, tool manipulation – spatial orientation and navigation • Determination – information integration – judgement, decision, execution
  • 22. Medical and surgical trends • Imaging improved dramatically diagnosis – started with X-rays last century – 30% of all cases use images • Move towards minimally invasive procedures – introduced in the mid ‘70s, slow acceptance (laparoscopy) – the method of choice now • More precise and delicate procedures • Development of sophisticated surgical hardware • High degree of craftsmanship and skills
  • 23. Socio-economical medical trends • Increase of aging population and associated problems: tumors, osteoporosis, Alzheimers • Larger population volumes • Universal, first rate, highly specialized care • Health care costs reduction (managed care) • Higher patient requirements • Legal and regulatory aspects
  • 24. Surgical Needs • Support for image-guided surgery • Passive and active devices for accurate spatial positioning, tracking, and execution • Modeling, planning, viewing, diagnosis systems • Systems integration: from diagnosis to post-op • Improve current practice and enable new procedures • Simulation and training systems Augment the surgeon’s capabilities with better quantitative planning, execution, and integration
  • 25. Current clinical status • Imaging – vast databases of medical images – digitized atlases – mostly uncorrelated unimodal qualitative interpretation • Devices – mostly passive and non-invasive (supports) – laparoscopic camera, – some real-time tracking • Planning, modeling, visualization – 3D reconstruction, some registration
  • 26. Part 2: Computers and Robots Technology and algorithms available today
  • 27. How can computers help? (or are already helping…) • Image processing – single image: enhancement, noise reduction, segmentation, quantitative measurements – image stacks: 3D reconstruction, segmentation – image sets: registration, comparison, data fusion • Planning and simulation – integrate medical images and CAD models – planning and simulation programs • Computer vision and graphics – camera modeling, image registration, rendering
  • 28. Image processing
  • 29. Planning and simulation
  • 30. Virtual man project -- digital model
  • 31. How can robots and sensors help? (or are already helping…) • Robotic devices – passive, semi-active, active devices – instrument and anatomy positioning and holding – cutting and machining • Real-time tracking – optical, video, electromagnetic devices – navigation tools
  • 32. Robotic devices
  • 33. Real-time tracking devices camera instrument Passive markers Instrument has infrared LEDs attached to it Active markers
  • 34. Computer-Assisted Surgery (CAS) A computer-integrated system to enhance the dexterity, visual feedback, and information integration of the surgeon Key points: • The goal is NOT to replace the surgeon • A new paradigm for surgical tools • Address a real clinical need • Prove efficacy and cost-effectiveness
  • 35. Elements of CAS systems
  • 36. Elements of CAS systems • Preoperative planning – image acquisition, modeling, analysis, simulation – plan elaboration, tool and prosthesis selection – Output: preop images, 3D models, prosthesis type and position, navigation and cutting plan • Intraoperative execution – passive, semi-active, active robot – real time tracking – intraoperative imaging (fluoroscopy, ultrasound)
  • 37. State of the Art (1) • Main clinical procedures – neurosurgery: biopsies, tumor removal – orthopaedics: hip and knee replacement, spine, pelvis and femur fractures – maxillofacial and cranofacial – laparoscopy: laparoscope holders – new fields: dentistry, ophtalmology, prostate • Mostly rigid structures: bones!!
  • 38. State of the Art (2) • Commercial navigation systems – main uses: neurosurgery and spine surgery • Commercial robotic systems – ROBODOC for total hip replacement – laparoscope arm holders • Research – very active, very interdisciplinary – a few dozen systems tested in-vitro
  • 39. State of the Art (3) • Major players – INRIA Sophia Antipolis, Grenoble, Johns Hopkins, Brigham Women’s H./MIT, Shadyside H./CMU, Imperial College, many places in Germany and Japan • Interdisciplinary conferences and journals – started in 1994: MRCAS’94; Orthopaedic CAS meetings, visualization, etc, – Journals: Computer-Aided Surgery, Medical Image Analysis
  • 40. Examples of CAS systems in use • Image-guided navigation systems • ROBODOC: Total hip replacement surgery • LARS: Laparoscopic assistant • Radiosurgery Brief overview follows; will be covered in detail later
  • 41. Image-guide navigation • Purpose – accurate placement of instruments with respect to imaged anatomy for several procedures • Problem addressed – provide 3D vision of unseen structures replace static 2D fluoroscopy or larger openings – improve precision of biopsies, screw placements • Scope – non-invasive – creates surface model from preop images – registration of images to anatomy by direct contact
  • 42. Image-guided navigation
  • 43. Image-guided navigation (2) pedicle screw insertion
  • 44. Status • In clinical use • Over 7,000 neurosurgeries performed with commercial systems • Gaining popularity in pedicle screw insertion • Decreased the misplacement rate from 10-40% to 5-18% (clinical study of 700 cases) • More clinical applications under development
  • 45. ROBODOC: Total hip replacement • Purpose – precise machining of cementless hip implant canal • Problem addressed – complications in canal preparation and implant fixation – improve positioning accuracy and surface finish • Scope – invasive, numerically controled machining – plan from preop CT, registered via pins – adapted commercial robot – custom bone fixator and bone motion detection
  • 46. Artificial hip joint
  • 47. Total hip replacement procedure
  • 48. ROBODOC: Total Hip Replacement
  • 49. ROBODOC system diagram
  • 50. ORTHODOC Planning
  • 51. ROBODOC robot diagram
  • 52. ROBODOC robot
  • 53. ROBODOC procedure
  • 54. ROBODOC cutting
  • 55. ROBODOC History • Developed by IBM Research and Integrated Surgical Systems • First active surgical robot – 1986: feasibility study – 1989: in-vitro testing of dog system – 1990: 26 dog cases – 1992: development of human system – 1994: first human procedure in Frankfurt – 1995- clinical trials in the US for FDA approval
  • 56. ROBODOC current status • Sold by Integrated Surgical Systems • Over 3,000 cases performed • 15 systems installed in Germany, 2 in Austria • Excellent short term clinical results (3 year study) – no fractures, few failures (continue manually) • Long-term clinical results to be determined – key issue: does the artificial hip last longer? • Problems: OR time, pin insertion
  • 57. Laparoscopic assistant: LARS • Purpose – laparocopic camera holding and precise navigation • Problem addressed – cumbersome, unintuitive, and unsteady camera positioning • Scope – non-invasive intraoperative device – video images interpreted by surgeon • Benefits – direct camera manipulation; stability, precise targeting
  • 58. Laparoscopic assistant: LARS
  • 59. LARS characteristics • Designed at IBM Research, 1993. Similar commercial devices available (AESOP) • Custom redundant 7 degree-of-freedom robot • Holds laparoscopic camera • Fulcrum motions: no motion at point of entry • Mouse-like controls on surgical scissors • Position memory and replay
  • 60. Stereotactic Radiosurgery • Purpose – plan and deliver precise radiation doses • Problem addressed – precise positioning and dosing of radiation to avoid healthy organ damage • Scope – non-invasive intraoperative device – active beam postioning and planning – complex preoperative planning based on MRI images – registers preoperative plan with stereotactic frame
  • 61. Stereotactic Radiosurgery
  • 62. CYBERKNIFE system
  • 63. CYBERKNIFE system
  • 64. Stereotactic Radiosurgery: planning
  • 65. Stereotactic Radiosurgery • Developed at Stanford starting in 1992 • Complex 3D radiation plans • Currently in clinical use • Frameless procedure under development follow head with markers, video, or X-rays • Company Accuray has performed several clinical trials with frameless procedure
  • 66. Developing CAS systems • Similarities – understand and address real needs of surgeons – consider established procedures, context, use – work on problems that will make qualitative difference – constant feedback from user; test ideas and prototypes • Differences – system performace requirements
  • 67. Developing CAS systems • understand and address real needs of surgeons • consider established procedures, context, use • constant feedback from user; test ideas and prototypes • system requirements – safety and reliability – fail-safe systems: can always stop and proceed as usual – system integration
  • 68. CAS systems design cycle • Prototype development • In-vitro experiments – system refinement • Cadaver studies – system refinement • In-vivo experiments – first animal and human trials • Clinical trials – double blind studies, Hospital and FDA protocols • Agency approval and commercial release
  • 69. Summary • Great potential for robots and computers inside and outside the operating room • Great research and commercial interest, especially in the past 3 years • Just the beginning of the road: many things remain to be invented • Great role for applied computer science: – image processing, geometric planning, registration, graphics, vision, real-time systems, robotics, etc.

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