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Surgical Navigation - insights into wayfinding and navigation processes in the human body

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Cognitive ergonomics for minimally invasive therapies – some insights into wayfinding and navigation processes in the human body. …

Cognitive ergonomics for minimally invasive therapies – some insights into wayfinding and navigation processes in the human body.
Farewell lecture given at Faculty of Industrial Design Engineering, Delft University of Technology, the Netherlands, 14 December 2009

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  • 1. Cognitive ergonomics for minimally invasive therapies – some insights into wayfinding and navigation processes in the human body Position Thomas Stüdeli 14 December 2009 Farewell lecture Thomas Stüdeli Faculty of Industrial Design Engineering Delft University of Technology Position Destination References and Obstacles New course
  • 2. Thomas Stüdeli Ergonomics, Human Factors, Safety Engineering Delft University of Technology, Faculty of Industrial Design Engineering Medisign group – Research and Product development in healthcare, e.g. “Surgical cockpit” www.io.tudelft.nl/medisign Human Information Communication Design Intelligent products, ambient intelligence, perception, information processing and information design “Augmented Reality in Surgery” (FP6, 2004-2008), AR/VR-Systems for Thomas Stüdeli 14 December 2009 2004-2008), AR/VR-Systems for surgery and intervention radiology www.ariser.info [Lamata 2007] [Mühl 2007]
  • 3. ARIS*ER www.ariser.info • “Augmented Reality for Surgery”, FP6 programme, 2005-2008 • Six academic and two industrial partners, app. 40 involved researchers Thomas Stüdeli 14 December 2009
  • 4. Augmented Reality in Surgery (ARIS*ER) - Laparoscopy Thomas Stüdeli 14 December 2009 Augmented laparoscopic images (liver resection) Lack of haptic feedback and limited orientation performance in laparoscopic images
  • 5. Augmented Reality in Surgery (ARIS*ER) – Robotic surgery Augmented robotic arms (robotic surgery) Collisions of robotic arms outside the field of view of the surgeons Thomas Stüdeli 14 December 2009
  • 6. Augmented Reality in Surgery (ARIS*ER) – Intervention radiology Thomas Stüdeli 14 December 2009 How to visualize relevant anatomical information for (safe and efficient) abdominal needle placements? Augmented needle trajectory line – 2D image & 3D map
  • 7. Minimally invasive cardiac surgery Keywords: Team work, Complex operation, Cardio pulmonary bypass, Time-critical, Patients safety Human factors: Safety, Efficiency, Quality Thomas Stüdeli 14 December 2009 Catheter positioning system Annuloplasty ring solution [Graduation Project Felipe Morales 2009] [ARIS*ER cardiac project 2006-2008]
  • 8. What could be an “intelligent” User Interface? (Exp. Needle placement) Thomas Stüdeli 14 December 2009 [Laban, Korteland, Boudri & Stüdeli 2008]
  • 9. Agenda • Motivation (ergonomic viewpoint) – Minimally invasive Surgery – Design of navigation support • Navigation and wayfinding processes (safe and prudent) Thomas Stüdeli 14 December 2009 (safe and prudent) – Orientation, Navigation Wayfinding • Latest research – Role of information modalities (visual, haptic, mental model) • Outlook
  • 10. Operation theater – a special work environment Thomas Stüdeli 14 December 2009 • Individual AND team work • High time pressure AND high demands • Action tasks AND monitoring / control tasks • Highly complex AND highly regulated “Entering an Operation Theater, it’s like going 100 years back in Ergonomics” Richard Goossens (10.8.2009 Beijing)
  • 11. Thomas Stüdeli 14 December 2009
  • 12. Motivation • Importance: Computer systems, visualization techniques, and robotic technology aim to enable and/or support surgical actions. Navigation is obviously one essential action. • Definition: “Surgical navigation” has not generally been well defined and therefore has been used inconsistently. It’s essential for communication in between multidisciplinary teams to be aware of those different foci Thomas Stüdeli 14 December 2009 multidisciplinary teams to be aware of those different foci and usages of key words. • Aims: – Know-how transfer: The aim is to translate know-how from cognitive models of navigation and wayfinding into the field of surgical navigation. – Support: The ultimate aim is to contribute to the design of more intuitive and more effective information and navigation system for the medical domain.
  • 13. Agenda • Motivation (ergonomic viewpoint) – Minimally invasive Surgery – Design of navigation support • Navigation and wayfinding processes (safe and prudent) Thomas Stüdeli 14 December 2009 processes (safe and prudent) – Orientation, Navigation Wayfinding • Latest research – Role of information modalities (visual, haptic, mental model) • Outlook
  • 14. Classical (maritime) navigation Navigation is… “process of planning, documentation and control of a movement of a ship or vehicle from one location to another” [Bowditch 1802] i. Positioning, Navigation process Navigation Thomas Stüdeli 14 December 2009 ii. Determination of next target position, landmarks and possible hazards between position and target position i. Positioning, determination of actual position iii. Movement, and control of actions Wayfinding
  • 15. Navigation process … • Classical navigation is an iterative process that is intuitively understood. • The process demands: – spatial capacities (thinking in space) – strategic decision making – safety and risks analyzes – management of parallel tasks Thomas Stüdeli 14 December 2009 – management of parallel tasks • Navigation is strongly influenced by – vehicle and or involved tools – navigation environment – navigation task • Medical procedures and surgical or interventional tasks can be interpreted as navigation processes.
  • 16. Safe navigation ? Factors: time, environment, tasks (demanded accuracy, prudence etc.) Thomas Stüdeli 14 December 2009 Thomas Stüdeli Basle 22 June 2009
  • 17. Navigation vs. Wayfinding • Navigation process demands: – Spatial orientation – Strategic decisions – Safety and Risk – Management of parallel tasks • Supported e.g. by topographical maps • “all the perceptual, cognitive, and decision-making processes necessary to find one’s way.” [Arthur and Passini 1992] • Supported e.g. by schematic maps or car navigation systems Thomas Stüdeli 14 December 2009 topographical maps
  • 18. Orientation • Absence of orientation is called disorientation, it’s seen as a symptom of confusion [Bellenkes et al 1992]. • Orientation is an active process: ”person's self- awareness with regard to position, time and place.” Thomas Stüdeli 14 December 2009 place.” • For every navigation step orientation is synonymous for “Where am I?” (Shewhart cycle (PDCA) Plan) • Orientation is a “mental registration” – registration of the mental spatial model to the real environment (reality)
  • 19. Wayfinding [Allen 1999, Professional Geographer] • Tasks – Commute: travel along familiar routes in familiar environments. – Explore: travel into unfamiliar environments. – Quest: exploratory travel in an unfamiliar environment to Thomas Stüdeli 14 December 2009 – Quest: exploratory travel in an unfamiliar environment to an unfamiliar destination. • Strategies – Depend on possible and preferred spatial updating methods – Field of save travel [Gibson & Crooks 1932, Dominguez 1997] – …
  • 20. Human body as navigation environment • Surgeons commute, explore and quest [Allen 1999, Professional Geographer] the human body during MIS. The navigation process depends on tissue characteristics and the body region. • Human body as a navigation environment can be characterized by: – Size of the working area (scale) Thomas Stüdeli 14 December 2009 – Size of the working area (scale) – Tissue properties (e.g. rigidity) – Risks in the working area • Wayfinding strategies differ e.g. between – Small working areas, e.g. brain surgery small part of a complex organ – Single organ (liver, heart, kidney) – Multiple organ (complicated and big abdominal or heart surgeries).
  • 21. Take home message… Surgical navigation supports • Be aware of the surgeons’ navigational process: – Parallel tasks – Iterative process (feedback important). • A support should aim to truly unburden the surgeon from a specific (entire) task Thomas Stüdeli 14 December 2009 surgeon from a specific (entire) task (e.g. car navigation system: wayfinding strategy). • Provide feed forward information not a feed now information. Take in account the “field of safe travel” and support learning of movement patterns (e.g. “in 200m to the right” and not “you are here”).
  • 22. Human body as an navigation environment • The human body is an atypical navigation environment with the special characteristics of being – relatively small in size – not easily accessible – non-rigid, and changeable. • The human body is too different from the classical Thomas Stüdeli 14 December 2009 • The human body is too different from the classical navigation environments in order that existing design guidelines for navigation aids can be directly translated. • Surgeons use the known cognitive concepts to navigate and therefore those cognitive models on human orientation, navigation and wayfinding help to describe and understand surgical navigation.
  • 23. Surgical navigation strategies • Safety constraints: – “Area of safe travel” (field of view, visibility) – Demanded accuracy (distance to vital structures) • Accessibility and characteristics of working area: – Small part of a complex organ (e.g. brain surgery) – Single organ (e.g. liver, heart, kidney) Thomas Stüdeli 14 December 2009 – Single organ (e.g. liver, heart, kidney) – Body region with multiple organs (e.g. major abdominal or heart surgeries) • Different tissue characteristics in different regions and organs (rigidity, changeability) • Complexity of surgical task – Shape and form of “surgical plain” – …
  • 24. • In the room – Different teams • In a team – Changing teams – Changing positions • In surgical work place and working field Adaption of the user to the technology… or … (re-)orientation in OR Thomas Stüdeli 14 December 2009 • In surgical work place and working field – Direct and indirect views – Surgical tools & complex technology, e.g. robotic tools or navigation system [examples: IORT corectal cancer, ARIS*ER UI-Workshop, Catharine Hospital Eindhoven]
  • 25. Safe Navigation Position Where am I? Hazards? Destination What do I want to see? Where do I want to go? What paths are possible? References and Obstacles What will I see? Check or Study Plan Do New course I move, and I control my movements! Act Thomas Stüdeli 14 December 2009 What paths are possible? What will I see? What elements do I want to avoid? • Two connected cycles (bold: navigation, italic: wayfinding) • Strategic and safety related problems (wayfinding aspects) • Location and orientation aspects (navigational aspects) adapted from [Stüdeli 2008 ARIS*ER] & [Stüdeli 2009 GfA] Based on [Shewhart 1939, Q-Kontroll-Zyklus, Plan-Do-Check-Act] [Bowditch1802, The American Practical Navigator]
  • 26. Agenda • Motivation (ergonomic viewpoint) – Minimally invasive Surgery – Design of navigation support • Navigation and wayfinding processes (safe and prudent) Thomas Stüdeli 14 December 2009 (safe and prudent) – Orientation, Navigation Wayfinding • Latest research – Role of information modalities (visual, haptic, mental model) • Outlook
  • 27. Questions • What is the role of the different information modalities? – visual, haptic, mental model – intra-operatively Thomas Stüdeli 14 December 2009 – intra-operatively (What can be transferred from pre-operative planning into intra-operative planning?) • What is the relation between spatial and safety aspects?
  • 28. Methods • Structured interviews – Interview (therapy, general type of difficulties, successful navigation strategies) – Sketch of “working area” (paper & pencil). • Intra-operative observations – Observation (n=3) surgeries or interventions (notes, sketches) – Encouraged to speak aloud everything that he/she Thomas Stüdeli 14 December 2009 – Encouraged to speak aloud everything that he/she was thinking and doing – Scene camera (record of workflow and verbalizing) • Analysis of interview data and sketches – spatial-orientational variables: node, path, district, landmark, edge (Lynch 1960, p.145), – safety-strategical variables: hazards, degree of accuracy, special attention – information sources: direct view, indirect view, haptic, mental model
  • 29. Lynch’s elements vs. anatomical landmarks Landmarks [Lynch 1960] Functions Examples of anatomical landmarks and landmarks used by surgeons in human bodies Node Focal point of travel Vessel bifurcations Path Channel for navigation Vessels, needle trajectory Thomas Stüdeli 14 December 2009 Path Channel for navigation movement Vessels, needle trajectory (indicated through a navigational aid) District Reference point Familiar region, e.g. tissue structures on a CT Landmark Reference point into which one does not enter Vital structures Edge Indicates district limits Capsules, ligaments, vessels
  • 30. Catheter vs needle Intervention • Catheter is flexible • Path follows anatomy / vascular system (inside aorta, around organs) • “Anatomical intervention” • Needle is rigid • Path follows needle trajectory (across organs) • “Unanatomical intervention” Thomas Stüdeli 14 December 2009 [pictures: Graduation report Thijs Van Oorschot 2009]
  • 31. Spatial information need for surgical action Anatomical (Catheter) (n=2) Mental model Visual (d) direct view Haptic Node *** *** ** Path *** ** *** District *** ** ** Landmark *** ** ** • High importance of mental model during ‘action’ (flow of work) • Subjects acquire ‘as much as possible’ Thomas Stüdeli 14 December 2009 ** ** Edge ** Unanatomical (Needle) (n=2) Node *** ** * Path *** ** - District *** * (d **) ** Landmark *** ** (d **) ** Edge ** * (d **) much as possible’ spatial information in all modalities • No differences in use of edges and landmarks on medical images *** Highly relevant (> 80%, 5 out of 6, found in interview, sketch, and verbalization) ** Relevant (> 50%, 3-4 out of 6) * Minor importance (> 15%, minimal 1 out of 6)
  • 32. spatial-orientational vs safety-strategical Navigation Wayfinding Position Destination References and Obstacles Check or Study Plan Do New course Act Thomas Stüdeli 14 December 2009 Navigation – Constant updating – ‘As much as possible’ – ‘Optimization’ of benefits (speed, quality) Wayfinding – ‘Stop-and-go’ – Decision points – Highly iterative – ‘Minimization of risks’
  • 33. Two worlds…? Position Where am I? Destination What do I want to see? References and Obstacles What will I see? Check or Study Plan Do New course I move, and I control my movements! Act Position strategic and safety related problems (wayfinding aspects) Thomas Stüdeli 14 December 2009 [adapted from Stüdeli 2009] Position Am I safe? Hazards? Destination Where do I want to go? What paths are possible? References and Obstacles What elements do I want to avoid? Check or Study Plan Do New course I control my movements! Act Control of location and orientation (navigational aspects)
  • 34. Conclusions • Mental model is highly relevant - even in simple applications – Transferred from pre-operative planning into intra-operative planning is important • Huge information need during MIS, Thomas Stüdeli 14 December 2009 • Huge information need during MIS, surgeons want “As much as possible”! • Safety information is highly spatial, but not necessary anatomical information – E.g. Angles, volumes, areas, length, distance to target
  • 35. Agenda • Motivation (ergonomic viewpoint) – Minimally invasive Surgery – Design of navigation support • Navigation and wayfinding processes (safe and prudent) Thomas Stüdeli 14 December 2009 (safe and prudent) – Orientation, Navigation Wayfinding • Recent research – Role of information modalities (visual, haptic, mental model) • Outlook
  • 36. Outlook & Questions Research Methods? • How to (better) quantify verbalization data? • What does eye tracking offer? Practical relevance for more complex applications? Thomas Stüdeli 14 December 2009 applications? • Two surgeons, 4 eyes, two mental models? • Collaborative mental models…? Practical implication for Ergonomist and Designers? • Selection, priorization, and presentation of information
  • 37. Operation time Surgical team Technology Safety / Information / Workload Idea finding: Moderated Workshops with Engineers and MD Design Surgery Systems Architecture & Graphics Robotics & Control Thomas Stüdeli 14 December 2009 [Stüdeli, Freudenthal, de Ridder 2007 WWCS] Thomas Stüdeli iNNOVATION fORUM, Tuttlingen 23 June 2009 Ergonomics Surgery & Graphics Computer graphics Robotics & Control Information processing and fusion
  • 38. MRI-Technology Surgery Anaesthesiology Ergonomics Robotics & Control Final Animal tests for the ARIS*ER cardiac system Thomas Stüdeli 14 December 2009 Systems Architecture & Graphics
  • 39. Thank you for your attention, good bye and see you again! ARIS*ER is funded by the European Union as part of the 6th framework programme for research under the Marie Curie Actions for Human Resources and Mobility, contract MRTN-CT-2004-512400. Thomas Stüdeli 14 December 2009 Thomas Stüdeli stuedelithomas@gmx.net LinkedIn http://nl.linkedin.com/in/stuedelithomas XING http://www.xing.com/profile/Thomas_Stuedeli