Computer-Assisted Surgery
Medical Robotics
Medical Image Processing
LECTURE 1
1. What‘s in a surgery
2. Technical tools in...
PAST: Cut, then see
PRESENT: See, then cut
FUTURE: Combine, see, minimally cut
How do surgeries proceed?
• Diagnosis
– based on physical exams, images, lab tests
• Preoperative planning
– determine the...
Treatment procedures
• Invasive
– neurosurgery: tumor removal
– hear surgery: clogged arteries, transplants
– orthopaedic ...
Medical imaging modalities
• Preoperative
– Film X-rays, Digital X-rays, Ultrasound,
Angiography, Doppler, ….
– Computed T...
Medical imaging modalities: X-rays
Film or Digital X-ray X-ray Fluoroscopy
Medical imaging modalities:
continuous X-ray angiography
Medical imaging modalities: Ultrasound
Medical imaging modalities: CT
Single slice
Series of parallel
slices 2mm apart
Medical imaging modalities: MRI
Good imaging of
soft tissue
Medical imaging modalities: Nuclear
medicine (PET, SPECT, NMR)
Functional imaging:
colors indicate
electrical activity
Medical imaging modalities: video
TV quality image from small camera
(laparoscope or endoscope)
Surgical approaches
• Open surgery
– area of interest directly exposed by cutting
– direct sight and touch of anatomy by s...
Minimally invasive surgery
• Provides treatment through small incisions
• Uses imaging equipment for seeing and
instrument...
Laparoscopic surgery
Brain surgery
Total Hip replacement -- principle
Total hip replacement procedure
What is required to perform surgery?
• Knowledge intensive task
– anatomy, procedures, cases
– experience, skills, customi...
Medical and surgical trends
• Imaging improved dramatically diagnosis
– started with X-rays last century
– 30% of all case...
Socio-economical medical trends
• Increase of aging population and associated
problems: tumors, osteoporosis, Alzheimers
•...
Surgical Needs
• Support for image-guided surgery
• Passive and active devices for accurate spatial positioning,
tracking,...
Current clinical status
• Imaging
– vast databases of medical images
– digitized atlases
– mostly uncorrelated unimodal qu...
Part 2: Computers and Robots
Technology and algorithms
available today
How can computers help?
(or are already helping…)
• Image processing
– single image: enhancement, noise reduction,
segment...
Image processing
Planning and simulation
Virtual man project -- digital model
How can robots and sensors help?
(or are already helping…)
• Robotic devices
– passive, semi-active, active devices
– inst...
Robotic devices
Real-time tracking devices
camera
instrument
Passive markers
Instrument has infrared
LEDs attached to it Active markers
Computer-Assisted Surgery (CAS)
A computer-integrated system to enhance the
dexterity, visual feedback, and information
in...
Elements of CAS systems
Elements of CAS systems
• Preoperative planning
– image acquisition, modeling, analysis, simulation
– plan elaboration, to...
State of the Art (1)
• Main clinical procedures
– neurosurgery: biopsies, tumor removal
– orthopaedics: hip and knee repla...
State of the Art (2)
• Commercial navigation systems
– main uses: neurosurgery and spine surgery
• Commercial robotic syst...
State of the Art (3)
• Major players
– INRIA Sophia Antipolis, Grenoble, Johns Hopkins,
Brigham Women’s H./MIT, Shadyside ...
Examples of CAS systems in use
• Image-guided navigation systems
• ROBODOC: Total hip replacement surgery
• LARS: Laparosc...
Image-guide navigation
• Purpose
– accurate placement of instruments with respect to
imaged anatomy for several procedures...
Image-guided navigation
Image-guided navigation (2)
pedicle screw insertion
Status
• In clinical use
• Over 7,000 neurosurgeries performed with
commercial systems
• Gaining popularity in pedicle scr...
ROBODOC: Total hip replacement
• Purpose
– precise machining of cementless hip implant canal
• Problem addressed
– complic...
Artificial hip joint
Total hip replacement procedure
ROBODOC: Total Hip Replacement
ROBODOC system diagram
ORTHODOC Planning
ROBODOC robot diagram
ROBODOC robot
ROBODOC procedure
ROBODOC cutting
ROBODOC History
• Developed by IBM Research and Integrated
Surgical Systems
• First active surgical robot
– 1986: feasibil...
ROBODOC current status
• Sold by Integrated Surgical Systems
• Over 3,000 cases performed
• 15 systems installed in German...
Laparoscopic assistant: LARS
• Purpose
– laparocopic camera holding and precise navigation
• Problem addressed
– cumbersom...
Laparoscopic assistant: LARS
LARS characteristics
• Designed at IBM Research, 1993. Similar
commercial devices available (AESOP)
• Custom redundant 7 d...
Stereotactic Radiosurgery
• Purpose
– plan and deliver precise radiation doses
• Problem addressed
– precise positioning a...
Stereotactic Radiosurgery
CYBERKNIFE system
CYBERKNIFE system
Stereotactic Radiosurgery: planning
Stereotactic Radiosurgery
• Developed at Stanford starting in 1992
• Complex 3D radiation plans
• Currently in clinical us...
Developing CAS systems
• Similarities
– understand and address real needs of surgeons
– consider established procedures, c...
Developing CAS systems
• understand and address real needs of surgeons
• consider established procedures, context, use
• c...
CAS systems design cycle
• Prototype development
• In-vitro experiments
– system refinement
• Cadaver studies
– system ref...
Summary
• Great potential for robots and computers inside
and outside the operating room
• Great research and commercial i...
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  1. 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. 2. PAST: Cut, then see
  3. 3. PRESENT: See, then cut
  4. 4. FUTURE: Combine, see, minimally cut
  5. 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. 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. 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. 8. Medical imaging modalities: X-rays Film or Digital X-ray X-ray Fluoroscopy
  9. 9. Medical imaging modalities: continuous X-ray angiography
  10. 10. Medical imaging modalities: Ultrasound
  11. 11. Medical imaging modalities: CT Single slice Series of parallel slices 2mm apart
  12. 12. Medical imaging modalities: MRI Good imaging of soft tissue
  13. 13. Medical imaging modalities: Nuclear medicine (PET, SPECT, NMR) Functional imaging: colors indicate electrical activity
  14. 14. Medical imaging modalities: video TV quality image from small camera (laparoscope or endoscope)
  15. 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. 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. 17. Laparoscopic surgery
  18. 18. Brain surgery
  19. 19. Total Hip replacement -- principle
  20. 20. Total hip replacement procedure
  21. 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. 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. 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. 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. 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. 26. Part 2: Computers and Robots Technology and algorithms available today
  27. 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. 28. Image processing
  29. 29. Planning and simulation
  30. 30. Virtual man project -- digital model
  31. 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. 32. Robotic devices
  33. 33. Real-time tracking devices camera instrument Passive markers Instrument has infrared LEDs attached to it Active markers
  34. 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. 35. Elements of CAS systems
  36. 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. 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. 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. 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. 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. 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. 42. Image-guided navigation
  43. 43. Image-guided navigation (2) pedicle screw insertion
  44. 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. 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. 46. Artificial hip joint
  47. 47. Total hip replacement procedure
  48. 48. ROBODOC: Total Hip Replacement
  49. 49. ROBODOC system diagram
  50. 50. ORTHODOC Planning
  51. 51. ROBODOC robot diagram
  52. 52. ROBODOC robot
  53. 53. ROBODOC procedure
  54. 54. ROBODOC cutting
  55. 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. 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. 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. 58. Laparoscopic assistant: LARS
  59. 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. 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. 61. Stereotactic Radiosurgery
  62. 62. CYBERKNIFE system
  63. 63. CYBERKNIFE system
  64. 64. Stereotactic Radiosurgery: planning
  65. 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. 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. 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. 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. 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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