Image-Guided Interventions and Tracking Technology - Robotics ...

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13 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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Image
-
Guided Interventions
and Tracking Technology



Kevin Cleary, PhD


Technical Director

Bioengineering Initiative

Sheikh
Zayed

Institute for Pediatric Surgical Innovation

Children’s National Medical Center

Washington, DC, USA

Robotics Summer School 2012

CAIMR

Georgetown University


Slide
2

Outline


Definition


History


Workflow / components


Some applications


Abdominal interventions


Some major research centers


Future trends

What is an image
-
guided intervention?

The use of
medical imaging
and computer
assistance to
assist in or
enable a
minimally
invasive
procedure

Image
-
guided lung biopsy using electromagnetic
tracking: courtesy of
Filip

Banovac, MD

History of IGT


Stereotactic frame concept dates from beginning of the 20
th

century (Horsley and Clarke 1908)


First computer
-
based systems appeared about 20 years ago
for neurosurgical applications


Incorporated mechanical arms as localizers


ENT and spine were also early adopters


Advances in computers and
tomographic

imaging were enablers


Mechanical localizers were replaced by optical tracking
systems in the early 1990s which became the gold standard


Other applications included tracked ultrasound and laparoscopic
augmentation


Optical tracking was supplemented by robust electromagnetic
tracking in the past five years


Enabled abdominal interventions


What does the future hold?


Integration with flexible endoscopy for
endoluminal

interventions
and robotic surgery including NOTES

Stereotactic Frame


First reported in Brain
(31:45
-
124, 1908)


Article entitled "The
Structure and functions of
the Cerebellum Examined
by a New Method”


Source:
http://www.neurosurgery.org/cyber
museum/stereotactichall/92exhibit.
html

Horsley
-
Clarke
Stereotactic Device

Mechanical Localizer (circa 1990)

CAIMR

Georgetown University


Slide
6

Courtesy of Robert Galloway, PhD, Vanderbilt University,

Technology Guided Therapy Program

Optical Tracking


Bucholz

and Smith in St. Louis


Intraoperative

localization using
a three
-
dimensional optical
digitizer


SPIE Medical Imaging 1993


The system


an infrared optical digitizer to
indicate position on CT, MRI, or PET


a ring attached to the patient's head,
hand held instruments of any type, a
camera array, and a computer
display.


position of the surgical instrument
relative to the patient's head is
computed by a personal computer.


a graphics workstation provides
three dimensional display of position.

© Richard D.
Bucholz
, St. Louis
University (1999)

Stealthstation

circa 2000


Three major
components


Computer for control
and display


Localizer for
tracking instruments


Software for image
processing

Courtesy of Medtronic Surgical Navigation Technologies


ENT: Viewing
Wand (ISG)


Computer
-
Assisted Surgery in the
Frontal and Maxillary Sinus


Gunkel
.
Freysinger
,
Thumfart
,
Innsbruck, 1997


Published in The Laryngoscope

CAIMR

Georgetown University


Slide
9

Spinal Pedicle Screw Placement


Pioneered by
Merloz

in France
and others


Clin

Orthop

Relat

Res. 1998


Common
application for
image guidance

CAIMR

Georgetown University


Slide
10

Park P, Foley KT, Cowan JA,
Marca

FL.
Minimally invasive pedicle screw fixation utilizing
O
-
arm fluoroscopy with computer
-
assisted
navigation: Feasibility, technique, and
preliminary results.
Surg

Neurol

Int

2010;1:44

Computer Assisted
Orthopaedic

Surgery


One of the first fields to
adopt these techniques


CAOS
-
International was
founded in 2000 in
Davos
, Switzerland by
Nolte et al.


Has held annual
meetings every year

CAIMR

Georgetown University


Slide
11

Medtronic Navigation Technologies

Workflow / Components

of an IGT Procedure

CAIMR

Georgetown University


Slide
12

Steps in an IGT procedure

Obtain
tomographic

images

Localize surgical tool

Register images to tool

Display tool relative to images

Courtesy of Galloway and Peters, Chapter 1, Image
-
Guided Interventions book

Components of an IGT system


Images


Trackers (localizers)


Registration


Visualization


Software

Images


Tomographic

images provide a 3D data set
for navigation


CT is the gold standard


Spiral CT


Cone beam CT (rotational fluoroscopy)

Siemens
Zeego

cone
-
beam
CT

CAIMR Lab

Georgetown University


Slide
16

Trackers (Localizers)


Locate objects in space


3 degrees of freedom for position


3 degrees of freedom for orientation


6 degrees of freedom for a rigid body


Modern localizers
can track multiple objects


Localizer types


Mechanical (early systems)


Optical (standard of care)


Electromagnetic
(rapidly improving)

Optical Trackers

Principle of Triangulation

Localizer slides courtesy of Robert Galloway, Vanderbilt University

CAIMR Lab

Georgetown University


Slide
18

Optotrak 3020



Northern Digital Inc

CAIMR Lab

Georgetown University


Slide
19

Multiface Tool

CAIMR Lab

Georgetown University


Slide
20

Polaris Optical
Localizer

Passive and Active Tools

AURORA Electromagnetic Tracking

Vendor: Northern Digital Inc. (Waterloo, Canada)

1. Field generator provides low strength magnetic field

2. The position sensor: induction coil: diameter 0.9 mm

Registration


Rigid body
registration is
standard in practice


Paired point
methods dominate


Iterative closest
point (ICP) methods
are also used
(cloud of points)

CAIMR

Georgetown University


Slide
22

Fiducials

for registration purposes

Courtesy of
Ziv

Yaniv
, PhD,
Georgetown University

Deformable Registration


Modeling and Registration
in Deforming and Moving
Tissues During an
Intervention Doesn’t Work
(not yet at least!)


The Future of
Interventions is Imaging


Systems must be
validated and validation is
very hard using non
-
rigid
registration technologies

Statistical Motion Models (
SMMs
):

Application to focal therapy in the
prostate,
Yipeng

Hu
, Dean Barratt, Mark
Emberton

et al. Ultrasound derived
model to intra
-
operative ultrasound
(MICCAI 2008)

Slide courtesy of Dave
Hawkes
,
PhD, University College London

CAIMR Lab

Georgetown University


Slide
24

Visualization


Four
-
quadrant
view is standard
in
commercial image
-
guided systems


Axial


Saggital


Coronal


3D view

Courtesy of Medtronic Surgical Navigation Technologies


Open Source Software


Open source revolution
has come to image
-
guided therapy


3D Slicer from BWH


MITK from Heidelberg


CISST from Johns
Hopkins


IGSTK from our group

CAIMR

Georgetown University


Slide
25

3D Slicer User Interface

http://www.slicer.org/publicatio
ns/item/view/1835

CAIMR

Georgetown University


Slide
26

Image Guided Surgical Toolkit (IGSTK)
Open Source Software Package


Basic components for an
image
-
guided system


Tracker


Registration


Visualization


Initial release at SPIE
Medical Imaging
2006


Can
be used in
commercial products


List of users can be
seen at
igstk.org

IGSTK Architecture

CAIMR

Georgetown University


Slide
27

IGSTK:

The Book

Image
-
Guided

Laparoscopic Surgery

CAIMR

Georgetown University


Slide
29

Georgetown University


Slide
30

Laparoscopic
-
assisted live donor
liver resection as performed by Dr.
Lynt

Johnson at Georgetown
University Hospital

Camera, phantom, trackers

CAIMR

Georgetown University


Slide
31

CAIMR

Georgetown University


Slide
32

Virtual reality augmented
laparoscopic surgery

CAIMR

Georgetown University


Slide
33

Another laparoscopic example

Three displays are provided: the standard laparoscopic view (left), laparoscopic ultrasound
(center), and real
-
time rendering of the ultrasound probe relative to a pre
-
procedure CT
angiogram. The top row shows three still images when the celiac axis is being imaged. The
bottom row shows the superior mesenteric artery being imaged. Figure courtesy of James
Ellsmere
, MD, and Kirby
Vosburgh
, PhD, Massachusetts General Hospital.

Thoraco
-
abdominal
interventions


(enabled by improvements in
electromagnetic tracking)

CAIMR

Georgetown University


Slide
35

Thoraco
-
abdominal

image
-
guided clinical trials

Organ/

Method


Procedure

Tracking
System

Modality

Reference

Lung

Bronchoscopic

Biopsy


Biosense

CT


Solomon

1998

Liver

Biopsy

Ultraguide

Ultrasound

Howard 2001

Kidney

Biopsy

Ultraguide

Ultrasound

Wallace 2006

Laparoscopy

Tumor

resection

Aurora,

Ascension

CT /
Ultrasound

Lango

/
Vosburgh

Courtesy
Filip

Banovac, MD, Chapter 13, Image
-
Guided Interventions book

First Clinical Case of Electromagnetically Tracked
Lung Biopsy at Georgetown University

CAIMR

Georgetown University


Slide
37

Registration

CAIMR

Georgetown University


Slide
38

Marking the Target in the Lesion

CAIMR

Georgetown University


Slide
39

Path Planning: Cannot Cross Rib

Slide
40

Off
-
axial View

Shows Clear Path

Slide
41

Navigation View

CAIMR

Georgetown University


Slide
42

Some Major

Research Groups


(apologies if I left yours out

)


Centre for Medical Image Computing


University College, London


Professor David
Hawkes


Rijkhorst

et al. Simulating Dynamic Ultrasound using MR
-
derived Motion
Models to assess Respiratory
Synchronisation

for Image
-
Guided Liver
Interventions. (To appear in the proceeding of IPCAI 2010


images below
from
http://cmic.cs.ucl.ac.uk/fileadmin/cmic/research/prostate/Fig_2_DynamicRe
gisteredLiver.gif)

Computer Aided Medical
Procedures & Augmented Reality


Technical University of Munich


Nassir
Navab
, PhD


Focuses on tracking,
intraoperative

imaging, and various user interface
technologies to represent the
information in a sophisticated way.


A common software
infrastucture

was developed to have the flexibility
of addressing various hardware
components (tracking systems, C
-
arm, ultrasound and on the other
side ensuring the robustness and
security of medical applications.


The group is active in labs at
Klinikum

rechts

der

Isar

and
Klinikum

Innenstadt
.


Augmented reality enabled
vertebroplasty

http://
campar.in.tum.de/Chair/Researc
hIssueCompAidedSurgery

Laboratory for
Percutaneous

Surgery

(The Perk Lab)


Queen’s University, Canada


Gabor
Fichtinger
, PhD


A large family of medical
interventions involves the placement
of some linear surgical instruments.


Typical examples include needle
based aspirations, injections, local
ablation therapies,
brachytherapy
,
but “virtual needles” like high energy
X
-
ray and laser beams are also
commonly applied.


The majority of these interventions
today are performed
percutaneously

(i.e., across the skin).


Typical guidance methods are
computed tomography, ultrasound,
magnetic resonance imaging, and
fluoroscopy.

Augmented reality liver biopsy

http://
perk.cs.queensu.ca
/

National Center for Image
Guided Therapy (NCIGT)


NIH funded Biomedical Technology Resource Center.


A national resource for all research into medical procedures enhanced
by imaging


Brigham and Women's Hospital in Boston, Massachusetts


Led by
Ferenc

A.
Jolesz

M.D. and Clare
Tempany

M.D.


Advanced Multimodality Image Guided Operating (AMIGO) Suite

http://
www.ncigt.org
/pages/AMIGO

National Centre of 3D Ultrasound in
Neurosurgery


Geirmund

Unsgård
, MD


Trondheim, Norway


St Olav’s Hospital


Pioneers in image
-
guided ultrasound


Spin
-
off company
Sonowand

SonoWand
® 1.4

System with Tracked
Ultrasound and Image Overlay

There are Several Journals
Covering the Field

CAIMR

Georgetown University


Slide
49

Summary and Future Directions


IGT as a field is about 20 years old


Has been applied to a wide variety of clinical
applications, starting with the brain and
moving to abdominal interventions


The basics of image
-
guided navigation have
been well
-
established


Overall market penetration is still modest


There is room for improvement in existing
applications and new clinical applications

CAIMR

Georgetown University


Slide
50

Future Directions: Slide 1


Medical push towards more minimally
invasive procedures will continue


Component technologies of image
-
guided
therapy systems will continue to improve


Intraoperative

imaging will become more
common


Deformable registration will become clinically
useful


Tracking systems, especially electromagnetic
tracking, will become smaller and more
precise



Future Directions: Slide 2


This will create unique opportunities to apply
these technology improvements to better
clinical care


Only through a partnership of scientists and
clinicians can this be enabled


Need to build prototypes and get in clinical
use as soon as possible (rapid prototyping)


You are on the right track


conferences such
as this are part of the success story

Future Directions Slide 3


Validation will continue to be an
important but elusive topic


Randomized clinical trials are difficult in
this field


Evidence
-
based trials should continue
to be pursued where feasible


But let us not stifle innovation


someone has to invent the future!


Some Areas for Future Work


Integration of tracking with robotic systems such as
the
da

Vinci to enable image guidance for robotic
laparoscopic surgery


Robotic NOTES (natural orifice
transluminal

endoscopic surgery), where robotic modules are
inserted through the stomach and self
-
assembled in
the abdomen


Endoluminal

interventions, using flexible or capsule
endoscopy, to provide situational awareness (a
macroscopic view of the anatomy)



CAIMR

Georgetown University


Slide
54

Acknowledgements


Technical team


Ziv

Yaniv
, Emmanuel Wilson, Patrick Cheng, Jae
Choi
, Ken
Wong, among others


Clinical partners


Filip

Banovac, Brad Wood, Vance Watson, Elliot Levy, Eric
Anderson, Karun Sharma, among others


For more information join us at MICCAI 2010


Image
-
guided interventions tutorial 20 September in Beijing

Book now
on
Amazon
and other
vendors



CAIMR

Slide
56

Thank you for your attention


CAIMR

Georgetown University


Slide
57