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The next

surgicalrevolutionIntraoperative Imaging and Robotics for

Energy De very

de qu estamos hablando?

hablamos de un Intelligent Robotic Sugeon?

O ms bien de Advanced Robotic Tools?

The next

surgical

revolution

Intraoperative Imaging and

Robotics for Energy Delivery

PASADO: cortar, y luego mirar

PRESENTE: mirar, planificar y luego cortar FUTURO CERCANO: mirar, planificar, fusionarinf., re-planificar, mnimo dao a tejidos sanos

Diagnosis

Clinical Image

analysis

Researchers goal.

Robotic tools

3D information

Current Clinical procedure

Manual surgicalintervention

Surgical path-planning

schedulingPlanning with

3D tools

Robot assistedsurgical procedures

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outline of the presentation

Goals in Robotic Energy Delivery Systems Robotic Energy delivery systems

Intraoperative imaging for positioning

Surgical robots for positioning

concept

is the use of high energy to treat disease.

Since the discovery of x-rays over one hundred

years ago, radiation has been used more andmore in medicine, both to help with diagnosis (bytaking pictures with x-rays), and as a treatment(radiotherapy).

rgyDeliverySystem

This can be given either as external source fromoutside the body using x-rays or from within thebody as internal source.

ROBOTICS + IMAGING =

FINE POSITIONING

GoalsinRoboticEn

whatwe pretend?

to develop a partnership between man (the

surgeon) and machine (the new robotic tools)

that seeks to exploit the capabilities of both to do

a task better than either can do alone R. Taylor

Treating the body without surgery and without

damaging healthy tissues will define the surgery

rgyDeliverySystem

o e u ure

GoalsinRo

boticEn

we can position ourselves very precisely but in

the precisely wrong place L. Joskowicz

accuracy

thebigpicture: presentCAS

PatientPreoperative medical images

atlas

Modelling, planning3D reconstruction

accuracy

Patient-specific treatmentGlobal accuracrg

yDeliverySystem

Intraoperative execution

Registration,navigation,Robotics, positioning accuracy

PostoperativeevaluationEvidence-basedaccuracy

accuracy

GoalsinRo

boticEn


Goals in Robotic Energy Delivery Systems

Robotic Energy delivery systems



presenttechnologies

DeliverySystem

CYBERKNIFE: A robotic radiosurgery system

RoboticEnergy

External source

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presenttechnologiesCYBERKNIFE : A robotic radiosurgerysystem

DeliverySystem

SynchronyRespiratory Tracking SystemContinuously synchronizes beam deliveryto the motion of the tumor, allowingclinicians to s ignificantly reduce marginswhile eliminating the need for gating orbreath-holding techniques.

Flexible roboticmaneuverability- Driven by continual imagingand intelligent movement corrections, the C yberKnifesroboticmanipulator automatically positions the linear accelerator to anunprecedented range of positionsallowing access to virtuallyany tumor from any direction

RoboticEnergy

presenttechnologies

DeliverySystem

HIFU technology uses a high-intensity convergentultrasound beam generated by high power transducers to

produce heat. HIFU is intended to allow the surgeon tonecrose prostatic tissue without damaging interveningand surrounding tissue, thus eliminating the need forincisions, transfusions, general anesthesia and theirresulting complications.

HIFU: High Intensity Focused Ultrasound

RoboticEnergy

transducer vibration. This results indilatation and contraction modificationof acoustical pressure. The acousticalpressure creates tissue movement(dilatation and contraction) whichamplitude is directly related to thepressure level. As the tissue responseis not perfectly elastic, energy is lostand converted into heat.

Internalsource

presenttechnologies

DeliverySystem

HIFU: High Intensity Focused Ultrasound

The AblathermHIFU device is made up of 2 modules: the treatment moduleon which the patient is positioned and the control module which enables the

RoboticEnergy surgeon to plan and check the treatment via a computerized system which

guides the robotic endorectal probe.

The probe is installed on a mobile support. The ultrasoundgenerator and the integrated ultrasound scanning equipment(or transducers) are located on the end of the probe.

presenttechnologies

DeliverySystem

LASER ABLATION SYSTEMS:

A large-scale, 12-year study has found that laserablation with magnetic resonance (MR) guidanceis as effective as traditional surgery in thetreatment of liver tumors in some patients.Annual Meeting of the Radiological Society of

North America (RSNA).

RoboticEnergy

Liver metastases 24 hoursafter LITT (left image noncontrast enhanced, right imageafter administration of acontrast agent.

presenttechnologiesLASER ABLATION SYSTEMS:

clinical specialities

Neurosurgery: biopsies, tumor removal,parkinson, epilepsy treatments,

Orthopaedics: hip and knee implants, fractures,ACL ligaments,

Laparoscopy, ENT: camera support, simulations,ergyDeliverySystem

virtual colonoscopy,

Craneoand maxilofacial: preoperative planningof fragments, precise placement,

Radiation therapy: tumor ablation, radiation,..

GoalsinRoboticEn

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where we go?

rgyDeliverySystem

"The main challenge is how can we gethigh-quality medical care onto thebattlefield as close to the action and asclose to the soldiers as possible,"

J ohn Bashkin, head of businessdevelopment at SRI InternationalG

oalsinRoboticEn





intraoperative imaging for positioning

Medical & surgical imagingTecnologas pre e intraoperatorias

Precisin en imgenes intraoperatorias

Registro entre imgenes intra y pre

Requisitos para los sistemas delivery enery

Soluciones investigadas y ejemplos de aplicaciones US-guidance uoroscopa para c avo sta Magnetico-acustico Ecohaptic

imagen mdica

Primera imagen mdica

Los valores de intensidad estnrelacionados con lascaractersticas del tejido y con elfenmeno fsico utilizado para laadquisicin de la imagen.

gingforpositioning

Roentgen, 1895

Importante herramienta de diagnstico

Intraoperativeima

imagen mdica

Characteristics:

Preoperativeor introperative use Depends on thesize and location of imagingmachine

Dimensionality: 2D, 2.5D, 3D, 4D,

Image quality Pixel intensity, spatial resolution, signal/noise ratio,

Field of viewgingforpositioning

Radiationtopatientand to surgeon

Functional or anatomical imaging Neurological activity, blood flow, cardiac activity,

Suitable for: bones, soft tissues, fetus, surface tumors

Clinical use Diagnosis, surgical, navigation

Intraoperativeima

ptica Tctil Rayos X Resonancia Magntica MRI,

fMRI, iMRI, MRAg

ingforpositioning

imagen mdica

Naturaleza fsica:

Fluoroscopia Ultrasonidos 2D / 3D /4D Electroencefalografias EEG,

MEG otras

Intraoperativeima

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Intraoperative imaging

Extractedfrom:Image-GuidedProcedures: A ReviewZivYaniv and Kevin Cleary

Procesado bidimensional. .

Pipeline Genrico

Leer Imgenes

Umbralizacin

Eliminar Islas

Remuestreo

ImagenLeer Imgenes

Umbralizacin

Eliminar Islas

Remuestreo

genericpipeline

gingforpositioning

Creacin de modelos 3D.

Suavizado del mallado 3D

Exportar la Salida

.

.

Difusion 2D

Reconstruccin 3D

Diezmado

Suavizado 3D

Calculo de las normales

Agrupacin

PolyDatos

Exportar

Difusion 2D

Reconstruccin 3D

Diezmado

Suavizado 3D

Calculo de las normales

Agrupaci n

Exportar

Principales formatos comerciales.

VRML, Ribe

PolyData

Structured gridIntraoperativeima

Volume Rendering

Algoritmos de raycasting(isosurface, MIP,composite,)

Surface Rendering

Realiza la reconstruccin del contorno de unobjeto

Bajo coste computacional

3D reconstruction

Identificacin difcil de los contornos si haymuchas intensidades en la imagen

Algoritmo del escultor (triangulacinDelaunay)

Algoritmo MarchingSquares / Cubes

Marching squares

Ej. Valor decontorno 5

Marching cubes planificacin y registro

gingforpositioning

Intraoperativeima

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navegacin

Optical-basedCAS

gingforpositioning

Intraoperativeima

navegacin

Principio defuncionamiento

gingforpositioning

Intraoperativeima

principios de la navegacin quirrgica

6 parameters(3 translations +3 rotations)uniquely determine the position andorientation of an object

By triangulation with two cameras, thes ance o a mar er rom e org n can

be determined

From three marker distances the positionand orientation of a rigid tracker isuniquely determined

principios de la navegacin quirrgica

Accuracy in navigation Registro 2D

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Registro 3D

gingforpositioning

Marcas invasivas

Marcas externas

Registro con datos atlas

Movimiento de los tejidos

Intraoperativeima

Algoritmo ICP Bsqueda del punto ms prximo: En la primera fase hay que identificar,

para cada punto de la superficie P, el punto ms cercano de la superficiedel modelo Q.

Calcular transformada: calcular la transformacin rgida T que minimiza

las sumas de los cuadrados de las distancias entre los pares de puntosprximos (p,q).

Transformacin: Aplicar la transformacin rgida T a todos los puntos delconjunto P.

Iterar: repetir los pasos 1 a 3 hasta converger, aplicando un umbral de.

Planificacin y registro

gingforpositioning

Intraoperativeima

Tejidos blandosRegistrosobre informacin3D reconstruda

Interventional ultrasoundProstateradiotherapy.Thedancingprostate. By A. Zitman(MGH)

gingforpositioning

operator dependentinvasively deforms tissuesno image outside the bodyneeds calibration

Intraoperativeima

Solucin posible: fussiondisplay

R. San J os Estepar

Ejemplos y aplicaciones de image-guidedsurgery

gingforpositioning

Intraoperativeima

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Reduccin de la fractura de la cabeza del fmur

M. Mitsuishi

gingforpositioning

Ejemplos y aplicaciones de image-guided surgery

Intraoperativeima

Ejemplos y aplicaciones de image-guidedsurgeryL. J oskovicz

gingforpositioning

Insercin

clavo distal

Intraoperativeima

Terror wounds are characterized by explosion injuries andpenetration of metal shrapnel

gingforpositioning

Sharpnel removalL. J oskovicz

Ejemplos y aplicaciones de image-guided surgery

Intraoperativeima

Sharpnel removal: indications

Removal of shrapnel is usually performed in

the subacute phase in cases where:

proximity to neurovascular structures

L. J oskovicz

gingforpositioning

presence of perio-articular involvement

in weight bearing areas in superficial location

Removal of shrapnels requires utmost

accuracy in detection and removal

Intraoperativeima

Sharpnel removal: requirements

Accurately removal of shrapnel relies on:

getting to the target

efficiently grasping the metal fragment

L. J oskovicz

gingforpositioning

Real-time fluoroscopy is the most

commonly used approach

Intraoperativeima

Fragment migration during navigation

L. J oskovicz

gingforpositioning

Fragment migration misleads the surgeon

actuallocation

viewedlocation

Intraoperativeima

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Metal detector probeExperimental design

Sensitivity range: 2-5 cm from fragmentlocation Output: audio frequency change. Limitations: designed to locate without

physical extraction.

L. J oskovicz

gingforpositioning

Solenoid

SureTrakTM

active frame

Probe location on x-y plane

shrapnel50mm

50mm

Frequency change (Hz)

Intraoperativeima

Fluoroscopic navigation

Navigation with the metal detector probe

L. J oskovicz

gingforpositioning

Intraoperativeima

Results

Metal detection (secs)FragmentFragment

Experiment #1: no fragment migrationno difference

Experiment #2: with fragment migrationgreat difference!

L. J oskovicz

gingforpositioning

num ernum er withwithout

251801

10652 10253104541525551806

12.586Average

More than six

times faster!!

180

180

Intraoperativeima

Concepto de EcoHaptic

gingforpositioning

Apli caci n ini cial: aplicacin ginecolgica. [ref. Fetouch project]A partir de la informacin de ecgrafos 2D/3D ser capaces depalpar la imagen ecogrfica.

Apli caci n fut ura: aplicacin de diagnstico e intraoperativa.Analizar y mejorar la informacin suministrada por US para unanlisis volumtrico de la misma.

Intraoperativeima

Experimentacin y comparativa

Interaccin hptica en EcoHaptic:

ConstantedeElasticidad

ConstantedeDamping

0,0010 0,0015 0,0020 0,0025 0,0030 0,0035

0,1 Mala Mala Mala Mala Mala Inestable

0,2 Buena Buena Buena Buena Mala Inestable


0, Buena Muybuena Muybuena Muybuena Mala Inestablegingforpositioning

Mejores resultados Valores intermedios de la constante de elasticidad

Valores pequeos de la constante de damping

0,5 Buena Muy buena Muy buena Muy buena Mala Inestable

0,6 Buena Muy buena Muy buena Muy buena Mala Inestable



0,9 Mala Mala Mala Mala Inestable Inestable

1,0 Mala Mala Mala Mala Inestable Inestable

Intraoperativeima

Experimentacin y comparativa

Geometra Tiempo deejecucin (segundos)

Convexa ngulos pequeos (Zona 1) Buena interaccin

Convexa ngulos grandes (Zona 2) Buena interaccin

Cncava ngulos pequeos (Zona 3) Interaccin aceptable

Cncavasngulosgrandes(Zona4) Fallosenlainteraccin

Interaccin h ptica en EcoHaptic. Zonas geomtricas:

gingforpositioning

Zona 1

Zona 2

Zona 4

Zona 3

Intraoperativeima

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Requisitos de posicionamiento

Esquema de posicionamiento Sistema teleoperado

Sistema autnomo

Patient-mounted robots vs table-mounted robots En paciente, en camilla, mvil

Problema de registro y precisin

A Safety Point of View

Weak capacity indeciding,

learning, adaptingIncomplete models

Reliability

Geometricaccuracy

Precision incontrolling forces

Possibility to workin hostileenvironment

Repeatability

Subject tofatigue

StabilityPrecisionUnable to seethrough tissues

Subject to

Efficient naturalsensors

DexterityCoordinationCapacity inreasoning andlearning

SURGEON

forpositioning

ROBOT

StationarityRapidity

skills

Better accuracySafety increasedTrauma decreasedDecreasing number of interventionsPost operative comfort and fast recovering

Surgicalrobots

Kinematic constraints: Remote Rotation Center

A classical spherical wrist does not rotate at the right point

forpositioning

A RRC system does

and thus cancel theConstraint3 =(6 +3) (6 x 1)

Surgicalrobots

RRC or The Magical Parallelogram

RRC with spherical links requires complex parts

while a basic parallelogram may do the job aswellfo

rpositioning

Surgicalrobot

Implementation of RRC

From solid links to timing belts

forpositioning

Surgicalrobot

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Sistemas teleoperados

Endoassist- intuitivecamera control inendoscopic surgery

Sistemas teleoperados

Project:Robotic Teleoperated High Intensity FocusedUltrasound (HIFU) System

Client: US Army

forpositioning

High Intensity Focused Ultrasound (HIFU) has been investigated since early last decade and has provento be a valuable non-invasive surgery technique. With currently available technology, HIFU energy can beprecisely targeted to cure some cancers, cauterize tumors, and stop bleeding. The concept of non-invasive hemorrhage control is particularly significant in combat scenarios where immediate access tosurgery is limited. HIFU has been shown to effectively control bleeding from vessels up to 2mm indiameter and the technology is evolving rapidly. It is expected that in the near future, HIFU will effectivelycontrol hemorrhage from vessels 8-10mm diameter.

The Army is interested in HIFU-based hemorrhage control on the battlefield by integrating a roboticteleoperated (where the surgeon is controlling the arm from a remote location) system with the LifeSupport for Trauma and Transport (LSTAT) system. The LSTAT is an advanced platform that allowsmonitoring and intervention on severely injured patients during transport.Energid is developing a robotic HIFU system that a) allows use of the device by remote users, b)integrates with LSTAT, and c) provides the dexterity and workspace necessary to apply HIFU on anextremity injury, femoral bleeding and some intra-abdominal injuries.

http://www.energid.com/energid-projects-robotics-hifu.htm

Surgicalrobots

Sistemas autnomos

Pat Fin er- rameessstereotactic precision

ROBONAV

(Robodoc, byCurexotech. Company)

M-850 hexapod fromFraunhofer-Institut frProduktionstechnik undAutomatisierung (IPA)

Tablemountedrobot

forpositioning

Surgicalrobots

Patientmounted robot MARSM. Shoam

forpositioning

Surgicalrobot

MARSM. Shoam

forpositioning

Surgicalrobot

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Our collaborators:

VR2 lab.J ose M Azorin, Nicolas Garcia, Carlos Perez, Eduardo Fdez. J over.HebrewUniversityof J erusalem.Leo Joskowicz,SECAO society: Andre Bauer, Jose M Fdez. Meroo, Roque Torres

CARTIF:J uan Carlos Fraile, J avier Perez Turiel,Hospital Clnico San Carlos:J ulio Mayol, Ernesto Santos, J ess A. Fdez.-Represa.

Thanks

Documents

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