计算机辅助外科技术

NSFEngineeringResearchCenterfor

Computer-IntegratedSurgicalSystems

fandTechnology

CISSTResearchProgram:

CurrentandFutureTrends

GregoryD.Hager

AssociateDirectorforResearch

CISSTERC

JohnsHopkinsUniversity

3400N.CharlesStreet,Baltimore,Md.21218

hager@

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

NSFEngineeringResearchCenter

forComputer-IntegratedSurgical

SystemsandTechnology

•Established1998

•Multi-institution,multi-disciplinarycenter

-JohnsHopkinsUniversity+MedicalInstitutions

-MIT+Brigham&Women5sHospital

-CMU+UPMC

—Others：MorganState,Georgetown,Harvard,Penn,Columbia

•Funding

一CoreNSFGrant+NIH+Industry;Total=$9-1OM

•Universityresearchers,clinicians,industry

•Research,Systems,Education,Outreach

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

CISSTPremise

Theimpactofcomput

integratedsurgical

systemsandtechnology

onmedicalcareinthe

next20yearswillbeas

greatastheimpactof

computer-integrated

manufacturingsystems

andtechnologyon

industrialproductionover

thepast20years.

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnofog*

Copyright©CISSTERC,2005

CISSystemsVision

PreoperativeIntraoperative

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

Computer-

Patient-specific

Model

Execution

Patient

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

SurgicalCAD-CAMActivities

Spine

ProstateLiver

Metastasisfrom$120billioncost

200,000cancers/yearcolorectalcancer70%ofpopulation

1Mbiopsies/year130,000new/yearaffectedinlifetime

10MBPHcurrently60,000death/yearBone

25%ofmenaffectedinHepatitisworldwide

lifetime400,000metastatic

cases/year

UnitedStatesnumbers

Whythese?

•Significanthealthproblems

•Clinicalcollaboration

•Experience

•Externalfunding

•Suitablemixforprototyping

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

Preoperativentraope

Computer-ateM

assisted

planning

Patient-specific[

Model।

Postoper

Assisted

Assessment

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

SurgicalAssistanceActivities

EyeEarSinusThroatBrainGeneralMIS

Hager,OkamuraTaylorOkamura,Hager

EngineeringTaylorTaylor

Riviere.Cole-WhitcombKazanzidesTaylor,Kanade

FacultyHagerSimaan

Rhodes,Etienne-HagerRiviere,

Okamura

CummingsRiviereKazanzides

HandaRothbaumYuh,Gott

ClinicalLong

HumayenFrancisIshiiFlintTalamini

FacultyClatterbuck

DeJuanChoti

Engh

ThompsonMarohn,Hanly

TremorreductionAdvancedHighdexterityIntegrationofTelesurgeryand

PrincipalAccessingthe

andimage-basedvisualizationinconfinedNavigationandhumanfactors/

FocusScala-Media

guidancewithSHRspacesRoboticsRobot-assisted

guidanceNeedlesteeringultrasound

NewJHU

JHUSHRwithIntuitiveSurgical

JHUSHRwithsnakedesign,JHUSHR,

adaptedDohenyEndActivedaVincisystem

PlatformspecialdeliveryIntuitiveMedtronic

EyeInstituteendoscope

systemSurgicaldaStealthstation

cannulaeCMULarsUltrasound

VincisystemSteeredNeedle

Micronwithsamerobot

Tasks2,eventually1,1,eventually2,

1,2,3,4112,3,4

Involved3and43,4

PhantomtrailsNewdeliverySystem

ClinicalCadaverand

(Micron,SHR)systemunderPhantomtrialsdevelopment/

StatusPhantomtrialsPhantomtrials

ongoingdevelopment.infrastructure

inAugust

underway

NIHR01(Micron)PittsburghNIHR01,SBIR

External

NIHR21SubmittedSeekingNIHNIHR21underFoundationP1,Whitaker,

Funding

(Image-guidedfundingrevisionNIHR21ABC2pendingNSF

Status

Micron)NIHR21/33OtherNIH,Army

PlannedNIH(SHR)pendingpending

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

TheSpectrumofCISSystems

Patienl

PostoperativePatient

Modeling&AnalysisInterfaceTechnology

•SegmentationSystems•Sensing

•Registration•Safety&verifiability•Robotics

•Atlases•Usability&maintainability•Human-machine

•Optimization•Performanceandvalidationinterfaces

•Visualization

Modeling&Analysis

•Real-timeregistration

InterfaceTechnology•Visualization

•Robotics•Taskcharacterization

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

CISSTResearchOrganization

Thrust1Thrust2

SurgicalSurgical

AssistantsCAD/CAM

Barrier1

Modeling

and

Analysis

Barrier2Thrust0

InterfaceEngineering

Technology

Infrastructure

Barrier3

Systems

Science

Copyright©CISSTERC,2005I

PlannedCISSTSystemsEvolution

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

199

Engineered

Systems&

Applications

Enablingcore

technology

Fundamental

Knowledge

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

2005

Engineered

Systems&

---------------1

EnablingcoreR\__广

technology

Fundamental号

KnowledgeHe%

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

CISSTResearchDevelopedthrough

clinicalandindustrial

ProgramTodaycollaborations

pplication

Clinical

Systems

Systems

ResearchTechnology

4

Thetranslationof

Createdbasedon

basicresearch

applicationneeds

intopractice

QF■

Thebasisforarich,self-sustainingprogramofbasicand

appliedresearch,andacademicandindustrialcollaboration

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

FutureTrends

•Combineimaging,visualizationandactionintheOR

-Multi-modalregistration,intra-operativeimaging,statistical

atlases

-In-scannerrobots

一Real-timeUScalibrationand3Delastography

•Novelinstruments/sensorsforspecificapplications

一Micron(CamRiviere,CMU)

一Scalablesnakerobot

-HeartLander(CamRiviere,CMU)

•Real-timeinformationupdateandassistance

-Virtualfixturesforsafetyandguidance

-Novelinstrumentsandsensorysubstitution

-ContextAwareSurgicalAssistance(CASA)

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

SurgicalCAD-CAM:Motivation

ProstateCancer

•1Millionprostatebiopsiesannually

•230,000newcases

•30,000deathsinU.S.in2004

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

CurrentPractice

ClinicalStandard:Ultrasoundguidedbiopsy

•Poortissuecontrast

・'Blind'systematicbiopsyofthegland(6-12samples)

•Falsenegative20-30%

•GleasonscoreonUSbiopsyof25%ofpatients

isbeing'upgraded'attimeofsurgery

AdvantagesofMRI:

•MRIwithendo-rectalcoilhasexcellentsensitivityfordetecting

tissueabnormalitiesandmayallowfortargeted5biopsy.

•HighSNRimprovesdiagnosticaccuracy,especiallyforMRSI

andDCE-MRL

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

MRI-GuidedProstateInterventions

ApexAnterio

,■

;Posterim

Left•Right

•Base

DeformableProstate

Atlas(Davatzikos,Shen)

DeformableFusion

Signalcorrection(Kikinis,Warfield)

(Warfield)

ProstateSegmenter

(Wells,Grimson)

QuickTime™anda

TIFF(LZW)decompressor

areneededtoseethispicture.

Planning(DiMaio,Fichtinger)

NeedleTracking(DiMaio)

3TProstateRobot(Whitcomb

IMRTRobot(Chinzei,

EngineeringResearchCenterforCompuFichtinger,Atalar,etal.)

Copyright©CISSTERC,2005Kikinis)

MRIGuidedProstateInterventions

A.Krieger1R.C.Susil3,CynthiaMenard5,

JonathanColeman6,AnuragSingh5,

L.L.Whitcomb1,E.Atalar2,G.Fichtinger24

1DepartmentofMechanicalEngineering

2DepartmentofRadiology

3DepartmentofBiomedicalEngineering

4CISSTEngineeringResearchCenter

JohnsHopkinsUniversity,Baltimore,MD

JERCICISST

J1ONAU

5RadiationOncologyBranch,NCI-NIH-DHHS\NCER

6UrologicOncologyBranch,NCI-NIH-DHHSriTUTH

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnologyg

Copyright©CISSTERC,2005

OverallSystem

.Manipulator

2.Tracking

Svstem>

Position3.Visualizationand

Parameters

TargetingProgram

Digital

Images

PhysicianInterface

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnologyg

Copyright©CISSTERC,2005

Manipulator

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

Simulation

QuickTime™anda

YUV420codecdecompressor

areneededtoseethispicture.

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

VisualizationandTargetingProgram

EngigResearchCenteHorComputermegratedSu丽SystemsandT-gyf

Copyright©CISSTERC,2005

Results

ClinicalTrialsunder1.5Tand3T

•Goldmarkerseedplacements

Implantationof4goldmarkerseedsto

guideexternalradiationbeamtherapy.

16patientswith4seedimplantseach

•Biopsies

15patientswith4-10biopsieseach

•Nosevereadverseevents

•Averagetargetingaccuracybetween2.8mmand7.4mm

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

MRimaqesdurin。aclinicalprocedure:

Left:Atarget(reddot)isselectedonanaxialTSET2-weightedimage.

Middle:TheneedletipvoidisvisualizedinanaxialTSEProtonDensityimage.

Thedesiredtargetmatchestheactualpositionoftheneedle.

Right:TheneedlevoidisvisualizedonasagittalTSEProtonDensityimage,

CurrentandFutureWork

RedesignoftheProstateInterventionalSystem

•Fasterproceduretime

•Easyimplementationwithdifferentscannerarchitectures

Improvementsinclude:

•Steerableneedleguide

•Newtrackingscheme

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

SteerableNeedles

A.Okamura,N.Cowan,G.Chirikjian,K.T.DeWeese,K.Murphy

/publications/iser04-webster.pdf

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

SteerableNeedleGuideDesign

WheelforWheelfor

toMountHelicalCut

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

NewTrackingScheme

Combinationof

•PassiveTrackingforinitialregistration

•OpticalEncodersforrotationandneedleangle

CodeWheelforPassiveMarker

codingofRotationTubes

CodeWheelfor

EncodingofNeedle

GuideAngle.jchnologyg

Copyright©CISSTERG,2005

USGuidedProstateInterventions

RegistrationofUltrasoundtoFluoroscopy

・SBIRPhase-1

•DoDClinicaltrialaward

•Burdette/fellowship

•SBIRPhase-2(pending)

•SPOREsupplement(pending)

•DoDfellowship(pending)

•R21(pending)

•IRB/clinicaltrialapproved

RoboticBrachytherapy

TransrectalUSAblation

•SBIRPhase-1TRUSGuidedBrachytherapy

•SBIRPhase-2(BurdetteMedicalSystems)

•IRB/clinicaltrialapproved

AtlasBasedUSBiopsy

•STTRPhase-1

kPi/slerit•Burdette/fellowship

"Right

RO1--atlas

RO1-segmentation(pending)

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

Example:Atlas-based,image-guidedprostatebiopsy

DetectionRateof>99%!

Comparedto77%usingstandardmethods

PeformableSegmentation^

ofProstateImages/

Facultymembers:D.Shen,C.

MRIprostateimageDavatzikos,C.Tempany,G.

Fichtinger,S.Haker

Engineenng4^esearTHi-<}errter-fareornpirterIntegratedSurgicalSystemsandTechnology

,2005I

Example:BiomechanicalSimulation

ofMedicalNeedleInsertion

RonAlterovitz,KenGoldberg(UCBerkeley)

JeanPouliot,l-ChowHsu(UCSF)

•Goal'.Reduceradioactiveseedplacementerrorinprostatecancer

brachytherapytreatmentusingbiomechanicalsimulation

•Developed2Ddynamicfiniteelementmodelofneedleinsertionintissue

•Interactivesimulation:24fpsona750MHzPC

•Applications:Physiciantrainingandtreatmentplanning

QuickTime™andaQuickTime™anda

YUV420codecdecompressorYUV420codecdecompressor

areneededtoseethispicture.areneededtoseethispicture.

TissuedeformationscauseseedPlannercomputesoffsetstocompensate

placementerrorforsimulatedtissuedeformations

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005I

Robot-AssistedUS-GuidedLiverTherapy

Ultrasound

system

Surgicalworkstation

UltrasoundAblationN

e

RobotrobotM

o

r

□Rk

JHMI:Choti(Sura),Kavoussi(Urology),Solomon(Radiology)

WSE:Fichtiger,Taylor,Boctor,Jain,Fischer,Vishwanathan,etal.

Industry:BurdetteMedical,IntuitiveSurgical,Aloka,Siemens

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnology

Copyright©CISSTERC,2005

Averageerror

for10trials

〜3mm

Mainlimitation

wasEMtracker

Credit:Boctor,

Fichtinger,

Vishwanathan,

Fischer,Taylor,

Jain,Choti,etal.

EngineeringResearchCenterforComputerIntegratedSurgicalSystemsandTechnologyg

Copyright©CISSTERC,2005

In-VivoUltrasoundCali