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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
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