image-guided interventions and tracking technology kevin cleary, phd technical director...
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Image-Guided Interventions and Tracking Technology
Kevin Cleary, PhD
Technical DirectorBioengineering Initiative
Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National Medical Center
Washington, DC, USA
Robotics Summer School 2012
CAIMR Georgetown UniversitySlide 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 20th
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/cybermuseum/stereotactichall/92exhibit.html Horsley-Clarke
Stereotactic Device
Mechanical Localizer (circa 1990)
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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
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Spinal Pedicle Screw Placement
• Pioneered by Merloz in France and others– Clin Orthop Relat
Res. 1998• Common
application for image guidance
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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
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Medtronic Navigation Technologies
Workflow / Componentsof an IGT Procedure
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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 UniversitySlide 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 TrackersPrinciple of Triangulation
Localizer slides courtesy of Robert Galloway, Vanderbilt University
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Optotrak 3020 – Northern Digital Inc
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Multiface Tool
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Polaris Optical LocalizerPassive and Active Tools
AURORA Electromagnetic TrackingVendor: Northern Digital Inc. (Waterloo, Canada)
1. Field generator provides low strength magnetic field2. 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 UniversitySlide 22
Fiducials for registration purposesCourtesy 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 UniversitySlide 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
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3D Slicer User Interfacehttp://www.slicer.org/
publications/item/view/1835
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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
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IGSTK: The Book
Image-Guided Laparoscopic Surgery
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Georgetown UniversitySlide 30
Laparoscopic-assisted live donor liver resection as performed by Dr.
Lynt Johnson at Georgetown University Hospital
Camera, phantom, trackers
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Virtual reality augmented laparoscopic surgery
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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 UniversitySlide 35
Thoraco-abdominal image-guided clinical trials
Organ/Method
Procedure Tracking System
Modality Reference
Lung BronchoscopicBiopsy
Biosense CT Solomon1998
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
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Registration
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Marking the Target in the Lesion
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Path Planning: Cannot Cross Rib
Slide 40
Off-axial View Shows Clear Path
Slide 41
Navigation View
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Some MajorResearch 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_DynamicRegisteredLiver.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/ResearchIssueCompAidedSurgery
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 biopsyhttp://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
SonowandSonoWand® 1.4 System with Tracked
Ultrasound and Image Overlay
There are Several Journals Covering the Field
CAIMR Georgetown UniversitySlide 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 UniversitySlide 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 UniversitySlide 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
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CAIMR Slide 56
Thank you for your attention
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