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Image Guided Surgery
Kazuhiro Yasufuku MD, PhD
Director of Endoscopy, University Health Network
Director, Interventional Thoracic Surgery Program
Associate Professor of Surgery, University of Toronto
Division of Thoracic Surgery, Toronto General Hospital
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2016 Duke Masters of Minimally Invasive Thoracic Surgery Sep 15-17th, 2016
Disclosure
• Industry-sponsored grants
• Educational and research grants from Olympus Corporation
• Consultant
• Olympus America Inc.
• Intuitive Surgical Inc.
• Covidien
• Johnson and Johnson
• Research Collaboration
• Siemens
• Novadaq Corp.
• Veran Medical Systems
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63F
3
2009
•40pk yr smoker
•CT screening
•R lower lobe GGO
63F, 40pk yr smoker
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2009 2011
63F, 40pk yr smoker
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2009 2011 2012
CT guided FNA non-diagnostic
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2012
•What next?
a. Follow up
b. VATS
c. Thoracotomy
d. None of the above
Image Guided Surgery (IGS) – Definition?
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Image Guided Surgery (IGS) – Definition?
• General term used for any surgical procedure where surgeons employs tracked surgical instruments in conjunction with preoperative or intraoperative images in order to indirectly guide the procedure
• IGS was originally developed for treatment of brain tumors
• Various applications of navigations for neurosurgery have been widely used for almost two decades
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Image Guided Surgery (IGS) – in Thoracic Surgery
• Fluorescence Image Guided Surgery
• Virtual/Electromagnetic Navigation Guided Surgery
• Preoperative CT Guided Surgery
• Intraoperative Cone Beam CT Guided Surgery
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Fluorescence Image Guided Surgery
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ICG and Near Infrared (NIR) Imaging
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Surv Opthalmol, 2000
820-835nm
Mo
lar
exti
nct
ion
co
effi
cien
t (c
m-
1/M
)
M.W: 775
Indocyanine green NIR thoracoscope
PinPoint, Novadaq TechnologiesTM
ICG Fluorescence-Guided Surgery
• Sentinel LN Mapping
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J Thorac Cardiovasc Surg. 2013; 146: 562-70
• A-dose escalation phase 1 clinical trial
real-time NIR imaging after peritumoral
injection of 3.8 to 2500 μg
• 26 NIR(+) SLNs identified in 15 pts with 7
NIR(+) SLNs (6 pts) harboring metastatic
disease on histologic analysis
• Metastatic nodal disease never identified
in pts with a histologically negative NIR(+)
SLN
ICG Fluorescence-Guided Surgery
• NIR Thoracoscopic Segmental Resection
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J Thorac Cardiovasc Surg. 2012; 143: 1330-5
• ICG injection into the bronchus of target pulmonary segments under GA
• NIR Thoracoscopic identification of the target segments (Hamamatsu Photonics, Hamamatsu, Japan)
• Intersegmental lines and planes identified to
allow segmental resection
ICG Fluorescence-Guided Surgery
• NIR Robotic Segmental Resection
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J Thorac Cardiovasc Surg. 2014; 148: 737-8
• iv ijection of ICG after division of segment bronchus, vein and artery (2.5mg/10mL, 6-8mL bolus)
• Da Vinci Firefly fluorescence imaging for identification of the target segments
Virtual/Electromagnetic Navigation Guided Surgery
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Virtual assisted Lung Mapping
• VAL-MAP
• Bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection
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J Thorac Cardiovasc Surg. 2014; 147: 1813-9
Preoperative bronchoscopic marking
• CT Fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules
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CHEST 2004; 125:1747–1752
Preoperative ENB marking (fiducial, dye)
• ENB-guided VATS wedge resection of peripheral lung nodules
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Seminars in Thoracic and Cardiovascular Surgery, 22 , 2011 J Community Hosp Intern Med Perspect. 2014; 4(1): 10
GTx (Guided Therapeutics) Program
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GTx OR at Toronto General Hospital
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GTx OR Capabilities
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Cone-Beam CT Dual Source- Dual Energy CT
MIS, Endoscopic Technology
Guided Therapeutics (GTx) Core
GTx OR Capabilities
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Cone-Beam CT
Guided Therapeutics (GTx) Core
Multi-Modality Surgical Guidance
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Optical Imaging
Surgical Tool Tracking
Intraoperative CBCT
Surgical Planning “Surgical Dashboard”
Pre-Operative Imaging
“X-Eyes” 3D Visualization Software (University Health Network)
Courtesy of Michael Daly
Multi-Modality Surgical Guidance
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Optical Imaging
Surgical Tool Tracking Intraoperative CBCT
Surgical Planning
Pre-Operative Imaging
Intraoperative localization Image assistance during MIS/Robotic Surgery
Real time monitoring of minimally invasive thoracic
intervention
Optical Surgical Navigation
Surgical Tool Tracking Intraoperative CBCT Pre-Operative Imaging
1. Preoperative CT imaging
2. Cone-beam CT nodule
localization
3. Image registration with
surgical navigation
GTx OR – VATS localization
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GTx OR – Image guided Transbronchial Interventions
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A Novel Minimally Invasive Near-infrared Thoracoscopic
Localization Technique of Small Pulmonary Nodules
– A Phase I Feasibility Trial
Hideki Ujiie1, Tatsuya Kato1, Hsin-pei Hu1, Priya Patel1, Hironobu Wada1, Daiyoon Lee1,
Kosuke Fujino1, Robert Weersink2,3, Elsie Nguyen4, Marcelo Cypel1, Andrew Pierre1,
Marc de Perrot1, Gail Darling1, Thomas K. Waddell1, Shaf Keshavjee1, Kazuhiro
Yasufuku1,2
1Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada 2TECHNA Institute, University Health Network, University of Toronto 3Department of Radiation Oncology, University Health Network, University of Toronto 4Division of Cardiothoracic Imaging, Joint Department of Medical Imaging and University Health Network, University of
Toronto
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small lung nodule CT guided microcoil
insertion
CT guided injection of
ICG
CT-guided Microcoil Placement and ICG Injection
Ujiie et al, AATS 2016 abstract
Ujiie et al, AATS 2016 abstract
CT-guided Microcoil Placement and ICG Injection
Ujiie et al, AATS 2016 abstract
Intraoperative NIR Localization
CT nodule size 12 mm (5 - 24)
CT nodule depth 13.5 mm (2 - 48)
CT findings
Pure GGN 11
Part-solid GGN 6
Solid nodule 3
Pathological tumor size 10mm (5 - 24)
Pathological diagnosis
Adenocarcinoma (AIS, MIA, LPD, ACI) 16 (6, 2, 4, 4)
Squamous cell carcinoma 1
SCLC 1
Metastatic lung tumor 1
Focal perivascular lymphoid infiltrate 1
Patient characteristics (n=20)
CT-guided intervention time 35 min (19-59)
VATS procedural time 54 min (28-84)
Localization success rate 19/20 (95%)
Negative surgical margin rate 20/20 (100%)
Adverse effect 0 /20 (0%)
Results
GTx OR – CBCT localization
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Intraoperative pulmonary nodule tracking with CBCT and deformable image registration
• Pilot clinical study to acquire cone-beam CT images during VATS
• Lung deflation for VATS decreased CT image contrast, so nodules cannot be distinguished directly
• Image registration methods help determine the correspondence of regions between CT images
• Registering the cone-beam CT images of the inflated lung to the deflated lung helps “project” the known nodule location to the deflated lung
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Hsin-pei Hu, Master of Health Science in Clinical Engineering, 2016
Institute of Biomaterials and Biomedical Engineering, University of Toronto
Axial
Coronal
Sagittal
Axial
Coronal
Sagittal
Axial
Coronal
Sagittal
Inflated Lung Deflated Lung Registered Lung
Legend: Inflated Lung Deflated Lung Registered Lung
Example Region of
Interest (ROI) (inflated lung)
Actual location and size of ROI in deflated lung
Registered (projected) location and size of ROI in deflated lung
3D reconstruction of registration results helps localize regions of interest
Summary
• Hybrid OR with capabilities of preoperative and intraoperative real-time radiologic imaging as well as advanced endoscopic procedures will assist surgeons during Image Guided Surgery
• Advances in imaging technology will enable intraoperative localization of small peripheral nodule during minimally invasive surgery
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Acknowledgement Latner Thoracic Surgery Laboratory Yasufuku Laboratory
Tatsuya Kato
Hideki Ujiie
Kosuke Fujino
Hitoshi Igai
Spencer Hu
Salma Hindy
Judy McConnell
Alexandria Grindlay
TECHNA Institute
David Jaffray
Robert Weersink
Jonathan Irish
Harley Chan
Michael Dunne
Jimmy Qiu
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Thank you
Division of Thoracic Surgery
Toronto General Hospital
University Health Network
Kazuhiro Yasufuku, MD, PhD, FCCP