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Computer-Aided Surgery The emergence of medical CAD/CAM. Dr. Leo Joskowicz School of Computer Science and Engineering The Hebrew University of Jerusalem. Invited lecture, Tel-Aviv University, 23.3.2000. PAST: Cut, then see. PRESENT: See, then cut. Preoperative Imaging.

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computer aided surgery the emergence of medical cad cam

Computer-AidedSurgeryThe emergence of medical CAD/CAM

Dr. LeoJoskowicz

School of Computer Science and Engineering

The Hebrew University of Jerusalem

Invited lecture, Tel-Aviv University, 23.3.2000

present see then cut
PRESENT: See, then cut

Preoperative Imaging

Intraoperative Execution

future combine see minimally cut
FUTURE: Combine, see, minimally cut

Image guidance

Augmented reality

computer aided surgery cas
Computer Aided Surgery (CAS)

Computer-based systems to enhance the surgeon’s dexterity, visual feedback, and information integration

  • Trend towards minimally invasive surgery:
    • laparoscopy, endoscopy, minimal incisions
  • Computer plays a key role in:
    • 3D visualization, model construction
    • quantitative integration of information
    • preoperative planning and intraoperative execution
  • Medical CAD/CAM -- a paradigm shift!
current practice
Current practice




Doppler US

computer based technologies

3D Visualization

Preoperative Planning

Intraoperative Navigation


Computer-based technologies
talk outline
Talk outline
  • Elements of CAS systems
  • Three examples of CAS systems:

1. Navigation: FRACAS

2. Robotics: ROBODOC

3. Virtual colonoscopy and endoscopy

  • Conclusion, state of the art, and perspectives
medical cad cam a new paradigm r h taylor
Medical CAD/CAM: a new paradigm (R.H. Taylor)
  • CAD/CAM has revolutionized the way consumer goods are designed and produced.
  • The key: 3D visualization, simulation, design tools, precise CNC and robotic execution, and most importantly INTEGRATION
  • By analogy, apply paradigm to medicine: design is preoperative planning, production is intraoperative execution, postoperative evaluation is quality assurance
medical cad cam
Medical CAD/CAM
  • Differences: individualized data, custom planning and execution, safety
  • Medical CAD/CAM will change the ways in which are some conditions are diagnosed and treated
  • New computer-based technologies are more that “just another, fancier tool” because they provide unprecedented integration and potentially higher accuracy and repeatability
cas systems clinical specialties
CAS systems: clinical specialties
  • Neurosurgery:biopsies, tumor removal, epilepsy.
  • Orthopaedics:total hip and knee replacement trauma.
  • Laparoscopy and endoscopy: camera holders, simulators.
  • Craniofacial and maxillofacial surgery:fragment and cut planning, precise positioning
  • Emerging: radiology, dentristry, ophtalmology.
fracas cas for femur fracture reduction

FRACAS: CAS for femur fracture reduction

Joint project HUJI and Hadassah Hospital since 1996

Illustrates real-time navigation and integration in orthopaedics

fracas project goals
FRACAS: project goals
  • Substantial reduction of surgeon’s cumulative exposure to radiation
  • Reduction of alignement and positioning errors
  • Improve chances of completing the reduction closed
  • Improve the surgeon’s hand/eye coordination
  • Reduce overall intraoperative time and fatigue
  • Improved preoperative planning in both fracture assessment and nail selection
FRACAS conceptFollow the bone fragment positions with 3D models on a computer screen instead of fluoroscopy


  • 3D bone fragment models from preop CT
  • Real-time bone fragment tracking
  • Registration with fluoroscopic images
fracas system concept

During surgery

CT images


bone fragment


optical tracker




nail selection


FRACAS system concept

Before surgery

fracas current status
FRACAS current status
  • Prototype system integrated with tracker
  • Fluoroscopic image processing completed: in-vitro tests show submilimetric accuracy
  • 2D/3D registration experiments in progress
  • In-vitro experimentation with bone holder
  • Key ideas: entire procedure support, fluoroscopy-based registration
robodoc thr
  • Developed by Integrated Surgical Systems, IBM Research, Johns Hopkins (1986, 1994, 1997)
  • Precise implant positioning planning and machining of cementless hip implant canal
  • Reduces complications in canal preparation and implant fixation
  • Improves positioning and surface finish
  • Preoperative planning
  • Robotic intraoperative execution
total hip replacement procedure
Total hip replacement procedure



Fluoroscopic images

robodoc total hip replacement
ROBODOC: Total Hip Replacement


e e

m c

u t

r i



Manual broaching

Robotic broaching

robodoc thr current status
ROBODOC THR: current status
  • Over 4,000 surgeries in 20 centers since 1994
  • Very satisfactory short and mid-term results
  • Recent work on Revision THR
    • Interactive cement cut volume definition
    • Pin-based registration, work on fluoroscopic registration

video camera view


anatomic structrure

virtual endoscopy
Virtual endoscopy
  • Purposes:
    • training simulator for surgeons
    • diagnosis of polypes and other tumors without actually inserting a video camera
  • Method: build a “fly-though” of the anatomy from CT and MRI data so that the surgeon can examine the anatomy or move the camera
  • Projects: Stony Brook, USA, Karlhuse, Germany
virtual endoscopy principle













Virtual Endoscopy: principle
cas state of the art
CAS: state of the art
  • Neuronavigation: routine clinical use in a few dozen hospitals (including Israel)
  • Orthopaedics: about 7,000 pedicle screws, 4,000 robotic total hip replacements, a few hundred trauma cases
  • Laparoscopy, endoscopy: commercial arm
  • In Israel:IZMEL consortium on image-guided therapy
cas summary
CAS -- Summary
  • Medical CAD/CAM -- a new paradigm
  • Interdisciplinary:close cooperation in all stages of design and deployment!
  • Long term: long R&D cycle
  • Active and rapidly growing field; only the tip of the iceberg has been explored.
  • Extensive clinical studies are starting
  • Many challenging applied research problems
  • Commercial opportunities: established and start-up companies
grand challenges
Grand challenges
  • More percutaneous procedures
  • Soft tissue procedures: grafts, ligament releases, tendon transfer
  • Computational challenges:
    • deformable tissue shape and behavior modeling
    • image-based tracking (fluoroscopy, ultrasound)
    • accurate deformable registration
    • realistic surgical simulators
    • systems integration

ISRACAS’2000May 18, TechnionThird Israeli Symposium on Computer-Aided Surgery, Medical Robotics, and Medical Imaging

  • G. Barnett, USACAS Neurosurgery
  • J. Bowersocks, USA Telesurgery
  • P. Dario, Italy Medical Robotics
  • F. Jolesz, USA OR of the future
  • P. Merloz, France CAS Spine Surgery
  • 15 refereed papers + industrial exhibit session