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The AMIGO Project: An Advanced Multi-Modality Image-Guided Operating Suite

Randy Ellis, Ph.D. The AMIGO Project: An Advanced Multi-Modality Image-Guided Operating Suite. AMIGO: Phase II Layout. AMIGO: Central Operating Room. AMIGO: Phase I View to 3T MRI. AMIGO: Phase II View to PET/CT. AMIGO Applications, Phase I (2005-2006). BRAIN: FUS (MRI, fMRI, DTI, T-MRI)

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The AMIGO Project: An Advanced Multi-Modality Image-Guided Operating Suite

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  1. Randy Ellis, Ph.D. The AMIGO Project: An Advanced Multi-ModalityImage-Guided Operating Suite

  2. AMIGO: Phase II Layout

  3. AMIGO: Central Operating Room

  4. AMIGO: Phase I View to 3T MRI

  5. AMIGO: Phase II View to PET/CT

  6. AMIGO Applications, Phase I (2005-2006) BRAIN: FUS (MRI, fMRI, DTI, T-MRI) BRAIN: Open Surgery(MRI, fMRI, DTI, US) BREAST: MRI-Guided Lumpectomy (MRI,3D-US,4D MRI of contrast uptake) BRAIN: Skull Base Surgery(MRI, fMRI, DTI, CT, US, Endoscope)

  7. AMIGO Applications, Phase II (2006-2007) BREAST CANCER: FUS LIVER THERMAL ABLATION KIDNEY THERMAL ABLATION CERVICAL CANCER BRACHYTHERAPY BONE METASTATSIS THERMAL ABLATION BONE TUMOR FUS VERTEBROPLASTY PROSTATE BIOPSY PROSTATE BRACHYTHERAPY PROSTATE FUS

  8. AMIGO Applications, Phase II (2007-2008) SPINE SURGERY NEUROVASCULAR INTERVENTIONS CRANIOFACIAL SURGERY LIVER ENDSOCOPIC SURGERY KIDNEY FUS LUNG THERMAL ABLATION LUNG BRONCHOSCOPY JOINT ENDOSCOPIC SURGERY CARDIAC EP ABLATION AVM EMBOLIZATION, AVM FUS

  9. Image Intensive Environment • Preoperative images: • diagnostic & planning • Intraoperative images: • Updating anatomical changes • Functional monitoring • Postoperative images: • Verification

  10. Imaging Modalities Unite modalities in a patient coordinate frame: • MR for soft tissues • PET for metabolic imaging • CT for bone surfaces • Fluoroscopy for updates • 3D ultrasound for soft tissues • Microscopes/endoscopes for sight • 1D signals (EEG, ECG, etc.)

  11. Integrated Imaging and Intervention +Image/patient registration problem disappears + Real-time monitoring of procedures - Visualization challenges + Multi-system assessment and treatment

  12. Interoperability is Key - Information management • Maintain registration across rooms • Multiple software systems • GE/NAV for established procedures • 3D Slicer, etc. for novel applications • Multiple localization technologies • Primarily EM & optical • Robot also localizes

  13. Randy Ellis, Ph.D. The AMIGO Navigator: An Overview of the Software Development Process

  14. Software is Expensive and Complex An extensive 1994 study of thousands of US industrial projects found: • 31% were abandoned before delivery • Over 57% were a minimum of 189% over budget Since then: overall, limited progress Source: The Standish Group

  15. Our Guiding Principles • Open Source: • Collaborative process • Free to commercialization • Robust: • Use NAMIC/Kitware infrastructure • Automated testing of all changes • Extensible: • Gain from ongoing Slicer activities • Expect to add new imaging modalities • Expect new interventional procedures

  16. Breast Surgery app. Neurosurgery app. Application-Oriented Architecture MRI Biopsy app. Base (common) software

  17. Storyboards for Applications Engineer and clinicians work together: • Define the basic approach to the interventional procedure • Prototype screen appearances (paper cartoons or PowerPoint are useful) • Specify screen-to-screen actions • Implement “happy-day” scenario • Elaborate alternative workflows (e.g., error handling, new image acquisitions) Result: fast development of well tested software

  18. Technical Overview • Requirements drive the process • Application-specific: • Rapid specification of ideal workflow • Catch design problems early • Elaborate necessary extensions only, not all possible variants • Test-oriented: • The specification produces tests before code is written • Repeat all tests whenever changes are made Result: robust, trustable systems

  19. Example Application: CT-Guided Brain Tumor Biopsy

  20. Clinical Problem: Biopsy in CT Scanner Idea: • Perform brain biopsy using 2D slices Technique: • Attach fiducials to head holder • Scan holder and patient • Select slices showing structures at risk • Superimpose needle trajectory on slices • Verify biopsy with new CT acquisition(s)

  21. CT Biopsy Phase 1: Procedure Workflow • Prepare patient (including fiducials) • Transfer patient to CT scanner • Acquire the CT scan (?inject?, image) • Load scan into Navigator • Software calculates registration • Software displays needle trajectory in CT • Perform the biopsy • Close the patient

  22. CT Biopsy Phase 2: Software Actions • Load instrument descriptions • Load CT scan • Detect fiducials • Calculate registration • Select key CT slices • Track the needle guide • Overlay needle trajectory on slices

  23. CT Biopsy Phase 3: Procedure Steps • Screen to select scan from disk • Screen to give registration progress • Screen to select CT slices • Screen to display navigation Additional Requirements: • Forward/backward buttons • Exit button • Tool status display (e.g., visibility)

  24. LOAD SELECT NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE CT Biopsy Storyboard: File Selection All we need here is a simple dialog box

  25. LOAD SELECT NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE CT Biopsy Storyboard : Registration Need a progress bar during registration, then report RMS error after registration

  26. LOAD SELECT NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE CT Biopsy Storyboard: Selection Idea #1 SELECT SLICE 1/2/3/4 Show original slices in here  Scroll bar 

  27. LOAD SELECT NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE CT Biopsy Storyboard: Selection Idea #2 Show original slices in here Drag/Drop into here  Scroll bar 

  28. LOAD SELECT NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE CT Biopsy Storyboard: 2D Navigation Show the needle trajectory on top of each slice Slice #1 Slice #2 Slice #3 Slice #4

  29. CT Biopsy Phase 5: Implement and Test • Create scans with/without fiducials (to test registration algorithms) • Build phantoms to measure navigation accuracy • Power cycle computer to test system robustness • Unplug/plug tracking system, etc.

  30. CT Biopsy Phase 6: Next Iteration Next round, we may need to: • Calibrate the biopsy needle intraoperatively • Navigate the biopsy needle • Use needle-oriented reslicing • Migrate system to use MRI scans (new application: software re-use) • Control MRI scanner for in-scanner biopsy (new application: software re-use)

  31. Example Application: Ventriculoscopy for Brain Tumor Biopsy

  32. Clinical Problem: Deep Brain Biopsy Idea: • Use flexible scope to biopsy from within a brain ventricle Technique: • Same setup as for CT biopsy navigation • Show 3D location of scope inside volumetric image • Needs calibration of optical image to tracking device

  33. Deep-Biopsy Phase 1: Procedure Workflow • Prepare patient (including fiducials) • Transfer patient to CT or MRI scanner • Acquire the 3D scan (inject & image) • Load scan into Navigator • Software calculates registration • Calibrate ventriculoscope • Software displays scope in volumetric scan • Perform the biopsy • Close the patient

  34. Deep-Biopsy Phase 2: Software Actions • Load instrument descriptions • Load volumetric (MRI/PET/CET) scan • Detect fiducials • Calculate registration • Calibrate ventriculoscope to tracker device • Confirm calibration using a sharp probe • Track the ventriculoscope • Show scope in volumetric (MRI/PET/CET) scan

  35. Deep-Biopsy Phase 3: Procedure Steps • Screen to select scan from disk • Screen to give registration progess • Screen to calibrate ventriculoscope • Screen to verify calibration • Screen to display navigation Additional Requirements: • Forward/backward/exit buttons • “Tabs” to other tasks  label “forward”

  36. LOAD CALIBRATE VERIFY NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE Deep-Biopsy Storyboard: File Selection All we need here is a simple dialog box ACCEPT

  37. LOAD CALIBRATE VERIFY NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE Deep-Biopsy Storyboard: Registration Need a progress bar during registration, then report RMS error after registration ACCEPT

  38. LOAD CALIBRATE VERIFY NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE Deep-Biopsy Storyboard: Calibrate Vscope Show live video feed in here CALIBRATE

  39. LOAD CALIBRATE VERIFY NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE Deep-Biopsy Storyboard: Verification 3D probe model on top of live video feed here ACCEPT

  40. LOAD CALIBRATE VERIFY NAVIGATE REGISTER Tool Status Display EXIT LOGO GOES HERE Deep-Biopsy Storyboard: 3D Navigation Live video feed from scope Forward rendering from scope Scope field-of-view cone inside volume

  41. Deep-Biopsy Phase 5: Implement and Test • Create scans with/without fiducials (to test registration algorithms) • Calibrate optics to tracker device • Verify calibration with sharp probe • Build phantoms to measure navigation accuracy • Power cycle computer to test system robustness • Unplug/plug tracking system, etc.

  42. Deep-Biopsy Phase 6: Next Iteration Next round, we may need to: • Calibrate the biopsy needle • Navigate the biopsy needle • Use needle-oriented reslicing • Acquire/integrate intraoperative MRI (new application: software re-use) • Migrate to laparoscopic ultrasound (new application: software re-use)

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