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Computer-Assisted Surgery Medical Robotics Medical Image Processing. LECTURE 1 What‘ s in a surgery Technical tools in CS CAS systems. PAST: Cut, then see. PRESENT: See, then cut. Preoperative Imaging. Intraoperative Execution . FUTURE: Combine, see, minimally cut. Image guidance.

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computer assisted surgery medical robotics medical image processing

Computer-Assisted Surgery Medical Robotics Medical Image Processing


What‘s in a surgery

Technical tools in CS

CAS systems

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

how do surgeries proceed
How do surgeries proceed?
  • Diagnosis
    • based on physical exams, images, lab tests
  • Preoperative planning
    • determine the surgical approach
    • elaborate intraoperative plan (path, tools, implants)
  • Surgery
    • prepare patient and assess condition
    • acquire intraoperative images, adapt and execute plan
  • Postoperative follow-up
    • exams, lab tests, images to be corroborated
treatment procedures
Treatment procedures
  • Invasive
    • neurosurgery: tumor removal
    • hear surgery: clogged arteries, transplants
    • orthopaedic surgery: spine, hip replacement, knee, fractures
    • gall bladder removal, prostate, various cancers
  • Non-invasive
    • radiation therapy
    • kidney stone pulverization
medical imaging modalities
Medical imaging modalities
  • Preoperative
    • Film X-rays, Digital X-rays, Ultrasound, Angiography, Doppler, ….
    • Computed Tomography (CT), Magnetic Resonance (MR), Nuclear Medicine (PET, SPECT, …)
  • Intraoperative
    • X-ray fluoroscopy, ultrasound
    • video images (laparoscopy, arthorscopy)
    • Open MR
medical imaging modalities x rays
Medical imaging modalities: X-rays

X-ray Fluoroscopy

Film or Digital X-ray

medical imaging modalities ct
Medical imaging modalities: CT

Series of parallel slices 2mm apart

Single slice

medical imaging modalities mri
Medical imaging modalities: MRI

Good imaging of soft tissue


Medical imaging modalities: Nuclear medicine (PET, SPECT, NMR)

Functional imaging: colors indicate electrical activity

medical imaging modalities video
Medical imaging modalities: video

TV quality image from small camera (laparoscope or endoscope)

surgical approaches
Surgical approaches
  • Open surgery
    • area of interest directly exposed by cutting
    • direct sight and touch of anatomy by surgeon
    • direct access but causes additional damage
  • Closed surgerynot always feasible
    • indirect access to anatomical area of interest
    • no direct visual sight or tactile feel
    • catheterization, biopsies
    • intraoperative imaging is often required
    • require more skills: lengthier, more difficult
  • Diagnostic surgery
minimally invasive surgery
Minimally invasive surgery
  • Provides treatment through small incisions
  • Uses imaging equipment for seeing and instruments for touching
  • Advantages: less damage, faster recovery
  • Disadvantages: hand/eye coordination, time
  • Examples:
    • brain tumor removal, laparoscopic surgery
total hip replacement procedure
Total hip replacement procedure



Fluoroscopic images

what is required to perform surgery
What is required to perform surgery?
  • Knowledge intensive task
    • anatomy, procedures, cases
    • experience, skills, customization and generalization
  • Manual and cognitive skills
    • dexterity, precision, strength, tool manipulation
    • spatial orientation and navigation
  • Determination
    • information integration
    • judgement, decision, execution
medical and surgical trends
Medical and surgical trends
  • Imaging improved dramatically diagnosis
    • started with X-rays last century
    • 30% of all cases use images
  • Move towards minimally invasive procedures
    • introduced in the mid ‘70s, slow acceptance (laparoscopy)
    • the method of choice now
  • More precise and delicate procedures
  • Development of sophisticated surgical hardware
  • High degree of craftsmanship and skills
socio economical medical trends
Socio-economical medical trends
  • Increase of aging population and associated problems: tumors, osteoporosis, Alzheimers
  • Larger population volumes
  • Universal, first rate, highly specialized care
  • Health care costs reduction (managed care)
  • Higher patient requirements
  • Legal and regulatory aspects
surgical needs
Surgical Needs

Augment the surgeon’s capabilities with better

quantitative planning, execution, and integration

  • Support for image-guided surgery
  • Passive and active devices for accurate spatial positioning, tracking, and execution
  • Modeling, planning, viewing, diagnosis systems
  • Systems integration: from diagnosis to post-op
  • Improve current practice and enable new procedures
  • Simulation and training systems

Parts of the technology already available elsewhere!

current clinical status
Current clinical status
  • Imaging
    • vast databases of medical images
    • digitized atlases
    • mostly uncorrelated unimodal qualitative interpretation
  • Devices
    • mostly passive and non-invasive (supports)
    • laparoscopic camera,
    • some real-time tracking
  • Planning, modeling, visualization
    • 3D reconstruction, some registration
part 2 computers and robots

Part 2: Computers and Robots

Technology and algorithms

available today

how can computers help or are already helping
How can computers help?(or are already helping…)
  • Image processing
    • single image: enhancement, noise reduction, segmentation, quantitative measurements
    • image stacks: 3D reconstruction, segmentation
    • image sets: registration, comparison, data fusion
  • Planning and simulation
    • integrate medical images and CAD models
    • planning and simulation programs
  • Computer vision and graphics
    • camera modeling, image registration, rendering
image processing
Image processing


2D segmentation

3D segmentation

Surface modeling

Image fusion


planning and simulation
Planning and simulation

Nail selection

Walking simulation

how can robots and sensors help or are already helping
How can robots and sensors help?(or are already helping…)
  • Robotic devices
    • passive, semi-active, active devices
    • instrument and anatomy positioning and holding
    • cutting and machining
  • Real-time tracking
    • optical, video, electromagnetic devices
    • navigation tools
robotic devices
Robotic devices




real time tracking devices
Real-time tracking devices



Passive markers

Instrument has infrared

LEDs attached to it

Active markers

computer assisted surgery cas
Computer-Assisted Surgery (CAS)

A computer-integrated system to enhance the dexterity, visual feedback, and information integration of the surgeon

  • Key points:
  • The goal is NOT to replace the surgeon
  • A new paradigm for surgical tools
  • Address a real clinical need
  • Prove efficacy and cost-effectiveness
elements of cas systems36
Elements of CAS systems
  • Preoperative planning
    • image acquisition, modeling, analysis, simulation
    • plan elaboration, tool and prosthesis selection
    • Output: preop images, 3D models, prosthesis type and position, navigation and cutting plan
  • Intraoperative execution
    • passive, semi-active, active robot
    • real time tracking
    • intraoperative imaging (fluoroscopy, ultrasound)

All integrated by computer!

state of the art 1
State of the Art (1)
  • Main clinical procedures
    • neurosurgery: biopsies, tumor removal
    • orthopaedics: hip and knee replacement, spine, pelvis and femur fractures
    • maxillofacial and cranofacial
    • laparoscopy: laparoscope holders
    • new fields: dentistry, ophtalmology, prostate
  • Mostly rigid structures: bones!!
state of the art 2
State of the Art (2)
  • Commercial navigation systems
    • main uses: neurosurgery and spine surgery
  • Commercial robotic systems
    • ROBODOC for total hip replacement
    • laparoscope arm holders
  • Research
    • very active, very interdisciplinary
    • a few dozen systems tested in-vitro
state of the art 3
State of the Art (3)
  • Major players
    • INRIA Sophia Antipolis, Grenoble, Johns Hopkins, Brigham Women’s H./MIT, Shadyside H./CMU, Imperial College, many places in Germany and Japan
  • Interdisciplinary conferences and journals
    • started in 1994: MRCAS’94; Orthopaedic CAS meetings, visualization, etc,
    • Journals: Computer-Aided Surgery, Medical Image Analysis
examples of cas systems in use
Examples of CAS systems in use
  • Image-guided navigation systems
  • ROBODOC: Total hip replacement surgery
  • LARS: Laparoscopic assistant
  • Radiosurgery

Brief overview follows; will be covered in detail later

image guide navigation
Image-guide navigation
  • Purpose
    • accurate placement of instruments with respect to imaged anatomy for several procedures
  • Problem addressed
    • provide 3D vision of unseen structures replace static 2D fluoroscopy or larger openings
    • improve precision of biopsies, screw placements
  • Scope
    • non-invasive
    • creates surface model from preop images
    • registration of images to anatomy by direct contact
  • In clinical use
  • Over 7,000 neurosurgeries performed with commercial systems
  • Gaining popularity in pedicle screw insertion
  • Decreased the misplacement rate from 10-40% to 5-18% (clinical study of 700 cases)
  • More clinical applications under development
robodoc total hip replacement
ROBODOC: Total hip replacement
  • Purpose
    • precise machining of cementless hip implant canal
  • Problem addressed
    • complications in canal preparation and implant fixation
    • improve positioning accuracy and surface finish
  • Scope
    • invasive, numerically controled machining
    • plan from preop CT, registered via pins
    • adapted commercial robot
    • custom bone fixator and bone motion detection
total hip replacement procedure47
Total hip replacement procedure



Fluoroscopic images

robodoc total hip replacement48
ROBODOC: Total Hip Replacement


e e

m c

u t

r i



Manual broaching

Robotic broaching

robodoc history
  • Developed by IBM Research and Integrated Surgical Systems
  • First active surgical robot
    • 1986: feasibility study
    • 1989: in-vitro testing of dog system
    • 1990: 26 dog cases
    • 1992: development of human system
    • 1994: first human procedure in Frankfurt
    • 1995- clinical trials in the US for FDA approval
robodoc current status
ROBODOC current status
  • Sold by Integrated Surgical Systems
  • Over 3,000 cases performed
  • 15 systems installed in Germany, 2 in Austria
  • Excellent short term clinical results (3 year study)
    • no fractures, few failures (continue manually)
  • Long-term clinical results to be determined
    • key issue: does the artificial hip last longer?
  • Problems: OR time, pin insertion
laparoscopic assistant lars
Laparoscopic assistant: LARS
  • Purpose
    • laparocopic camera holding and precise navigation
  • Problem addressed
    • cumbersome, unintuitive, and unsteady camera positioning
  • Scope
    • non-invasive intraoperative device
    • video images interpreted by surgeon
  • Benefits
    • direct camera manipulation; stability, precise targeting
lars characteristics
LARS characteristics
  • Designed at IBM Research, 1993. Similar commercial devices available (AESOP)
  • Custom redundant 7 degree-of-freedom robot
  • Holds laparoscopic camera
  • Fulcrum motions: no motion at point of entry
  • Mouse-like controls on surgical scissors
  • Position memory and replay
stereotactic radiosurgery
Stereotactic Radiosurgery
  • Purpose
    • plan and deliver precise radiation doses
  • Problem addressed
    • precise positioning and dosing of radiation to avoid healthy organ damage
  • Scope
    • non-invasive intraoperative device
    • active beam postioning and planning
    • complex preoperative planning based on MRI images
    • registers preoperative plan with stereotactic frame
stereotactic radiosurgery65
Stereotactic Radiosurgery
  • Developed at Stanford starting in 1992
  • Complex 3D radiation plans
  • Currently in clinical use
  • Frameless procedure under development follow head with markers, video, or X-rays
  • Company Accuray has performed several clinical trials with frameless procedure
developing cas systems
Developing CAS systems
  • Similarities
    • understand and address real needs of surgeons
    • consider established procedures, context, use
    • work on problems that will make qualitative difference
    • constant feedback from user; test ideas and prototypes
  • Differences
    • system performace requirements
developing cas systems67
Developing CAS systems
  • understand and address real needs of surgeons
  • consider established procedures, context, use
  • constant feedback from user; test ideas and prototypes
  • system requirements
    • safety and reliability
    • fail-safe systems: can always stop and proceed as usual
    • system integration
cas systems design cycle
CAS systems design cycle
  • Prototype development
  • In-vitro experiments
    • system refinement
  • Cadaver studies
    • system refinement
  • In-vivo experiments
    • first animal and human trials
  • Clinical trials
    • double blind studies, Hospital and FDA protocols
  • Agency approval and commercial release
  • Great potential for robots and computers inside and outside the operating room
  • Great research and commercial interest, especially in the past 3 years
  • Just the beginning of the road: many things remain to be invented
  • Great role for applied computer science:
    • image processing, geometric planning, registration, graphics, vision, real-time systems, robotics, etc.