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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Medical Robotics and Computer-Integrated Therapy Delivery: Coupling Information to Action in 21’st Century Surgery
Russell H. TaylorDept. of Computer Science/Radiology/Mechanical EngineeringDirector, Center for Computer-Integrated Surgical Systems and
TechnologyThe Johns Hopkins University3400 N. Charles Street; Baltimore, Md. 21218rht@cs.jhu.edu
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Thanks to many people …
• J. Anderson• W. Bargar• A. Bzostek• B. Eldridge• G. Fichtinger• J. Funda• F. Frassica• R. Goldberg• S. Gomory• G. Hager• L. Joskowicz• Y. Kim• R. Kumar• D. Shen• C. Riviere• D. Yousem• A. Kalvin• C. Cutting• A. Morris
• J. Lazarus• D. Long• K. Masamune• K. Murphy• D. Yousem• B. Jaramaz• A. DiGioia• A. Lahmer• M. Borner• A. Bauer• A. Barnes• P. Jensen• J. Yao• B. Mittelstadt• M. Li• D. Sheng• D. Rothbaum• A. Gueziec• M. Talamini
• K. Chinzei• N. Hata• R. Kikinis• D. Stoianovici• A. Patriciu• L. Whitcomb• A. Okamura• C. Davatzikos• E. Atalar• E. Zerhouni• L. Kavoussi• P. Kazanzides• H. Paul• J. Wenz• E. DeJuan• J. Roy
… and many more
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Prediction
The impact of computer-integrated surgical systems and technology on medical care in the next 20 years will be as great as the impact of computer-integrated manufacturing systems and technology on industrial production over the past 20 years.
Engineering Research Center for Computer Integrated Surgical Systems and Technology
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Basic means for fulfilling prediction: systems that integrate information to action
• Provide new capabilities that transcend human limitations in surgery
• Increase consistency and quality of surgical treatments
• Promote better outcomesand more cost-effectiveprocesses in surgical practice
3
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Basic means for fulfilling prediction: systems that integrate information to action
• Provide new capabilities that transcend human limitations in surgery
• Increase consistency and quality of surgical treatments
• Promote better outcomesand more cost-effectiveprocesses in surgical practice
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Patient images & treatment
plans
Interface devices
Computers and networks
patient surgeon
Images & other sensor data
Command & control
Decision support &
commandsTreatment records &
outcome data
4
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
PostoperativePatient
Surgical “CAD”
Surgical “TQM”
Surgical “CAM”
5
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical
Assistants
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
NSF Engineering Research Center for Computer-Integrated Surgical
Systems and Technology
• Multi-institution, multi-disciplinary center– Johns Hopkins University + Medical Institutions– MIT + Brigham & Women’s Hospital– CMU + Shadyside Hospital
• University researchers, clinicians, industry• Research, Systems, Education, Outreach
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Medical Applications
Engineering Research
Novel algorithms& technology
Requirements/ContextValidation of research
Enabling systems, Validation & evaluation
Requirements/ContextNovel therapy ideas
Engineered CIS Systems
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Medical robotics and CIS Systems
• Surgical CAD/CAM Systems
• Surgical Assistant Systems
• Concluding remarksCopyright © CISST ERC, 2000 Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted
Execution
Update Plan
Computer -Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical CAD/CAM
7
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Surgical CAD/CAM Advantages
• Optimized planning• Accurate and
consistent execution• Safety• Verification• Information
managementCopyright © CISST ERC, 2000 Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted
Execution
Update Plan
Computer -Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical CAD/CAM
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Orthopaedic Surgical CAD/CAM Example: Joint Replacement Surgery
Photo: courtesy Brian Davies
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Urologic Surgical CAD/CAM Example: Robotic TURP
Photo: courtesy Brian Davies
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Optimized Local Therapy• Deliver optimized patterns of local
treatments (e.g., radiation seeds, injections) with an image-guided robot
• Applications
– Prostate, brain, spine, liver, bone, kidney ….
• Advantages
– Accuracy of dose– Cost and time of procedure– Lower morbidity– Avoid complications– Enable new treatments
Photo: D. Stoianovici, L. Kavoussi
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Stereotactic Neurosurgery
IGOR (Lavallee, Troccaz, et al)
Neuromate (ISS)
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Radiosurgery
Varian Clinac®
Accuray Cyberknife®
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Current ERC focus applications
Spine$120 billion cost70% in lifetime
LiverMets from colorectal130,000 new /year60,000 death /year
Prostate~210,000 new/year25% men in lifetime
~30-40% prostatectomy~20% radiation seeds
~30-40% extracapsular
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
•Follow up•Statistics•Process learning
Pre-op Screening
Image patient and plan treatment pattern
In-scanner robotically assisted treatment
Post-op imaging
Reimagevolume
MaintainMaintainTreatmentTreatment
LogLog
One endpoint: 1-stop shopping
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Key Enablers
• Imaging – Image-based modeling & analysis– Integration of image sensors with delivery
devices for guidance and monitoring– Design points set for interventions
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: integrated MRI imaging and therapy delivery
Coaxial transmission line
LCR ScannerSurface coilRF electrodes
Combined endoscopic MRI coil & RF ablator
78 µm resolution !
Canine urethra
Beagle prostate
Photo: E. Atalar, JHU
E. Atalar, JHU
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
• Labeled images* of 20 subjects for cancer and normal tissue
• Deformably registered images to average prostate (red)
• Computed spatial distribution of cancer (green)
• Computed 5 needle positions to maximize probability of detection
• Use statistical correlation of cancer spatial distributions to optimize pattern
Statistical atlas of prostate cancerChristos Davatzikos & Dinggang Shen
* Images provided by Jianchao Zeng, Georgetown U.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Key Enablers
• Imaging • Robots & delivery aids
– Modular designs – Compatible with imaging
device– End effectors
Sketch: Kirby Vosberg, Ferenc Jolesz
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Remote Center of Motion (RCM)
• 2 DOF
• Mechanically constrained motion center
• Maintains entry site
R. Taylor, D. Stoianovici, L. Whitcomb, A. Barnes
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Remote Center of Motion (RCM)
• 2 DOF
• Mechanically constrained motion center
• Maintains entry site
R. Taylor, D. Stoianovici, L. Whitcomb, A. Barnes
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Alternate RCM implementations:Parallel linkages
Goniometer arcsDavies, et al.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyEngineering Research Center for Computer Integrated Surgical Systems and Technology
Clinical example• Percutaneous access to kidney• Radiolucent needle driver• Robot aligns needle under x-ray
fluoroscopy guidance• Has been done both locally and
remotely
Photos: D. Stoianovici, L. Kavoussi
D. Stoianivici
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyPhoto: D. Stoianovici, JHU Urology Dept
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
X-ray/CT compatible robots
R. Susil, K. Masamune, R. Taylor, D. Stoianovici, G. Fichtinger
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
CT-Compatible End-Effector
R. Susil, R. Taylor, J. Anderson, D. Stoianovici
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Phantom Experiment• Standard prostate phantom• Demonstrated ~1mm accuracy
with robot from single CT image targeting
R. Susil, G. Fichtinger, K. Masamune, A.Patriciu, D. Stoianovici, E. DeWeese, R. Taylor
17
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Clinical example• Kidney biopsy• Robot registered to CT
from single image using markers on end-effector
Photos: D. Stoianovici, L. Kavoussi, A. Patriciu, S. Solomon (JHU Bayview)
Other contributors: R. Susil, G. Fichtinger, K. Masamune, R. Taylor (JHU WSE)
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Clinical example• Lung biopsy• Robot registered to CT manually
using scanner alignment laser
Credit: D. Stoianovici, L. Kavoussi , A. Patriciu, S. Solomon, JHU Bayview
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Burdette Medical
CISST ERC
Ultrasound-Guided Robotically-Assisted Prostate Brachytherapy
G. Fichtinger, D. Stoianovici, C. Burdette
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
• Throughput• Accurate and
consistent dose delivery
• Verification• Data capture• Improved
documentation
Advantages
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
• Safely performs all routine tasks– Imaging– Volume definition– Dose calculation &
visualization– Robotically-assisted
seed placement– Data logging
• Leaves clinician free to focus on therapy
Goal: An “Ideal” Brachytherapy System
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Photos: Harald Fischer FZ Karlsruhe
In-MRI Biopsy (FZK)
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Key Enablers
• Imaging • Robots & delivery aids• Integrated systems
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Integration Example: Open-MR Brachytherapy System (BWH/MEL)
• MR-compatible mechanical manipulator
• Pneumatic and ultrasound motors
• 5 DOF holder
Engineering Research Center for Computer Integrated Surgical Systems and Technology
Credit: K. Chinzei & N. Hata
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Laserpointer
Provided by Hata, Peters, Chinzei et al.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyTempanyet al .
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Visualization Workstation
Intraoperative MRI System Planning System
Robot control PC
High-B
andwidth N
etwork
MR Compatible Robot
Security monitoring host
Open MRI robot system overview
Chinzei, Hata,Bzostek, Fichtinger, et al.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Visualization Workstation
Intraoperative CT System Planning System
Robot control PC
High-B
andwidth N
etwork
Security monitoring host
Open MRI robot system overview
Chinzei, Hata, Stoianovici, Fichtinger, Susil, MasamunePatriciu, Taylor, et al.
CT Compatible Robot
CT-guided
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Visualization Workstation
Intraoperative ultrasound Planning System
Robot control PC
High-B
andwidth N
etwork
Security monitoring host
Open MRI robot system
Chinzei, Hata, Stoianovici, Fichtinger, Susil, MasamunePatriciu, Taylor, et al.
Ultrasound Robot
Ultrasound-guided
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Surgical CAD/CAM Examples
• Robot-assisted execution– Joint replacement– Percutaneous therapies
• Navigation-assisted execution– Navigation systems for
brain, spine, ENT– Evolution: Information-
enhanced minimally-invasive surgery
Copyright © CISST ERC, 2000 Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted
Execution
Update Plan
Computer -Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical CAD/CAM
24
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient-specific Model
Update Model
Computer-Assisted Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Cutting, Bookstein, Taylor, et al.
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Navigation Systems
Photo: VTI Inc.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: “Virtual Fluoroscopy”
Source: Sofamor Danek, Inc.
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Pedicle Screw Placement
Photos: Orthosoft, Inc.
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Cup Placement in THR
• Navigation system to set angle of cup component in hip replacement
• Potential to reduce dislocations
• Used clinically at Shadyside Hospital Source: Center for Orthopaedic
Research, Shadyside Hospital
27
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Cup Placement in THR
Source: Center for Orthopaedic Research, Shadyside Hospital
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: “Virtual Fluoroscopy”
• Computer tracks patient, instruments, and x-ray c-arm
• Computer overlays real-time graphics onto x-ray images
• Advantages– Reduced x-ray exposure– Easy to learn & use
• Limitations– 2D projections– Relies on accurate
tracking
Source: Sofamor Danek, Inc.
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Advanced Image Overlay
Photo: CMU and Shadyside Hospital
29
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Medical robotics and CIS Systems
• Surgical CAD/CAM Systems
• Surgical Assistant Systems
• Some concluding remarks
Copyright © CISST ERC, 2000Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient -specific Model
Update Model
Computer-Assisted
Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical
Assistants
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Surgical Assistant Examples
• Navigation-assisted execution– May be viewed as
“information assistants” for surgery
• Robotic systems– Endoscopic surgery– Microsurgery
• Evolution: a grand fusion
Copyright © CISST ERC, 2000Engineering Research Center for Computer Integrated Surgical Systems and Technology
Computer-assisted planning
Patient -specific Model
Update Model
Computer-Assisted
Execution
Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
Postoperative
Patient
Surgical
Assistants
30
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Skilled Tasks
• Situation assessment• Task strategy & decisions• Sensory-motor coordination
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Skilled Task Augmentation
• Situation assessment• Task strategy & decisions• Sensory-motor coordination
Augmentation System
• Sensor processing• Model interpretation• Display
atlases
• Manipulation enhancement
• Online references & decision support
• Cooperative control and “macros”
atlases
librariesR. Taylor
31
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Research & Technology Barriers
Augmentation System
atlases
libraries
Performance assessment• Metrics & measurements • Human baseline data• System evaluation
Robotics & cooperative control
Human-machine interfaces• Displays & visualization • Haptic input/output• Voice
Sensor processing, modeling, and anatomical atlases
Task & task element characterization
System infrastructure, integration, and end user experience
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
• Robot holds endoscope• Surgeon controls view
through various interfaces– Joystick or foot pedal– Voice recognition– Head or eye tracking
• Main current justifications– Labor cost saving– Somewhat steadier view
Example: Robotic endoscope Holders
Photo: Computer Motion, Inc
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
R. Taylor, K. Gruben, J. Funda
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
R. Taylor
33
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Robotic retraction assistant
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Ultrasound Manipulation Robots
Salcludean ultrasound system Hippocrate Robot
E.Degoulange, et al
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Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyR. Goldberg
Credit: Randy Goldberg
High Dexterity End-Effector
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
High Dexterity End-Effector for Ultrasound
Credit: Randy Goldberg
35
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Volume Scan Demonstration
Credit: Randy Goldberg
36
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Volume Scan Demonstration - Rotation
Credit: Randy Goldberg
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Volume Scan Demonstration - Fan
Credit: Randy Goldberg
37
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Volume Scan Demonstration -Translation
Credit: Randy Goldberg
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Applications/Future Development
• Image volume reconstruction
• Real time tracking & registration
• Ultrasonography skill enhancement
• “Third hand” for ultrasound-guided interventions
Photo: Randy Goldberg
38
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Robotic Assistants for Microsurgery
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Microsurgical Assistant
• Develop human augmentation systems to assist surgeons in delicate microsurgical procedures
• Applications
– Eye, ENT, Neurosurgery, Vascular
• Advantages
– Tremor, precision, force feedback– Information integration– New procedures (e.g., injections
into retinal vessels)
Photo: D Rothbaumr
39
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Limitations of microsurgerySurgical microscopes– Resolution (~ 30 mm)– Visible light
Human sensory-motor performance– Precision (~ 15 – 20 mm)– Dexterity– Force/tactile sensitivity
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Reducing limitations will
• Increase performance
• Make new surgical procedures possible
• Make surgery better, safer, faster, cheaper
40
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Current focus: mostly Eye & ENT
Eye:– Retinal vein cannulation– Retinal translocation– …
ENT:– Stapes prosthesis– Cochlear implant– …
MicrovascularNeurosurgery….
Retina with occluded retinal vein
2 mm
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example Procedure
Retinal Vein Cannulation: the insertion of a needle into the lumen (interior) of a retinal vein or artery in order to introduce theraputic drugs.
Retina with occluded retinal vein
2 mm
100 um
Cross Section of Retina
Retinal Vein
Micropipette
0.5 µm
41
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Stapedotomy drilling
• Have established surgical simulation station for evaluating stapedotomies
• Clinical problem is making very small hole in stapes (bone in middle ear) without damaging inner ear
• Quantitative outcome measures– Compare robot-assisted
versus unaided procedure
D. Rothbaum
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Cooperative force guiding of surgical robots
Photo: JHU
Photo: BGU
42
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Handle force
Kv
Steady Hand Guiding for Microsurgery
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyR. Taylor, R. Kumar, P. Jensen, L. Whitcomb, J. Roy
43
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Handle force
Tip force
Khandle
Ktip
Kv
+
-
Steady Hand Force Scaling Concept
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and TechnologyR. Kumar
44
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
High-resolution visualization sensors
1 mm 500 µm
100 µm250 µm
GRIN Lens Endoscope
Operating Microscope
Next-generation end effector
GRIN Lens
Force sensors
MovieP. Jensen
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Free hand motion Steady-hand motion
Robot as stable platform for intraoperative sensing
Movies: CISST ERC, MADLAB, JHU
R. Kumar, P. Jensen, G. Hager
45
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
positions
images
R. Kumar
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
GRIN lens endoscopy; OCT;
tissue sensors
Real time image fusion & overlay
Steady-hand robotic systems
Tissue & task characterization
and modeling
Current Practice
Surgical knowledge /
action enhancement
Information-Enhanced Microsurgery
Microsurgery Augmentation
Microsurgical Assistant
46
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Evolution: Integrate imaging and robots
• In-scanner visualization and guidance• Steady-hand robots for ultrasound & instrument manipulation• Applications include biopsies, ablations, MIS
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Evolution: Integration with imaging
• Combine robotic system with intraoperative imagers and navigation systems
• Applications include ENT, Brain, Spine, Bone, Perc.
************Misc. percutaneous
******ENT
******Spine
********Bone
*****BrainUSX-rayCTMRI
47
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Telerobotic Surgical Augmentation
• Surgeon manipulates “master” robot
• “Slave” robot mimics motions
• Typically systems have:– Force & position
scaling– Remote visualization
via video• Can be expensive but
provide improved capability for minimally invasive procedures
Photo: Intuitive Surgical
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
48
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Evolution: Augmented Teleoperation
• Situation assessment• Task strategy & decisions• Sensory-motor coordination
Augmentation System
• Sensor processing• Model interpretation• Display
atlases
• Manipulation enhancement
• Online references & decision support
• Cooperative control and “macros”
atlases
libraries
R. Taylor
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Example: Robotic Knot Tying
John Wen, et al., RPI
49
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Medical robotics and CIS Systems
• Surgical CAD/CAM Systems
• Surgical Assistant Systems
• Concluding remarks
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
• Robots are simply information-driven surgical tools
• Their real potential will come from their use within the context of computer-integrated surgical systems.
Medical robotics and CIS Systems
• There is much research to be done.
50
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
Research and technology barriers
Modeling & analysis• Segmentation• Registration• Atlases• Optimization• Visualization• Task characterization• etc.
Interface Technology• Sensing• Robotics• Human-machine
interfacesSystems• Safety & verifiability• Usability & maintainability• Performance and validation
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
How can we get there?
Strong and committed teams
– Surgeons– Engineers– Industry
Focus on systems that address important needs
Rapid iteration with measurable goals
Have fun!
51
Copyright © CISST ERC, 2000, 2001 NSF Engineering Research Center for Computer Integrated Surgical Systems and Technology
The real bottom line: patient care
• Provide new capabilities that transcend human limitations in surgery
• Increase consistency and quality of surgical treatments
• Promote better outcomesand more cost-effectiveprocesses in surgical practice
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