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Image-Guided Interventions and Tracking Technology Kevin Cleary, PhD Technical Director Bioengineering Initiative Sheikh Zayed Institute for Pediatric.

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Presentation on theme: "Image-Guided Interventions and Tracking Technology Kevin Cleary, PhD Technical Director Bioengineering Initiative Sheikh Zayed Institute for Pediatric."— Presentation transcript:

1 Image-Guided Interventions and Tracking Technology Kevin Cleary, PhD Technical Director Bioengineering Initiative Sheikh Zayed Institute for Pediatric Surgical Innovation Children’s National Medical Center Washington, DC, USA Robotics Summer School 2012

2 CAIMRGeorgetown UniversitySlide 2 Outline Definition History Workflow / components Some applications Abdominal interventions Some major research centers Future trends

3 What is an image-guided intervention? The use of medical imaging and computer assistance to assist in or enable a minimally invasive procedure Image-guided lung biopsy using electromagnetic tracking: courtesy of Filip Banovac, MD

4 History of IGT Stereotactic frame concept dates from beginning of the 20 th century (Horsley and Clarke 1908) First computer-based systems appeared about 20 years ago for neurosurgical applications –Incorporated mechanical arms as localizers –ENT and spine were also early adopters –Advances in computers and tomographic imaging were enablers Mechanical localizers were replaced by optical tracking systems in the early 1990s which became the gold standard –Other applications included tracked ultrasound and laparoscopic augmentation Optical tracking was supplemented by robust electromagnetic tracking in the past five years –Enabled abdominal interventions What does the future hold? –Integration with flexible endoscopy for endoluminal interventions and robotic surgery including NOTES

5 Stereotactic Frame First reported in Brain (31:45-124, 1908) Article entitled "The Structure and functions of the Cerebellum Examined by a New Method” Source: museum/stereotactichall/92exhibit. html Horsley-Clarke Stereotactic Device

6 Mechanical Localizer (circa 1990) CAIMRGeorgetown UniversitySlide 6 Courtesy of Robert Galloway, PhD, Vanderbilt University, Technology Guided Therapy Program

7 Optical Tracking Bucholz and Smith in St. Louis Intraoperative localization using a three-dimensional optical digitizer SPIE Medical Imaging 1993 The system –an infrared optical digitizer to indicate position on CT, MRI, or PET –a ring attached to the patient's head, hand held instruments of any type, a camera array, and a computer display. –position of the surgical instrument relative to the patient's head is computed by a personal computer. –a graphics workstation provides three dimensional display of position. © Richard D. Bucholz, St. Louis University (1999)

8 Stealthstation circa 2000 Three major components –Computer for control and display –Localizer for tracking instruments –Software for image processing Courtesy of Medtronic Surgical Navigation Technologies

9 ENT: Viewing Wand (ISG) Computer-Assisted Surgery in the Frontal and Maxillary Sinus Gunkel. Freysinger, Thumfart, Innsbruck, 1997 Published in The Laryngoscope CAIMRGeorgetown UniversitySlide 9

10 Spinal Pedicle Screw Placement Pioneered by Merloz in France and others –Clin Orthop Relat Res Common application for image guidance CAIMRGeorgetown UniversitySlide 10 Park P, Foley KT, Cowan JA, Marca FL. Minimally invasive pedicle screw fixation utilizing O-arm fluoroscopy with computer-assisted navigation: Feasibility, technique, and preliminary results. Surg Neurol Int 2010;1:44

11 Computer Assisted Orthopaedic Surgery One of the first fields to adopt these techniques CAOS-International was founded in 2000 in Davos, Switzerland by Nolte et al. Has held annual meetings every year CAIMRGeorgetown UniversitySlide 11 Medtronic Navigation Technologies

12 Workflow / Components of an IGT Procedure CAIMRGeorgetown UniversitySlide 12

13 Steps in an IGT procedure Obtain tomographic imagesLocalize surgical toolRegister images to toolDisplay tool relative to images Courtesy of Galloway and Peters, Chapter 1, Image-Guided Interventions book

14 Components of an IGT system Images Trackers (localizers) Registration Visualization Software

15 Images Tomographic images provide a 3D data set for navigation CT is the gold standard –Spiral CT –Cone beam CT (rotational fluoroscopy) Siemens Zeego cone-beam CT

16 CAIMR LabGeorgetown UniversitySlide 16 Trackers (Localizers) Locate objects in space –3 degrees of freedom for position –3 degrees of freedom for orientation –6 degrees of freedom for a rigid body –Modern localizers can track multiple objects Localizer types –Mechanical (early systems) –Optical (standard of care) –Electromagnetic (rapidly improving)

17 Optical Trackers Principle of Triangulation Localizer slides courtesy of Robert Galloway, Vanderbilt University

18 CAIMR LabGeorgetown UniversitySlide 18 Optotrak 3020 – Northern Digital Inc

19 CAIMR LabGeorgetown UniversitySlide 19 Multiface Tool

20 CAIMR LabGeorgetown UniversitySlide 20 Polaris Optical Localizer Passive and Active Tools

21 AURORA Electromagnetic Tracking Vendor: Northern Digital Inc. (Waterloo, Canada) 1. Field generator provides low strength magnetic field 2. The position sensor: induction coil: diameter 0.9 mm

22 Registration Rigid body registration is standard in practice –Paired point methods dominate –Iterative closest point (ICP) methods are also used (cloud of points) CAIMRGeorgetown UniversitySlide 22 Fiducials for registration purposes Courtesy of Ziv Yaniv, PhD, Georgetown University

23 Deformable Registration Modeling and Registration in Deforming and Moving Tissues During an Intervention Doesn’t Work (not yet at least!) The Future of Interventions is Imaging Systems must be validated and validation is very hard using non-rigid registration technologies Statistical Motion Models (SMMs): Application to focal therapy in the prostate, Yipeng Hu, Dean Barratt, Mark Emberton et al. Ultrasound derived model to intra-operative ultrasound (MICCAI 2008) Slide courtesy of Dave Hawkes, PhD, University College London

24 CAIMR LabGeorgetown UniversitySlide 24 Visualization Four-quadrant view is standard in commercial image- guided systems –Axial –Saggital –Coronal –3D view Courtesy of Medtronic Surgical Navigation Technologies

25 Open Source Software Open source revolution has come to image- guided therapy 3D Slicer from BWH MITK from Heidelberg CISST from Johns Hopkins IGSTK from our group CAIMRGeorgetown UniversitySlide 25 3D Slicer User Interface ns/item/view/1835

26 CAIMRGeorgetown UniversitySlide 26 Image Guided Surgical Toolkit (IGSTK) Open Source Software Package Basic components for an image-guided system –Tracker –Registration –Visualization Initial release at SPIE Medical Imaging 2006 Can be used in commercial products List of users can be seen at

27 IGSTK Architecture CAIMRGeorgetown UniversitySlide 27

28 IGSTK: The Book

29 Image-Guided Laparoscopic Surgery CAIMR Georgetown University Slide 29

30 Georgetown UniversitySlide 30 Laparoscopic-assisted live donor liver resection as performed by Dr. Lynt Johnson at Georgetown University Hospital

31 Camera, phantom, trackers CAIMRGeorgetown UniversitySlide 31

32 CAIMRGeorgetown UniversitySlide 32

33 Virtual reality augmented laparoscopic surgery CAIMRGeorgetown UniversitySlide 33

34 Another laparoscopic example Three displays are provided: the standard laparoscopic view (left), laparoscopic ultrasound (center), and real-time rendering of the ultrasound probe relative to a pre-procedure CT angiogram. The top row shows three still images when the celiac axis is being imaged. The bottom row shows the superior mesenteric artery being imaged. Figure courtesy of James Ellsmere, MD, and Kirby Vosburgh, PhD, Massachusetts General Hospital.

35 Thoraco-abdominal interventions (enabled by improvements in electromagnetic tracking) CAIMR Georgetown University Slide 35

36 Thoraco-abdominal image-guided clinical trials Organ/ Method ProcedureTracking System ModalityReference LungBronchoscopic Biopsy BiosenseCT Solomon 1998 LiverBiopsyUltraguideUltrasoundHoward 2001 KidneyBiopsyUltraguideUltrasoundWallace 2006 LaparoscopyTumor resection Aurora, Ascension CT / Ultrasound Lango / Vosburgh Courtesy Filip Banovac, MD, Chapter 13, Image-Guided Interventions book

37 First Clinical Case of Electromagnetically Tracked Lung Biopsy at Georgetown University CAIMRGeorgetown UniversitySlide 37

38 Registration CAIMRGeorgetown UniversitySlide 38

39 Marking the Target in the Lesion CAIMRGeorgetown UniversitySlide 39

40 Path Planning: Cannot Cross Rib Slide 40

41 Off-axial View Shows Clear Path Slide 41

42 Navigation View CAIMRGeorgetown UniversitySlide 42

43 Some Major Research Groups (apologies if I left yours out )

44 Centre for Medical Image Computing University College, London Professor David Hawkes Rijkhorst et al. Simulating Dynamic Ultrasound using MR-derived Motion Models to assess Respiratory Synchronisation for Image-Guided Liver Interventions. (To appear in the proceeding of IPCAI 2010 – images below from gisteredLiver.gif)

45 Computer Aided Medical Procedures & Augmented Reality Technical University of Munich Nassir Navab, PhD Focuses on tracking, intraoperative imaging, and various user interface technologies to represent the information in a sophisticated way. –A common software infrastucture was developed to have the flexibility of addressing various hardware components (tracking systems, C- arm, ultrasound and on the other side ensuring the robustness and security of medical applications. –The group is active in labs at Klinikum rechts der Isar and Klinikum Innenstadt. Augmented reality enabled vertebroplasty hIssueCompAidedSurgery

46 Laboratory for Percutaneous Surgery (The Perk Lab) Queen’s University, Canada Gabor Fichtinger, PhD A large family of medical interventions involves the placement of some linear surgical instruments. –Typical examples include needle based aspirations, injections, local ablation therapies, brachytherapy, but “virtual needles” like high energy X-ray and laser beams are also commonly applied. –The majority of these interventions today are performed percutaneously (i.e., across the skin). –Typical guidance methods are computed tomography, ultrasound, magnetic resonance imaging, and fluoroscopy. Augmented reality liver biopsy

47 National Center for Image Guided Therapy (NCIGT) NIH funded Biomedical Technology Resource Center. A national resource for all research into medical procedures enhanced by imaging Brigham and Women's Hospital in Boston, Massachusetts Led by Ferenc A. Jolesz M.D. and Clare Tempany M.D. Advanced Multimodality Image Guided Operating (AMIGO) Suite

48 National Centre of 3D Ultrasound in Neurosurgery Geirmund Unsgård, MD Trondheim, Norway St Olav’s Hospital Pioneers in image- guided ultrasound Spin-off company Sonowand SonoWand® 1.4 System with Tracked Ultrasound and Image Overlay

49 There are Several Journals Covering the Field CAIMRGeorgetown UniversitySlide 49

50 Summary and Future Directions IGT as a field is about 20 years old Has been applied to a wide variety of clinical applications, starting with the brain and moving to abdominal interventions The basics of image-guided navigation have been well-established Overall market penetration is still modest There is room for improvement in existing applications and new clinical applications CAIMRGeorgetown UniversitySlide 50

51 Future Directions: Slide 1 Medical push towards more minimally invasive procedures will continue Component technologies of image-guided therapy systems will continue to improve –Intraoperative imaging will become more common –Deformable registration will become clinically useful –Tracking systems, especially electromagnetic tracking, will become smaller and more precise

52 Future Directions: Slide 2 This will create unique opportunities to apply these technology improvements to better clinical care Only through a partnership of scientists and clinicians can this be enabled Need to build prototypes and get in clinical use as soon as possible (rapid prototyping) You are on the right track – conferences such as this are part of the success story

53 Future Directions Slide 3 Validation will continue to be an important but elusive topic Randomized clinical trials are difficult in this field Evidence-based trials should continue to be pursued where feasible But let us not stifle innovation – someone has to invent the future!

54 Some Areas for Future Work Integration of tracking with robotic systems such as the da Vinci to enable image guidance for robotic laparoscopic surgery Robotic NOTES (natural orifice transluminal endoscopic surgery), where robotic modules are inserted through the stomach and self-assembled in the abdomen Endoluminal interventions, using flexible or capsule endoscopy, to provide situational awareness (a macroscopic view of the anatomy) CAIMRGeorgetown UniversitySlide 54

55 Acknowledgements Technical team –Ziv Yaniv, Emmanuel Wilson, Patrick Cheng, Jae Choi, Ken Wong, among others Clinical partners –Filip Banovac, Brad Wood, Vance Watson, Elliot Levy, Eric Anderson, Karun Sharma, among others For more information join us at MICCAI 2010 –Image-guided interventions tutorial 20 September in Beijing

56 Book now on Amazon and other vendors CAIMRSlide 56

57 Thank you for your attention CAIMRGeorgetown UniversitySlide 57

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