image-guided interventions and tracking technology kevin cleary, phd technical director...

Image-Guided Interventions and Tracking Technology

Kevin Cleary, PhD

Technical DirectorBioengineering Initiative

Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National Medical Center

Washington, DC, USA

Robotics Summer School 2012

CAIMR Georgetown UniversitySlide 2

Outline

• Definition• History• Workflow / components• Some applications• Abdominal interventions• Some major research centers• Future trends

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

History of IGT• Stereotactic frame concept dates from beginning of the 20th

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

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: http://www.neurosurgery.org/cybermuseum/stereotactichall/92exhibit.html Horsley-Clarke

Stereotactic Device

Mechanical Localizer (circa 1990)

Courtesy of Robert Galloway, PhD, Vanderbilt University, Technology Guided Therapy Program

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.

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

ENT: Viewing Wand (ISG)

• Computer-Assisted Surgery in the Frontal and Maxillary Sinus

• Gunkel. Freysinger, Thumfart, Innsbruck, 1997

• Published in The Laryngoscope

Spinal Pedicle Screw Placement

• Pioneered by Merloz in France and others– Clin Orthop Relat

Res. 1998• Common

application for image guidance

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

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

Medtronic Navigation Technologies

Workflow / Componentsof an IGT Procedure

Steps in an IGT procedure

Obtain tomographic images

Localize surgical tool

Register images to tool

Display tool relative to images

Courtesy of Galloway and Peters, Chapter 1, Image-Guided Interventions book

Components of an IGT system

• Images• Trackers (localizers)• Registration• Visualization• Software

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

CAIMR Lab Georgetown 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)

Optical TrackersPrinciple of Triangulation

Localizer slides courtesy of Robert Galloway, Vanderbilt University

Optotrak 3020 – Northern Digital Inc

Multiface Tool

Polaris Optical LocalizerPassive and Active Tools

AURORA Electromagnetic TrackingVendor: Northern Digital Inc. (Waterloo, Canada)

1. Field generator provides low strength magnetic field2. The position sensor: induction coil: diameter 0.9 mm

Registration

• Rigid body registration is standard in practice– Paired point

methods dominate– Iterative closest

point (ICP) methods are also used (cloud of points)

Fiducials for registration purposesCourtesy of Ziv Yaniv, PhD,

Georgetown University

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

Visualization

• Four-quadrant view is standard in commercial image-guided systems– Axial– Saggital– Coronal– 3D view

Courtesy of Medtronic Surgical Navigation

Technologies

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

3D Slicer User Interfacehttp://www.slicer.org/

publications/item/view/1835

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 igstk.org

IGSTK Architecture

IGSTK: The Book

Image-Guided Laparoscopic Surgery

Georgetown UniversitySlide 30

Laparoscopic-assisted live donor liver resection as performed by Dr.

Lynt Johnson at Georgetown University Hospital

Camera, phantom, trackers

Virtual reality augmented laparoscopic surgery

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.

Thoraco-abdominal interventions

(enabled by improvements in electromagnetic tracking)

Thoraco-abdominal image-guided clinical trials

Organ/Method

Procedure Tracking System

Modality Reference

Lung BronchoscopicBiopsy

Biosense CT Solomon1998

Liver Biopsy Ultraguide Ultrasound Howard 2001

Kidney Biopsy Ultraguide Ultrasound Wallace 2006

Laparoscopy Tumor resection

Aurora, Ascension

CT / Ultrasound

Lango / Vosburgh

Courtesy Filip Banovac, MD, Chapter 13, Image-Guided Interventions book

First Clinical Case of Electromagnetically Tracked Lung Biopsy at Georgetown University

Registration

Marking the Target in the Lesion

Path Planning: Cannot Cross Rib

Off-axial View Shows Clear Path

Navigation View

Some MajorResearch Groups

(apologies if I left yours out )

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 http://cmic.cs.ucl.ac.uk/fileadmin/cmic/research/prostate/Fig_2_DynamicRegisteredLiver.gif)

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

http://campar.in.tum.de/Chair/ResearchIssueCompAidedSurgery

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 biopsyhttp://perk.cs.queensu.ca/

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

http://www.ncigt.org/pages/AMIGO

National Centre of 3D Ultrasound in Neurosurgery

• Geirmund Unsgård, MD• Trondheim, Norway• St Olav’s Hospital• Pioneers in image-

guided ultrasound• Spin-off company

SonowandSonoWand® 1.4 System with Tracked

Ultrasound and Image Overlay

There are Several Journals Covering the Field

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

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

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

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!

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)

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

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CAIMR Slide 56

Thank you for your attention

image-guided interventions and tracking technology kevin cleary, phd technical director...

md slide

vanderbilt university

multiface tool slide

active tools slide

therapy program slide

optical tracking systems

optical tracking bucholz

computer display

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