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Computer-Aided Surgery The emergence of medical CAD/CAM

Computer-Aided Surgery The emergence of medical CAD/CAM. Dr. Leo Joskowicz School of Computer Science and Engineering The Hebrew University of Jerusalem. Invited lecture, Tel-Aviv University, 23.3.2000. PAST: Cut, then see. PRESENT: See, then cut. Preoperative Imaging.

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Computer-Aided Surgery The emergence of medical CAD/CAM

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  1. Computer-AidedSurgeryThe emergence of medical CAD/CAM Dr. LeoJoskowicz School of Computer Science and Engineering The Hebrew University of Jerusalem Invited lecture, Tel-Aviv University, 23.3.2000

  2. PAST: Cut, then see

  3. PRESENT: See, then cut Preoperative Imaging Intraoperative Execution

  4. FUTURE: Combine, see, minimally cut Image guidance Augmented reality

  5. Computer Aided Surgery (CAS) Computer-based systems to enhance the surgeon’s dexterity, visual feedback, and information integration • Trend towards minimally invasive surgery: • laparoscopy, endoscopy, minimal incisions • Computer plays a key role in: • 3D visualization, model construction • quantitative integration of information • preoperative planning and intraoperative execution • Medical CAD/CAM -- a paradigm shift!

  6. Current practice CT MRI + NMR X-rays Doppler US

  7. 3D Visualization Preoperative Planning Intraoperative Navigation Robotics Computer-based technologies

  8. Talk outline • Elements of CAS systems • Three examples of CAS systems: 1. Navigation: FRACAS 2. Robotics: ROBODOC 3. Virtual colonoscopy and endoscopy • Conclusion, state of the art, and perspectives

  9. Elements of a CAS system

  10. Medical CAD/CAM: a new paradigm (R.H. Taylor) • CAD/CAM has revolutionized the way consumer goods are designed and produced. • The key: 3D visualization, simulation, design tools, precise CNC and robotic execution, and most importantly INTEGRATION • By analogy, apply paradigm to medicine: design is preoperative planning, production is intraoperative execution, postoperative evaluation is quality assurance

  11. Medical CAD/CAM • Differences: individualized data, custom planning and execution, safety • Medical CAD/CAM will change the ways in which are some conditions are diagnosed and treated • New computer-based technologies are more that “just another, fancier tool” because they provide unprecedented integration and potentially higher accuracy and repeatability

  12. CAS systems: clinical specialties • Neurosurgery:biopsies, tumor removal, epilepsy. • Orthopaedics:total hip and knee replacement trauma. • Laparoscopy and endoscopy: camera holders, simulators. • Craniofacial and maxillofacial surgery:fragment and cut planning, precise positioning • Emerging: radiology, dentristry, ophtalmology.

  13. Neurosurgery: tumor removal

  14. Spine: pedicle screw insertion

  15. Laparoscopic surgery

  16. Craniofacial surgery

  17. Stereotactic Radiosurgery:

  18. FRACAS: CAS for femur fracture reduction Joint project HUJI and Hadassah Hospital since 1996 Illustrates real-time navigation and integration in orthopaedics

  19. Today's method of choice. Success rates > 90% Closed medulary nailing

  20. Femur fracture fixationClosedinterlocking intramedulary nailing all under fluoroscopy!

  21. FRACAS: project goals • Substantial reduction of surgeon’s cumulative exposure to radiation • Reduction of alignement and positioning errors • Improve chances of completing the reduction closed • Improve the surgeon’s hand/eye coordination • Reduce overall intraoperative time and fatigue • Improved preoperative planning in both fracture assessment and nail selection

  22. FRACAS conceptFollow the bone fragment positions with 3D models on a computer screen instead of fluoroscopy CT+Fluoro-based • 3D bone fragment models from preop CT • Real-time bone fragment tracking • Registration with fluoroscopic images

  23. During surgery CT images computer bone fragment modelling optical tracker instruments fluoroscopic images nail selection patient FRACAS system concept Before surgery

  24. In-vitro feasibility study

  25. FRACAS current status • Prototype system integrated with tracker • Fluoroscopic image processing completed: in-vitro tests show submilimetric accuracy • 2D/3D registration experiments in progress • In-vitro experimentation with bone holder • Key ideas: entire procedure support, fluoroscopy-based registration

  26. Total Hip Replacement (THR)

  27. ROBODOC THR • Developed by Integrated Surgical Systems, IBM Research, Johns Hopkins (1986, 1994, 1997) • Precise implant positioning planning and machining of cementless hip implant canal • Reduces complications in canal preparation and implant fixation • Improves positioning and surface finish • Preoperative planning • Robotic intraoperative execution

  28. Total hip replacement procedure Procedure Tools Fluoroscopic images

  29. ROBODOC Planning

  30. ROBODOC procedure

  31. ROBODOC: Total Hip Replacement F S e e m c u t r i o n Manual broaching Robotic broaching

  32. ROBODOC THR: current status • Over 4,000 surgeries in 20 centers since 1994 • Very satisfactory short and mid-term results • Recent work on Revision THR • Interactive cement cut volume definition • Pin-based registration, work on fluoroscopic registration

  33. video camera view Endoscopy anatomic structrure

  34. Virtual endoscopy • Purposes: • training simulator for surgeons • diagnosis of polypes and other tumors without actually inserting a video camera • Method: build a “fly-though” of the anatomy from CT and MRI data so that the surgeon can examine the anatomy or move the camera • Projects: Stony Brook, USA, Karlhuse, Germany

  35. Preprocessing Interaction Volume acquisition Segmentation Navigation Rendering Input Devices Output Devices User Virtual Endoscopy: principle

  36. Virtual Colonoscopy: Stony Brook

  37. Karlsruhe Endoscopic Surgery Trainer

  38. Futuristic concept: teleoperation

  39. CAS: state of the art • Neuronavigation: routine clinical use in a few dozen hospitals (including Israel) • Orthopaedics: about 7,000 pedicle screws, 4,000 robotic total hip replacements, a few hundred trauma cases • Laparoscopy, endoscopy: commercial arm • In Israel:IZMEL consortium on image-guided therapy

  40. CAS -- Summary • Medical CAD/CAM -- a new paradigm • Interdisciplinary:close cooperation in all stages of design and deployment! • Long term: long R&D cycle • Active and rapidly growing field; only the tip of the iceberg has been explored. • Extensive clinical studies are starting • Many challenging applied research problems • Commercial opportunities: established and start-up companies

  41. Grand challenges • More percutaneous procedures • Soft tissue procedures: grafts, ligament releases, tendon transfer • Computational challenges: • deformable tissue shape and behavior modeling • image-based tracking (fluoroscopy, ultrasound) • accurate deformable registration • realistic surgical simulators • systems integration

  42. ISRACAS’2000May 18, TechnionThird Israeli Symposium on Computer-Aided Surgery, Medical Robotics, and Medical Imaging • G. Barnett, USACAS Neurosurgery • J. Bowersocks, USA Telesurgery • P. Dario, Italy Medical Robotics • F. Jolesz, USA OR of the future • P. Merloz, France CAS Spine Surgery • 15 refereed papers + industrial exhibit session

  43. Contact information

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