Systematic distortions in magnetic position digitizers

Localization of reference points in electromagnetic tracking data and their application for treatment error detection in interstitial breast brachytherapy

BACKGROUND

Electromagnetic tracking (EMT) is a promising technology that holds great potential to advance patient-specific pre-treatment verification in interstitial brachytherapy (iBT). It allows easy determination of the implant geometry without line-of-sight restrictions and without dose exposure to the patient. What it cannot provide, however, is a link to anatomical landmarks, such as the exit points of catheters or needles on the skin surface. These landmarks are required for the registration of EMT data with other imaging modalities and for the detection of treatment errors such as incorrect indexer lengths, and catheter or needle shifts.

PURPOSE

To develop an easily applicable method to detect reference points in the positional data of the trajectory of an EMT sensor, specifically the exit points of catheters in breast iBT, and to apply the approach to pre-treatment error detection.

METHODS

Small metal objects were attached to catheter fixation buttons that rest against the breast surface to intentionally induce a local, spatially limited perturbation of the magnetic field on which the working principle of EMT relies. This perturbation can be sensed by the EMT sensor as it passes by, allowing it to localize the metal object and thus the catheter exit point. For the proof-of-concept, different small metal objects (magnets, washers, and bushes) and EMT sensor drive speeds were used to find the optimal parameters. The approach was then applied to treatment error detection and validated in-vitro on a phantom. Lastly, the in-vivo feasibility of the approach was tested on a patient cohort of four patients to assess the impact on the clinical workflow.

RESULTS

All investigated metal objects were able to measurably perturb the magnetic field, which resulted in missing sensor readings, that is two data gaps, one for the sensor moving towards the tip end and one when retracting from there. The size of the resulting data gaps varied depending on the choice of gap points used for calculation of the gap size; it was found that the start points of the gaps in both directions showed the smallest variability. The median size of data gaps was ⩽8 mm for all tested materials and sensor drive speeds. The variability of the determined object position was ⩽0.5 mm at a speed of 1.0 cm/s and ⩽0.7 mm at 2.5 cm/s, with an increase up to 2.3 mm at 5.0 cm/s. The in-vitro validation of the error detection yielded a 100% detection rate for catheter shifts of ≥2.2 mm. All simulated wrong indexer lengths were correctly identified. The in-vivo feasibility assessment showed that the metal objects did not interfere with the routine clinical workflow.

CONCLUSIONS

The developed approach was able to successfully detect reference points in EMT data, which can be used for registration to other imaging modalities, but also for treatment error detection. It can thus advance the automation of patient-specific, pre-treatment quality assurance in iBT.

Magnetic Tracking System for Heart Surgery

Cardiac ablation is a minimally invasive, low risk procedure that can correct heart rhythm problems. Current techniques which determine catheter positioning while a patient is undergoing heart surgery are usually invasive, often inaccurate, and require some forms of imaging. In this study, we develop a unique real-time tracking system which can track the position and orientation of a medical catheter inside a human heart with fast update rate of 200 Hz and high precision of 1.6 mm. The system utilizes a magnetic field-based positioning method involving an efficient solution algorithm, new magnetic field detection hardware and software designs. We show that this type of positioning has the benefits of not needing a line-of-sight between emitter and sensor, supporting a wide dynamic range, and can be applied to other medical systems in need of real-time positioning.

Motion estimation and correction in SPECT, PET and CT

Patient motion impacts single photon emission computed tomography (SPECT), positron emission tomography (PET) and X-ray computed tomography (CT) by giving rise to projection data inconsistencies that can manifest as reconstruction artifacts, thereby degrading image quality and compromising accurate image interpretation and quantification. Methods to estimate and correct for patient motion in SPECT, PET and CT have attracted considerable research effort over several decades. The aims of this effort have been two-fold: to estimate relevant motion fields characterizing the various forms of voluntary and involuntary motion; and to apply these motion fields within a modified reconstruction framework to obtain motion-corrected images. The aims of this review are to outline the motion problem in medical imaging and to critically review published methods for estimating and correcting for the relevant motion fields in clinical and preclinical SPECT, PET and CT. Despite many similarities in how motion is handled between these modalities, utility and applications vary based on differences in temporal and spatial resolution. Technical feasibility has been demonstrated in each modality for both rigid and non-rigid motion, but clinical feasibility remains an important target. There is considerable scope for further developments in motion estimation and correction, and particularly in data-driven methods that will aid clinical utility. State-of-the-art machine learning methods may have a unique role to play in this context.

Quantitative Augmented Reality-Assisted Free-Hand Orthognathic Surgery Using Electromagnetic Tracking and Skin-Attached Dynamic Reference

The purpose of this study was to develop a quantitative AR-assisted free-hand orthognathic surgery method using electromagnetic (EM) tracking and skin-attached dynamic reference. The authors proposed a novel, simplified, and convenient workflow for augmented reality (AR)-assisted orthognathic surgery based on optical marker-less tracking, a comfortable display, and a non-invasive, skin-attached dynamic reference frame. The 2 registrations between the physical (EM tracking) and CT image spaces and between the physical and AR camera spaces, essential processes in AR-assisted surgery, were pre-operatively performed using the registration body complex and 3D depth camera. The intraoperative model of the maxillary bone segment (MBS) was superimposed on the real patient image with the simulated goal model on a flat-panel display, and the MBS was freely handled for repositioning with respect to the skin-attached dynamic reference tool (SRT) with quantitative visualization of landmarks of interest using only EM tracking. To evaluate the accuracy of AR-assisted Le Fort I surgery, the MBS of the phantom was simulated and repositioned by 6 translational and three rotational movements. The mean absolute deviations (MADs) between the simulation and post-operative positions of MBS landmarks by the SRT were 0.20, 0.34, 0.29, and 0.55 mm in x- (left lateral, right lateral), y- (setback, advance), and z- (impaction, elongation) directions, and RMS, respectively, while those by the BRT were 0.23, 0.37, 0.30, and 0.60 mm. There were no significant differences between the translation and rotation surgeries or among surgeries in the x-, y-, and z-axes for the SRT. The MADs in the x-, y-, and z-axes exhibited no significant differences between the SRT and BRT. The developed method showed high accuracy and reliability in free-hand orthognathic surgery using EM tracking and skin-attached dynamic reference.

Technical Note: Assessment of electromagnetic tracking systems in a surgical environment using ultrasonography and ureteroscopy instruments for percutaneous renal access

PURPOSE

Electromagnetic tracking systems (EMTSs) have been proposed to assist the percutaneous renal access (PRA) during minimally invasive interventions to the renal system. However, the influence of other surgical instruments widely used during PRA (like ureteroscopy and ultrasound equipment) in the EMTS performance is not completely known. This work performs this assessment for two EMTSs [Aurora^® Planar Field Generator (PFG); Aurora^® Tabletop Field Generator (TTFG)].

METHODS

An assessment platform, composed by a scaffold with specific supports to attach the surgical instruments and a plate phantom with multiple levels to precisely translate or rotate the surgical instruments, was developed. The median accuracy and precision in terms of position and orientation were estimated for the PFG and TTFG in a surgical environment using this platform. Then, the influence of different surgical instruments (alone or together), namely analogic flexible ureterorenoscope (AUR), digital flexible ureterorenoscope (DUR), two-dimensional (2D) ultrasound (US) probe, and four-dimensional (4D) mechanical US probe, was assessed for both EMTSs by coupling the instruments to 5-DOF and 6-DOF sensors.

RESULTS

Overall, the median positional and orientation accuracies in the surgical environment were 0.85 mm and 0.42° for PFG, and 0.72 mm and 0.39° for TTFG, while precisions were 0.10 mm and 0.03° for PFG, and 0.20 mm and 0.12° for TTFG, respectively. No significant differences were found for accuracy between EMTSs. However, PFG showed a tendency for higher precision than TTFG. AUR, DUR, and 2D US probe did not influence the accuracy and precision of both EMTSs. In opposition, the 4D probe distorted the signal near the attached sensor, making readings unreliable.

CONCLUSIONS

Ureteroscopy- and ultrasonography-assisted PRA based on EMTS guidance are feasible with the tested AUR or DUR together with the 2D probe. More studies must be performed to evaluate the probes and ureterorenoscopes' influence before their use in PRA based on EMTS guidance.

Versatile Low-Cost Volumetric 3-D Ultrasound Platform for Existing Clinical 2-D Systems

Ultrasound imaging has indications across many areas of medicine, but the need for training and the variability in skill and acquired image quality among 2-D ultrasound users have limited its wider adoption and utilization. Low-cost volumetric ultrasound with a known frame of reference has the potential to lower these operator-dependent barriers and enhance the clinical utility of ultrasound imaging. In this paper, we improve upon our previous research-scanner-based prototype to implement a versatile volumetric imaging platform for existing clinical 2-D ultrasound systems. We present improved data acquisition and image reconstruction schemes to increase quality, streamline workflow, and provide real-time visual feedback. We present initial results using the platform on a Vimedix simulator, as well as on phantom and in vivo targets using a variety of clinical ultrasound systems and probes.

Distorter Characterisation Using Mutual Inductance in Electromagnetic Tracking

Electromagnetic tracking (EMT) is playing an increasingly important role in surgical navigation, medical robotics and virtual reality development as a positional and orientation reference. Though EMT is not restricted by line-of-sight requirements, measurement errors caused by magnetic distortions in the environment remain the technology's principal shortcoming. The characterisation, reduction and compensation of these errors is a broadly researched topic, with many developed techniques relying on auxiliary tracking hardware including redundant sensor arrays, optical and inertial tracking systems. This paper describes a novel method of detecting static magnetic distortions using only the magnetic field transmitting array. An existing transmitter design is modified to enable simultaneous transmission and reception of the generated magnetic field. A mutual inductance model is developed for this transmitter design in which deviations from control measurements indicate the location, magnitude and material of the field distorter to an approximate degree. While not directly compensating for errors, this work enables users of EMT systems to optimise placement of the magnetic transmitter by characterising a distorter's effect within the tracking volume without the use of additional hardware. The discrimination capabilities of this method may also allow researchers to apply material-specific compensation techniques to minimise position error in the clinical setting.

Low-cost Volumetric Ultrasound by Augmentation of 2D Systems: Design and Prototype

Conventional two-dimensional (2D) ultrasound imaging is a powerful diagnostic tool in the hands of an experienced user, yet 2D ultrasound remains clinically underutilized and inherently incomplete, with output being very operator dependent. Volumetric ultrasound systems can more fully capture a three-dimensional (3D) region of interest, but current 3D systems require specialized transducers, are prohibitively expensive for many clinical departments, and do not register image orientation with respect to the patient; these systems are designed to provide improved workflow rather than operator independence. This work investigates whether it is possible to add volumetric 3D imaging capability to existing 2D ultrasound systems at minimal cost, providing a practical means of reducing operator dependence in ultrasound. In this paper, we present a low-cost method to make 2D ultrasound systems capable of quality volumetric image acquisition: we present the general system design and image acquisition method, including the use of a probe-mounted orientation sensor, a simple probe fixture prototype, and an offline volume reconstruction technique. We demonstrate initial results of the method, implemented using a Verasonics Vantage research scanner.

An Acoustic Tracking Approach for Medical Ultrasound Image Simulator

Ultrasound examinations are a standard procedure in the clinical diagnosis of many diseases. However, the efficacy of an ultrasound examination is highly dependent on the skill and experience of the operator, which has prompted proposals for ultrasound simulation systems to facilitate training and education in hospitals and medical schools. The key technology of the medical ultrasound simulation system is the probe tracking method that is used to determine the position and inclination angle of the sham probe, since this information is used to display the ultrasound images in real time. This study investigated a novel acoustic tracking approach for an ultrasound simulation system that exhibits high sensitivity and is cost-effective. Five air-coupled ultrasound elements are arranged as a 1D array in front of a sham probe for transmitting the acoustic signals, and a 5 × 5 2D array of receiving elements is used to receive the acoustic signals from the moving transmitting elements. Since the patterns of the received signals can differ for different positions and angles of the moving probe, the probe can be tracked precisely by the acoustic tracking approach. After the probe position has been determined by the system, the corresponding ultrasound image is immediately displayed on the screen. The system performance was verified by scanning three different subjects as image databases: a simple commercial phantom, a complicated self-made phantom, and a porcine heart. The experimental results indicated that the tracking and angle accuracies of the presented acoustic tracking approach were 0.7 mm and 0.5°, respectively. The performance of the acoustic tracking approach is compared with those of other tracking technologies.

A software solution to dynamically reduce metallic distortions of electromagnetic tracking systems for image-guided surgery

PURPOSE

Electromagnetic tracking systems (EMTS) have achieved a high level of acceptance in clinical settings, e.g., to support tracking of medical instruments in image-guided interventions. However, tracking errors caused by movable metallic medical instruments and electronic devices are a critical problem which prevents the wider application of EMTS for clinical applications.

METHODS

We plan to introduce a method to dynamically reduce tracking errors caused by metallic objects in proximity to the magnetic sensor coil of the EMTS. We propose a method using ramp waveform excitation based on modeling the conductive distorter as a resistance-inductance circuit. Additionally, a fast data acquisition method is presented to speed up the refresh rate.

RESULTS

With the current approach, the sensor's positioning mean error is estimated to be 3.4, 1.3 and 0.7 mm, corresponding to a distance between the sensor and center of the transmitter coils' array of up to 200, 150 and 100 mm, respectively. The sensor pose error caused by different medical instruments placed in proximity was reduced by the proposed method to a level lower than 0.5 mm in position and [Formula: see text] in orientation. By applying the newly developed fast data acquisition method, we achieved a system refresh rate up to approximately 12.7 frames per second.

CONCLUSIONS

Our software-based approach can be integrated into existing medical EMTS seamlessly with no change in hardware. It improves the tracking accuracy of clinical EMTS when there is a metallic object placed near the sensor coil and has the potential to improve the safety and outcome of image-guided interventions.

A Robotic Ultrasound Scanner for Automatic Vessel Tracking and Three-Dimensional Reconstruction of B-Mode Images

Locating and evaluating the length and severity of a stenosis is very important for planning adequate treatment of peripheral arterial disease (PAD). Conventional ultrasound (US) examination cannot provide maps of entire lower limb arteries in 3-D. We propose a prototype 3D-US robotic system with B-mode images, which is nonionizing, noninvasive, and is able to track and reconstruct a continuous segment of the lower limb arterial tree between the groin and the knee. From an initialized cross-sectional view of the vessel, automatic tracking was conducted followed by 3D-US reconstructions evaluated using Hausdorff distance, cross-sectional area, and stenosis severity in comparison with 3-D reconstructions with computed tomography angiography (CTA). A mean Hausdorff distance of 0.97 ± 0.46 mm was found in vitro for 3D-US compared with 3D-CTA vessel representations. To evaluate the stenosis severity in vitro, 3D-US reconstructions gave errors of 3%-6% when compared with designed dimensions of the phantom, which are comparable to 3D-CTA reconstructions, with 4%-13% errors. The in vivo system's feasibility to reconstruct a normal femoral artery segment of a volunteer was also investigated. These results encourage further ergonomic developments to increase the robot's capacity to represent lower limb vessels in the clinical context.

An advanced navigation protocol for endoscopic transsphenoidal surgery

OBJECTIVE

To report our clinical experience with an advanced navigation protocol that provides seamless integration into the operating workflow of endoscopic transsphenoidal surgery.

PATIENTS AND METHODS

From 32 consecutive cases of endoscopic transsphenoidal surgery, an optimal setup of continuous electromagnetic instrument navigation was created. Additionally, our standard multimodality image navigation of T1-weighted magnetic resonance (MR) images for soft tissue, MR angiogram for vascular structures, and computed tomography (CT) for solid bone was advanced by the addition of a CT surface rendering for fine paranasal sinus structures. The anatomic structures visualized and their clinical impacts were compared between standard and advanced visualization protocol. Bone-windowed CT images served as reference. The accuracy of the navigation setup was assessed by intraoperative landmark tests. Potential tissue shift was calculated by comparing pre- and postoperative MR angiograms of 20 macroadenomas.

RESULTS

After a learning curve of 2 cases (1 ferromagnetic interference and 1 dislocation of the patient reference tracker), the advanced navigation protocol was feasible in 30 cases. Advanced multimodality imaging was able to visualize significantly finer paranasal sinus structures than multimodality image navigation without CT surface rendering, equal to bone-windowed CT images (P < 0.001, McNemar test). This was found helpful for orientation in cases of complex sphenoid sinus anatomy. The accuracy of the advanced navigation setup corresponded to standard optic navigation with skull fixation. A tissue shift of median 2 mm (range 0-9 mm) was observed in the posterior genu of the internal carotid arteries after tumor resection.

CONCLUSIONS

The advanced navigation protocol permits continuous suction-tracked navigation guidance during endoscopic transsphenoidal surgery and optimal visualization of solid bone, fine paranasal sinus structures, soft-tissue and vascular structures. This may add to the safety of the procedure especially in cases of anatomical variations and in cases of recurrent adenomas with distorted anatomy.

Electromagnetic tracking in medicine--a review of technology, validation, and applications

Object tracking is a key enabling technology in the context of computer-assisted medical interventions. Allowing the continuous localization of medical instruments and patient anatomy, it is a prerequisite for providing instrument guidance to subsurface anatomical structures. The only widely used technique that enables real-time tracking of small objects without line-of-sight restrictions is electromagnetic (EM) tracking. While EM tracking has been the subject of many research efforts, clinical applications have been slow to emerge. The aim of this review paper is therefore to provide insight into the future potential and limitations of EM tracking for medical use. We describe the basic working principles of EM tracking systems, list the main sources of error, and summarize the published studies on tracking accuracy, precision and robustness along with the corresponding validation protocols proposed. State-of-the-art approaches to error compensation are also reviewed in depth. Finally, an overview of the clinical applications addressed with EM tracking is given. Throughout the paper, we report not only on scientific progress, but also provide a review on commercial systems. Given the continuous debate on the applicability of EM tracking in medicine, this paper provides a timely overview of the state-of-the-art in the field.

A 3-D ultrasound imaging robotic system to detect and quantify lower limb arterial stenoses: in vivo feasibility

The degree of stenosis is the most common criterion used to assess the severity of lower limb peripheral arterial disease. Two-dimensional ultrasound (US) imaging is the first-line diagnostic method for investigating lesions, but it cannot render a 3-D map of the entire lower limb vascular tree required for therapy planning. We propose a prototype 3-D US imaging robotic system that can potentially reconstruct arteries from the iliac in the lower abdomen down to the popliteal behind the knee. A realistic multi-modal vascular phantom was first conceptualized to evaluate the system's performance. Geometric accuracies were assessed in surface reconstruction and cross-sectional area in comparison to computed tomography angiography (CTA). A mean surface map error of 0.55 mm was recorded for 3-D US vessel representations, and cross-sectional lumen areas were congruent with CTA geometry. In the phantom study, stenotic lesions were properly localized and severe stenoses up to 98.3% were evaluated with -3.6 to 11.8% errors. The feasibility of the in vivo system in reconstructing the normal femoral artery segment of a volunteer and detecting stenoses on a femoral segment of a patient was also investigated and compared with that of CTA. Together, these results encourage future developments to increase the robot's potential to adequately represent lower limb vessels and clinically evaluate stenotic lesions for therapy planning and recurrent non-invasive and non-ionizing follow-up examinations.

Real-time catheter tracking for high-dose-rate prostate brachytherapy using an electromagnetic 3D-guidance device: a preliminary performance study

PURPOSE

In order to increase the accuracy and speed of catheter reconstruction in a high-dose-rate (HDR) prostate implant procedure, an automatic tracking system has been developed using an electromagnetic (EM) device (trakSTAR, Ascension Technology, VT). The performance of the system, including the accuracy and noise level with various tracking parameters and conditions, were investigated.

METHODS

A direct current (dc) EM transmitter (midrange model) and a sensor with diameter of 1.3 mm (Model 130) were used in the trakSTAR system for tracking catheter position during HDR prostate brachytherapy. Localization accuracy was assessed under both static and dynamic analyses conditions. For the static analysis, a calibration phantom was used to investigate error dependency on operating room (OR) table height (bottom vs midposition vs top), sensor position (distal tip of catheter vs connector end of catheter), direction [left-right (LR) vs anterior-posterior (AP) vs superior-inferior (SI)], sampling frequency (40 vs 80 vs 120 Hz), and interference from OR equipment (present vs absent). The mean and standard deviation of the localization offset in each direction and the corresponding error vectors were calculated. For dynamic analysis, the paths of five straight catheters were tracked to study the effects of directions, sampling frequency, and interference of EM field. Statistical analysis was conducted to compare the results in different configurations.

RESULTS

When interference was present in the static analysis, the error vectors were significantly higher at the top table position (3.3 ± 1.3 vs 1.8 ± 0.9 mm at bottom and 1.7 ± 1.0 mm at middle, p < 0.001), at catheter end position (3.1 ± 1.1 vs 1.4 ± 0.7 mm at the tip position, p < 0.001), and at 40 Hz sampling frequency (2.6 ± 1.1 vs 2.4 ± 1.5 mm at 80 Hz and 1.8 ± 1.1 at 160 Hz, p < 0.001). So did the mean offset errors in the LR direction (-1.7 ± 1.4 vs 0.4 ± 0.5 mm in AP and 0.8 ± 0.8 mm in SI directions, p < 0.001). The error vectors were significantly higher with surrounding interference (2.2 ± 1.3 mm) vs without interference (1.0 ± 0.7 mm, p < 0.001). An accuracy of 1.6 ± 0.2 mm can be reached when using optimum configuration (160 Hz at middle table position). When interference was present in the dynamic tracking, the mean tracking errors in LR direction (1.4 ± 0.5 mm) was significantly higher than that in AP direction (0.3 ± 0.2 mm, p < 0.001). So did the mean vector errors at 40 Hz (2.1 ± 0.2 mm vs 1.3 ± 0.2 mm at 80 Hz and 0.9 ± 0.2 mm at 160 Hz, p < 0.05). However, when interference was absent, they were comparable in the both directions and at all sampling frequencies. An accuracy of 0.9 ± 0.2 mm was obtained for the dynamic tracking when using optimum configuration.

CONCLUSIONS

The performance of an EM tracking system depends highly on the system configuration and surrounding environment. The accuracy of EM tracking for catheter reconstruction in a prostate HDR brachytherapy procedure can be improved by reducing interference from surrounding equipment, decreasing distance from transmitter to tracking area, and choosing appropriated sampling frequency. A calibration scheme is needed to further reduce the tracking error when the interference is high.

On mixed reality environments for minimally invasive therapy guidance: systems architecture, successes and challenges in their implementation from laboratory to clinic

Mixed reality environments for medical applications have been explored and developed over the past three decades in an effort to enhance the clinician's view of anatomy and facilitate the performance of minimally invasive procedures. These environments must faithfully represent the real surgical field and require seamless integration of pre- and intra-operative imaging, surgical instrument tracking, and display technology into a common framework centered around and registered to the patient. However, in spite of their reported benefits, few mixed reality environments have been successfully translated into clinical use. Several challenges that contribute to the difficulty in integrating such environments into clinical practice are presented here and discussed in terms of both technical and clinical limitations. This article should raise awareness among both developers and end-users toward facilitating a greater application of such environments in the surgical practice of the future.

Recent advances in pituitary tumor management

PURPOSE OF REVIEW

Advances in the neurosurgical management of pituitary tumors have included the refinement of surgical access and significant progress in navigation technology to help further reduce morbidity and improve outcome. Similarly, stereotactic radiosurgery has evolved to become an integral part in pituitary tumors not amenable to medical or surgical treatment.

RECENT FINDINGS

The evolution of minimally invasive surgery has evolved toward endoscopic versus microscopic trans-sphenoidal approaches for pituitary tumors. Debate exists regarding each approach, with advocates for both championing their cause. Stereotactic and fractional radiosurgery have been shown to be a safe and effective means of controlling tumor growth and ensuring hormonal stabilization, with longer-term data available for GammaKnife compared with CyberKnife.

SUMMARY

The advances in trans-sphenoidal surgical approaches, navigation technological improvements and the current results of stereotactic radiosurgery are discussed.

Three-dimensional ultrasound imaging

This review is about the development of three-dimensional (3D) ultrasonic medical imaging, how it works, and where its future lies. It assumes knowledge of two-dimensional (2D) ultrasound, which is covered elsewhere in this issue. The three main ways in which 3D ultrasound may be acquired are described: the mechanically swept 3D probe, the 2D transducer array that can acquire intrinsically 3D data, and the freehand 3D ultrasound. This provides an appreciation of the constraints implicit in each of these approaches together with their strengths and weaknesses. Then some of the techniques that are used for processing the 3D data and the way this can lead to information of clinical value are discussed. A table is provided to show the range of clinical applications reported in the literature. Finally, the discussion relating to the technology and its clinical applications to explain why 3D ultrasound has been relatively slow to be adopted in routine clinics is drawn together and the issues that will govern its development in the future explored.

Computer assistance for intraoperative navigation in ENT surgery

The intraoperative need for exact orientation during interventions in the paranasal sinuses and the augmented need for navigational aids in lateral skull base surgery have lead to the development of computer-aided tools during the last fifteen years. These tools, which provide the position of a tool or a pointer in the patient's preoperative radiologic imaging, have quickly gained a wide acceptance for revision surgeries and the surgical treatment of complex pathologies in Ear-, Nose- and Throat (ENT-) surgery. Currently, the use of such systems is spreading from academic centers to smaller hospitals and will become a standard tool in the near future. We review the present state of computer-aided surgery (CAS) systems, based on our experience as clinical and research centers with a long experience in the field, provide some technological background information and, based on selected cases, show the merits of this technology. The systems we have been working with cover a wide variety of intraoperative navigational systems in ENT surgery (Easy Guide, MedScan II, MKM, SNN, STN, SurgiGATE ORL, Treon, VectorVision, Viewing Wand, [without claiming completeness]), and virtually the whole area of ENT surgeries: macroscopic, (video-)endoscopic and microscopic procedures. The 3D tracking technologies involved cover mechanical, optical (active and passive), magnetic and robotic principles. The visualization tools used are computer monitors, video monitors, head-up-displays and the microscope's oculars, thus spanning the area from pointer-systems to real navigators and a surgical telepresence demonstrator, implementing the majority of available patient-to-image referencing strategies. Clinically, the systems can be operated with an acceptable accuracy of around 1 mm, whereas in laboratory settings and in cadaver studies application accuracy may be pushed to its limits: the physical resolution of the radiologic imaging used for navigation.

Navigated CT‐guided interventions

Diagnostic and therapeutic CT- guided percutaneous interventions are clinical routine in interventional radiology. Image-guided navigation systems visualize the internal anatomy during interventions in real time not necessitating continuous image acquisition. Although multiple 3D image-guidance devices have been developed and used by several surgical disciplines in the last few years, they have not yet been fully applied by the interventional radiologist. The aim of this article is to review the currently performed methods of CT-guided percutaneous interventions and to discuss the potential benefits of newly developed 3D- navigation systems.

The effect of surface area digitizations on the prediction of spherical anatomical geometries for computer-assisted applications

Intraoperative digitization of osseous structures is an integral component of computer-assisted orthopaedic surgery. This study determined the repeatability and accuracy of predicting known radii and center locations of spherical objects for different proportions of digitized surface areas and various sphere sizes. Also, we investigated these accuracies for some relevant near-spherical osseous structures where results from full area digitizations were considered to be true. Digitizations were performed using an electromagnetic tracker with a stylus on the total and fractional surfaces of 10 hemispheres, ranging from 10 to 28mm in radius. Repeatability was quantified by digitizing five trials of the entire surface and various fractional areas of selected hemisphere sizes. Similar trials were conducted on models of a humeral and femoral head, using the full head area as baseline and digitizing 15 and 30mm diameter areas of the full head. Mean error for the predicted radii and center positions of the hemispheres ranged from 0.39+/-0.29 to 0.14+/-0.07mm and 0.52+/-0.31 to 0.22+/-0.12mm, respectively. Repeatability for the predicted radii and centers produced maximum standard deviations of 0.31 and 0.42mm, respectively. All errors decreased as fractional area (40%, 60%, 80% and 100%) increased (p<0.05). Radius of curvature and center position errors for the humeral head model were 1.51+/-2.11 and 2.28+/-1.51mm, respectively. These errors for the femoral head model were 3.37+/-4.14 and 4.25+/-4.14mm, respectively. Errors resulting from the prediction of radius and center indicate that non-spherical anatomical structures are more sensitive to the digitized area, and hence digitization of the largest surface possible seems warranted.

Towards image guided robotic surgery: multi-arm tracking through hybrid localization

OBJECTIVE

Use of the robotic assisted surgery has been increasing in recent years, due both the continuous increase in the number of applications and the clinical benefits that surgical robots can provide. Currently robotic assisted surgery relies on endoscopic video for navigation, providing only surface visualization, thus limiting subsurface vision. To be able to visualize and identify subsurface information, techniques in image-guidance can be used. As part of designing an image guidance system, all arms of the robot need to be co-localized in a common coordinate system.

METHODS

In order to track multiple arms in a common coordinate space, intrinsic and extrinsic tracking methods can be used. First, the intrinsic tracking of the daVinci, specifically of the setup joints is analyzed. Because of the inadequacy of the setup joints for co-localization a hybrid tracking method is designed and implemented to mitigate the inaccuracy of the setup joints. Different both optical and magnetic tracking methods are examined for setup joint localization.

RESULTS

The hybrid localization method improved the localization accuracy of the setup joints. The inter-arm accuracy in hybrid localization was improved to 3.02 mm. This inter-arm error value was shown to be further reduced when the arms are co-registered, thus reducing common error.

Navigated ultrasound in laparoscopic surgery

Laparoscopic surgery is performed through small incisions that limit free sight and possibility to palpate organs. Although endoscopes provide an overview of organs inside the body, information beyond the surface of the organs is missing. Ultrasound can provide real-time essential information of inside organs, which is valuable for increased safety and accuracy in guidance of procedures. We have tested the use of 2D and 3D ultrasound combined with 3D CT data in a prototype navigation system. In our laboratory, micro-positioning sensors were integrated into a flexible intraoperative ultrasound probe, making it possible to measure the position and orientation of the real-time 2D ultrasound image as well as to perform freehand 3D ultrasound acquisitions. Furthermore, we also present a setup with the probe optically tracked from the shaft with the flexible part locked in one position. We evaluated the accuracy of the 3D laparoscopic ultrasound solution and obtained average values ranging from 1.6% to 3.6% volume deviation from the phantom specifications. Furthermore, we investigated the use of an electromagnetic tracking in the operating room. The results showed that the operating room setup disturbs the electromagnetic tracking signal by increasing the root mean square (RMS) distance error from 0.3 mm to 2.3 mm in the center of the measurement volume, but the surgical instruments and the ultrasound probe added no further inaccuracies. Tracked surgical tools, such as endoscopes, pointers, and probes, allowed surgeons to interactively control the display of both registered preoperative medical images, as well as intraoperatively acquired 3D ultrasound data, and have potential to increase the safety of guidance of surgical procedures.

Real time noninvasive assessment of external trunk geometry during surgical correction of adolescent idiopathic scoliosis

Background

The correction of trunk deformity is crucial in scoliosis surgery, especially for the patient's self-image. However, direct visualization of external scoliotic trunk deformity during surgical correction is difficult due to the covering draping sheets.

Methods

An optoelectronic camera system with 10 passive markers is used to track the trunk geometry of 5 scoliotic patients during corrective surgery. The position of 10 anatomical landmarks and 5 trunk indices computed from the position of the passive markers are compared during and after instrumentation of the spine.

Results

Internal validation of the accuracy of tracking was evaluated at 0.41 +/- 0.05 mm RMS. Intra operative tracking during surgical maneuvers shows improvement of the shoulder balance during and after correction of the spine. Improvement of the overall patient balance is observed. At last, a minor increase of the spinal length can be noticed.

Conclusion

Tracking of the external geometry of the trunk during surgical correction is useful to monitor changes occurring under the sterile draping sheets. Moreover, this technique can used be used to reach the optimal configuration on the operating frame before proceeding to surgery. The current tracking technique was able to detect significant changes in trunk geometry caused by posterior instrumentation of the spine despite significant correction of the spinal curvature. It could therefore become relevant for computer-assisted guidance of surgical maneuvers when performing posterior instrumentation of the scoliotic spine, provide important insights during positioning of patients.

Navigation in laparoscopy--prototype research platform for improved image-guided surgery

The manipulation of the surgical field in laparoscopic surgery, through small incisions with rigid instruments, reduces free sight, dexterity, and tactile feedback. To help overcome some of these drawbacks, we present a prototype research and development platform, CustusX, for navigation in minimally invasive therapy. The system can also be used for planning and follow-up studies. With this platform we can import and display a range of medical images, also real-time data such as ultrasound and X-ray, during surgery. Tracked surgical tools, such as pointers, video laparoscopes, graspers, and various probes, allow surgeons to interactively control the display of medical images during the procedure. This paper introduces navigation technologies and methods for laparoscopic therapy, and presents our software and hardware research platform. Furthermore, we illustrate the use of the system with examples from two pilots performed during laparoscopic therapy. We also present new developments that are currently being integrated into the system for future use in the operating room. Our initial results from pilot studies using this technology with preoperative images and guidance in the retroperitoneum during laparoscopy are promising. Finally, we shortly describe an ongoing multicenter study using this surgical navigation system platform.

Intraoperative magnetic tracker calibration using a magneto-optic hybrid tracker for 3-D ultrasound-based navigation in laparoscopic surgery

This paper describes a ultrasound (3-D US) system that aims to achieve augmented reality (AR) visualization during laparoscopic surgery, especially for the liver. To acquire 3-D US data of the liver, the tip of a laparoscopic ultrasound probe is tracked inside the abdominal cavity using a magnetic tracker. The accuracy of magnetic trackers, however, is greatly affected by magnetic field distortion that results from the close proximity of metal objects and electronic equipment, which is usually unavoidable in the operating room. In this paper, we describe a calibration method for intraoperative magnetic distortion that can be applied to laparoscopic 3-D US data acquisition; we evaluate the accuracy and feasibility of the method by in vitro and in vivo experiments. Although calibration data can be acquired freehand using a magneto-optic hybrid tracker, there are two problems associated with this method--error caused by the time delay between measurements of the optical and magnetic trackers, and instability of the calibration accuracy that results from the uniformity and density of calibration data. A temporal calibration procedure is developed to estimate the time delay, which is then integrated into the calibration, and a distortion model is formulated by zeroth-degree to fourth-degree polynomial fitting to the calibration data. In the in vivo experiment using a pig, the positional error caused by magnetic distortion was reduced from 44.1 to 2.9 mm. The standard deviation of corrected target positions was less than 1.0 mm. Freehand acquisition of calibration data was performed smoothly using a magneto-optic hybrid sampling tool through a trocar under guidance by realtime 3-D monitoring of the tool trajectory; data acquisition time was less than 2 min. The present study suggests that our proposed method could correct for magnetic field distortion inside the patient's abdomen during a laparoscopic procedure within a clinically permissible period of time, as well as enabling an accurate 3-D US reconstruction to be obtained that can be superimposed onto live endoscopic images.

Image-guided surgery and medical robotics in the cranial area

Surgery in the cranial area includes complex anatomic situations with high-risk structures and high demands for functional and aesthetic results. Conventional surgery requires that the surgeon transfers complex anatomic and surgical planning information, using spatial sense and experience. The surgical procedure depends entirely on the manual skills of the operator. The development of image-guided surgery provides new revolutionary opportunities by integrating presurgical 3D imaging and intraoperative manipulation. Augmented reality, mechatronic surgical tools, and medical robotics may continue to progress in surgical instrumentation, and ultimately, surgical care. The aim of this article is to review and discuss state-of-the-art surgical navigation and medical robotics, image-to-patient registration, aspects of accuracy, and clinical applications for surgery in the cranial area.

Navigation-Based Needle Puncture of a Cadaver Using a Hybrid Tracking Navigational System

PURPOSE

The purpose of this study was to determine the puncture accuracy of a navigational system, Medarpa, in a soft tissue environment using augmented overlay imaging.

MATERIALS AND METHODS

Medarpa is an optical electromagnetic tracking system, which allows tracking of instruments, the radiologist's head position, and the transparent display. The display superimposes a computed tomography scan of a cadaver chest on a human cadaver in real time. In group A, needle puncture was performed using the Medarpa system. Three targets located inside the cadaver chest were selected. In group B, the same targets were used to perform standard computed tomography-guided puncture using a single-slice technique. A total of 42 punctures were performed in each group. Postpuncture computed tomography scans were made to verify needle tip positions.

RESULTS

Mean deviation from targets was 8.42 mm +/- 1.78 mm for group A and 8.90 mm +/- 1.71 mm for group B. No significant difference was found between group A and B in any target (P > 0.05). No significant difference was found between the targets of the same group (P > 0.05). Procedural time for 42 punctures was 160 minutes in group A versus 289 minutes in group B (P < 0.05).

CONCLUSION

Needle puncture in a soft tissue environment using the navigational system Medarpa can be reliably performed and matches the accuracy achieved by a computed tomography-guided puncture technique.

Effect of 3D ultrasound probes on the accuracy of electromagnetic tracking systems

In the last few years, 3D ultrasound probes have became readily available. New fields of image-guided surgery applications are opened by attaching small electromagnetic position sensors to 3D ultrasound probes. However, nothing is known about the distortions caused by 3D ultrasound probes regarding electromagnetic sensors. Several trials were performed to investigate error-proneness of state-of-the-art electromagnetic tracking systems when used in combination with 3D ultrasound probes. It was found that 3D ultrasound probes do distort electromagnetic sensors more than 2D probes do. When attaching electromagnetic sensors to 3D probes, maximum errors of 5 mm up to 119 mm occur. The distortion strongly depends on the electromagnetic technology as well on the probe technology used. Thus, for 3D ultrasound-guided applications using electromagnetic tracking technology, the interference of ultrasound probes and electromagnetic sensors have to be checked carefully.

Image-guidance for surgical procedures

Contemporary imaging modalities can now provide the surgeon with high quality three- and four-dimensional images depicting not only normal anatomy and pathology, but also vascularity and function. A key component of image-guided surgery (IGS) is the ability to register multi-modal pre-operative images to each other and to the patient. The other important component of IGS is the ability to track instruments in real time during the procedure and to display them as part of a realistic model of the operative volume. Stereoscopic, virtual- and augmented-reality techniques have been implemented to enhance the visualization and guidance process. For the most part, IGS relies on the assumption that the pre-operatively acquired images used to guide the surgery accurately represent the morphology of the tissue during the procedure. This assumption may not necessarily be valid, and so intra-operative real-time imaging using interventional MRI, ultrasound, video and electrophysiological recordings are often employed to ameliorate this situation. Although IGS is now in extensive routine clinical use in neurosurgery and is gaining ground in other surgical disciplines, there remain many drawbacks that must be overcome before it can be employed in more general minimally-invasive procedures. This review overviews the roots of IGS in neurosurgery, provides examples of its use outside the brain, discusses the infrastructure required for successful implementation of IGS approaches and outlines the challenges that must be overcome for IGS to advance further.

Evaluation of a new electromagnetic tracking system using a standardized assessment protocol

This note uses a published protocol to evaluate a newly released 6 degrees of freedom electromagnetic tracking system (Aurora, Northern Digital Inc.). A practice for performance monitoring over time is also proposed. The protocol uses a machined base plate to measure relative error in position and orientation as well as the influence of metallic objects in the operating volume. Positional jitter (E(RMS)) was found to be 0.17 mm +/- 0.19 mm. A relative positional error of 0.25 mm +/- 0.22 mm at 50 mm offsets and 0.97 mm +/- 1.01 mm at 300 mm offsets was found. The mean of the relative rotation error was found to be 0.20 degrees +/- 0.14 degrees with respect to the axial and 0.91 degrees +/- 0.68 degrees for the longitudinal rotation. The most significant distortion caused by metallic objects is caused by 400-series stainless steel. A 9.4 mm maximum error occurred when the rod was closest to the emitter, 10 mm away. The improvement compared to older generations of the Aurora with respect to accuracy is substantial.