Clinical results of percutaneous pelvic surgery. Computer assisted surgery using ultrasound compared to standard fluoroscopy

This study presents early results of clinical experience with the application of Computer Assisted Surgery (CAS) to percutaneous iliosacral screwing, with comparison to a historical series of patients treated using percutaneous fluoroscopy. Four patients were instrumented using a CAS system, with 10 screws being inserted. Thirty patients were treated by percutaneous fluoroscopic screwing, with 51 screws being inserted. The follow-up assessment included the following criteria; operative time, parameters of radiation exposure, neurological examination, screw placement evaluation on CT-scan, antalgic drug consumption, pain, Majeed grading, and loosening of implants. In the CAS group, the average radiation time was 0.35 min per patient and 0.14 min per screw. No trajectories outside the bone and no postoperative neurological deficits were found. In the fluoroscopic group, the average radiation time was 1.03 min per patient and 0.6 min per screw. Twelve screws had outside-bone trajectories, and iatrogenic neurological deficits were found in seven patients. The average operative time was 50 min in the CAS group and 35 min in the fluoroscopic group. The present CAS technique shows better placement of iliosacral screws, with no outside-bone trajectories and lower radiation exposure.

A methodological tool for computer-assisted surgery interface design: its application to computer-assisted pericardial puncture

Computer Assisted Surgery systems are becoming more and more prevalent. Design processes currently used, pay only a small attention to the surgeon's interaction. To address this lack in design, we propose the OP-a-S notation: OP-a-S modeling of a system adopts an interaction-centered point of view and highlights the links between the real world and the virtual world. Based on an OP-a-S modeling, predictive usability analysis can be performed by considering the ergonomic property. We illustrate our method on the retro-design of a computer assisted surgical application, CASPER.

Clinical validation of computer assisted pelvic surgery using ultrasound. A percutaneous safe technique with low radiation exposure

This study presents early results of the clinical experience of computer assisted surgery (CAS) applied to percutaneous iliosacral screwing. The results of these 10 first cases (4 patients) are compared to an historical series of 51 cases (30 patients). The CAS technique shows better screw placement without outside bone screw and a very low radiation exposure.

Computer-guided pericardiocentesis: experimental results and clinical perspectives

Percutaneous pericardial puncture is a relatively safe and effective technique in case of large pericardial effusions when practiced under echographic or radiological control. The goal of our project is to improve the performance of this technique, mainly in case of smaller and loculated effusions using an accurate guidance towards a preplanned target, based on a model of the pericardial effusion. This paper presents preclinical results of this new computer-assisted technique used to reach the pericardial cavity. The procedure is divided into 3 steps: 1. acquisition of ultrasound data, using an echocardiographic device connected to a 3-D localizer and to a computer, 2. modeling procedure to define the optimal strategy taking into account the mobility of organs on a digital model, 3. guided puncture with a localized needle to reach the predefined target using a passive guidance system. After validation on a dynamic phantom and a feasibility study on dogs, an accuracy and reliability analysis protocol was realized on pigs with experimental pericardial effusion. Feasibility of the technique is demonstrated on animal study with an accuracy of at least 2.5 mm. Further clinical investigation is in progress using a more ergonomic and less cumbersome system. This study demonstrates the feasibility of computer-assisted pericardiocentesis. Beyond the simple improvement of the current technique, this could be a new way to reach the heart or a new tool for percutaneous access and image-guided puncture of soft tissues.

CRIGOS: a compact robot for image-guided orthopedic surgery

The CRIGOS (compact robot for image-guided orthopedic surgery) project was set up for the development of a compact surgical robot system for image-guided orthopedic surgery based on user requirements. The modular system comprises a compact parallel robot and a software system for planning of the surgical interventions and for supervision of the robotic device. Because it is not sufficient to consider only technical aspects in order to improve in clinical routine the therapeutic outcome of conventional interventions, a user-centered and task-oriented design process has been developed which also takes human factors into account. The design process for the CRIGOS system was started from requirement analysis of various orthopedic interventions using information gathered from literature, questionnaires, and workshops with domain experts. This resulted in identification of conventional interventions for which the robotic system would improve the medical and procedural quality. A system design concept has been elaborated which includes definitions of components, functionalities, and interfaces. Approaches to the acquisition of calibrated X-rays will be presented in the paper together with design and evaluation of a first human-computer interface. Finally, the first labtype parallel robot based on low-cost standard components is presented together with the first evaluation results concerning positioning accuracy.

Accurate guidance for percutaneous access to a specific target in soft tissues: preclinical study of computer-assisted pericardiocentesis

In the field of percutaneous access to soft tissues, our project was to improve classical pericardiocentesis by performing accurate guidance to a selected target, according to a model of the pericardial effusion acquired through three-dimensional (3D) data recording. Required hardware is an echocardiographic device and a needle, both linked to a 3D localizer, and a computer. After acquiring echographic data, a modeling procedure allows definition of the optimal puncture strategy, taking into consideration the mobility of the heart, by determining a stable region, whatever the period of the cardiac cycle. A passive guidance system is then used to reach the planned target accurately, generally a site in the middle of the stable region. After validation on a dynamic phantom and a feasibility study in dogs, an accuracy and reliability analysis protocol was realized on pigs with experimental pericardial effusion. Ten consecutive successful punctures using various trajectories were performed on eight pigs. Nonbloody liquid was collected from pericardial effusions in the stable region (5 to 9 mm wide) within 10 to 15 minutes from echographic acquisition to drainage. Accuracy of at least 2.5 mm was demonstrated. This study demonstrates the feasibility of computer-assisted pericardiocentesis. Beyond the simple improvement of the current technique, this method could be a new way to reach the heart or a new tool for percutaneous access and image-guided puncture of soft tissues. Further investigation will be necessary before routine human application.

Percutaneous iliosacral screw placement using image guided techniques

A computer assisted technique of iliosacral screw placement that is applicable to unstable pelvic ring fractures is proposed. The goals are to operate noninvasively with a percutaneous procedure to decrease the complications of surgical exposure and to provide greater accuracy in locating the close neurovascular structures. Preoperative computed tomographic images of the pelvis are provided and a computed tomography three-dimensional model is built. In this model, the optimal trajectories for the drilling are planned. An ultrasound based registration is performed intraoperatively. This registration is the most original part of this work. After performing the passive drilling guidance step, the surgeon places the screws. The accuracy of the ultrasound based registration is checked by comparison with a standard surface based registration at the end of the test experiment. Each screw position is verified by a computed tomographic examination. Four human anatomic specimen pelves were tested with three screw insertions for each pelvis (12 screws). All of the screws were considered to be placed correctly. The method is safe and encourages the start of clinical application.

Computer assisted pericardial puncture: work in progress

Until now, computer assisted surgery has focused primarily on surgical procedures involving rigid anatomical structures. Because soft tissues can be highly mobile and deformable, they may require specific imaging devices, suitable modeling tools, and guiding systems. Percutaneous pericardial puncture is a good clinical target for computer assisted surgery; this procedure is often performed without direct visualization and is dangerous even though echographic control is used. Computer assistance can greatly improve this technique and will allow accurate puncture of preplanned targets. This paper describes a new approach for computer assisted pericardial punctures (CASPER) and describes a first feasibility analysis of CASPER demonstrated with anesthetized animals. The approach is based on the use of echographic data localized in space, from which an optimal strategy is defined. Because of the specificity of the pericardial effusion, a stable target can be selected despite the heart motions. A passive guiding system is used. We have demonstrated the feasibility of the approach.