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Development of an endoscopic navigation system on the base of an automatic visual control system
540
Endoscopy
IV-2-26I Three-dimensional CT angiography (3D-CTA) In unruptured cerebral aneurysms: usefulness of the endoscopic and extract surface modes Y.Usuda, H. Ujiie, Y.Tarnano, M. Izawa, K. Takakura. Department of Neurosurgery, Neurological Institute, Tokyo WomensMedical College, Tokyo, Japan Purpose: The new development in computer software allows rapid and detailed imaging of cerebral arteries. We presentthe clinical utilityof endoscopic and extract surface modes of 3D-CTA for patients with unruptured intracranial aneurysms, Materials and Methods: We reviewed 14 aneurysms in 9 patients. Helical CT angiography was obtained with a Proceed SA scanner (GE Yokogawa Medical systems, Tokyo, JAPAN). 3D images were made with a computer workstation (Advantage Windows 2.0, General Electric, Milwaukee, WI). CT angiography source images and conventional angiograms were reviewed by experienced neurosurgeons and neuroradiologists. Results: The endoscopic mode delineatedthe orificeof aneurysm exactly. The Extractsurface mode delineated the anatomical relationship between the aneurysm and surrounding arteries. It was difficult to differentiate the calcifications with in the thrombusfrom those in the wall due to atheriosclerosis. Conclusions: 3D-CTAmay playa role in determining the appropriate surgical and medicalmanagement. Endoscopic and extractsurface modes provide useful information on the anatomical relationship of the aneurysm for neurosurgeons and neuroradiologists. These modes provide the opportunities to extensively discussthe medicaltreatment. Particularly largebasilaraneurysms, these modesprovideuseful information.
IV-2-27I
3-D Neuroendoscope and CM-cube system in neurosurgery
T. Taira, H. lsakl, H. Kawamura, T Tanikawa, H. Kawabatake, K. Takakura. Deptof Neurosurgery, Tokyo WomensMedicalCollege Tokyo, Japan Introduction: Although three dimensional (3-D) visualization is essential in rnlcronsurosurqery, it is notcommonin neuroendoscopic surgery. Wedeveloped a system that consists of a single lens 3-D neuroendoscope and a computer aided micro-multichannel manlpulation device (CM-CUBE). Description of the System: The 3-D neuroendoscope is a 4 mm diameter single rod lens type with a specialsemi-lucent mirrorprism. The prismsplitsthe imagewith a certain angle of visionand the split imagesentertwo independent CCD cameras. There are two methods to observe3-D images. One is a liquid crystal (LC) shutter method. Images for each eye are alternatively (1/60 sec) displayed on a TV screen and surgeonswear glasseswith an LC shutter synchronized by infrared signalswith a TV screen. Another methodusesLCdisplay with a special flat lens. The flat lens separates the imagesfor individual eyes, The formermethodallows sharperimagesbut wearingthe glassesis awkward. Video images are stored in W-VHS video tape. The CM-CUBE consists of a cylindrical retractorof 10 mm in diameterwith multipleworkingchannels including one for the endoscope. This can be gUided with a stereotactic method. The working channelsare for a coaxialultrasonicimagingprobe, bipolarcoagulator, Laser knife optical fiber, surgicalforceps and facilities. These are manipulated manuallyat present, but a computerdriven systemis now under development. Future Perspective: In developing the 3-D imageneuroendoscope and the CM-CUBEsystem, we have future tele-surgery in mind. With further introduction of high quality TV images (Hi-vision) and full-controlled tele-manipulation system, a highly skilled surgeon can perform operations in his office even for patientsin distantisolated places.
'V-2-28! Navigated neuroendoscopy C. Matula, K. Roessler, A. Reinprecht, W.Th.Koos. Neurosurgical Departement, University of Vienna, Austria Due to the rapid technical developments in neuroendoscopy and in neuronavigation systems both techniques are nowadays established in modern neurosurgery. The combination of both technologies appears the next logical development in the effort to be as much minimal invasive as possible and to hold the risk thereby as minimallyas possible. The results and experiences of the existing work are based on more than 350 operations under application of a "neuroendoscope" and by more than 100 employments of three differentneuronavigational systems (MKM, SPOCS, EASY GUIDE). The neuroendoscopic experiences shows, that the most main complications are the traumatization of the CNSand the orientation of surgery. The neuronavigation with its nowadays satisfactory accuracyof referenciation and intraoperative reproducible precision seemsto be a perfect way to give a controlled orientation. Basedon that there seem to be two different concepts for the application of both techniques together. On one handthe simultaneous application, each one as a separateunit and on the other hand the real combinedapplication as one unit. For the combinedapplication an own adaptation for the pointerwas developed whichwill be
Monda y, 7 July 1997 presented and demonstrated in a short videoclip. From a group of 14 patients we treated in that way, we report our clinicalexperiences and discuss possible areasof application and indications as well as the personnel and organizational expense. Using that combined technique helps a lot to minimize the traumatization of surgery. The control and the effectiveness of surgery are raised clearly. The neuronavigation in neuroendoscopy brings essentially more orientation. The safetyin neuroendoscopy is raised therebysignificantly. The additional time for referenciation lay between 20 and 30 minutes, which surelyappearsacceptable withthe beforenamedadvantages. Theimplementation of neuroendoscopy and neuronavigation appearsfor the futureas absolutelynecessarilyand meaningfully. The creation of differenttechnical requirements is absoluteto push as well as the implementation of intraoperative ultrasound and intraoperative computer tomography as realtime intraoperative imagingwhich we wouldlike to present.
IV-2-29I
Development of an endoscopic navigation system on the base of an automatic visual control system
M. Scholz1, W. Konen2, M. von DOring 3, M. Hardenack1 , A.G. Harders1. of Neurosurgery. Ruhr-University Bocbum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892 Bochum, Germany. 2 ZN (Centerfor Neuroinformatics), Bochum, Germany, 3 Instituteof Neuroanatomy, Ruhr-University Bochum, Germany 1 Department
Introduction: During neuroendoscopy the endoscopic picture appears on the screenand is lost in the next momentwhen it is not recorded by tape or photo. But also in these cases the endoscopic picture can not be brought into exact correlation to a position in an 3-dimensional space. The aim of this study was to combine an endoscopic navigation system with a new visual control system based on video data in order to increasesafety and flexibility of endoscopical interventions. Materials and Methods: A humancadaveric head(phantom) was examined by MR(CT)with2 mmslices. Thesedataweretransferred to a navigationsystem (Easy GuideTM Neuro, Philips). A rigid endoscope (Wolf) was adaptedto the navigation system by combining it with an LED setup suitable to record the endoscopic position in 3D. The Video image was digitiZed by a frame grabber and used for different options of image control. 1) localization and display of anatomical landmarks in the endoscopic image and in the MR (CT), 2) an alarm system for standstill control, 3) the development of a virtual surrounding of the endoscopic image, 4) a measurement tool for intraoperative recalibration of preoperative MRdata, 5)the possibility of virtualbackmovements to avoidtissue damageand 6) the construction of a virtual background in case of bleeding. Results: The rigid Wolf endoscope connected to the Easy Guide System is a very precise tool for neuroendoscopical navigation. The described options weretested in 10 cadaveric specimen and several phantoms. Option 1}-3) are developed in a suitable way for neuroendoscopical interventions and can be transferred to clinical studies. Options 4)~) need further softwareimprovai. Conclusion: Development of an endoscopic navigation systemon the base of an automatic visualcontrol systemis possibleand offersthe neurosurgeons multipleoptionsof instrument controlwhich increasethe safetyand flexibilityof neuroendoscopic interventions.
IV-2-30 I Clinical experience of spinal endoscopy T. Yonemitsu , C. Ochiai, T. Takizawa,M. Matsumoto Jr.. Tokyo General Hospital, Tokyo, Japan The clinical use of endoscopes has become popular in various fields of less invasive surqsry, We have employed malleableendoscopes to observe spinal lesionssince 1993. The aim of this paper is to presentour clinical experiences. AHer positioning the patientlaterallyunderlocalor generalanesthesia an endoscope of small caliber (0.75-2.8 mm in diameter. Medical Science Co. Japan) is introduced from the L3-4or L4-5 regionthroughan introducing device for angiography, by which leakage of the cerebrospinal fluid (CSF) is avoidedduring the procedure. Images are displayed on CRT. Combined use of KTP-Iaser is availableby inserting a glass fiberthrougha channel parallelto the endoscope. A total of twelve patients underwent endoscopy. Representative findings were as follows; rapid to-and-fro movements of the CSF in canal stenosis (1 case), hypervascularity of the cauda equina in spinal AVM (1 case), thickening and adhesions of the arachnoid membrane in arachnoiditis (2 cases), and deformity of the spinal cord in spinal tumor (3 cases). In Hirayama disease (1 case) upward movement of the spinal cord along with the dural canal was prominent especially whenthe patientflexedthe neck anteriorly. In a case withneurinoma, anatomical relationship between lhe tumorand the root was well visualizedand the mass was, though partially, well evaporated by KTP-Iaser w~hout sequelae. In conclusion, spinal endoscopy is a safe and efficacious tool to examine the dynamic aspects of spinal pathology. Although the KTP-laserhas already been applicable to some endoscopes, development of equipment proper for spinal endoscopy such as a bipolar coagulator and an irrigation system is still mandatory for achieving surgerywithouta risk.
Endoscopy
IV-2-26I Three-dimensional CT angiography (3D-CTA) In unruptured cerebral aneurysms: usefulness of the endoscopic and extract surface modes Y.Usuda, H. Ujiie, Y.Tarnano, M. Izawa, K. Takakura. Department of Neurosurgery, Neurological Institute, Tokyo WomensMedical College, Tokyo, Japan Purpose: The new development in computer software allows rapid and detailed imaging of cerebral arteries. We presentthe clinical utilityof endoscopic and extract surface modes of 3D-CTA for patients with unruptured intracranial aneurysms, Materials and Methods: We reviewed 14 aneurysms in 9 patients. Helical CT angiography was obtained with a Proceed SA scanner (GE Yokogawa Medical systems, Tokyo, JAPAN). 3D images were made with a computer workstation (Advantage Windows 2.0, General Electric, Milwaukee, WI). CT angiography source images and conventional angiograms were reviewed by experienced neurosurgeons and neuroradiologists. Results: The endoscopic mode delineatedthe orificeof aneurysm exactly. The Extractsurface mode delineated the anatomical relationship between the aneurysm and surrounding arteries. It was difficult to differentiate the calcifications with in the thrombusfrom those in the wall due to atheriosclerosis. Conclusions: 3D-CTAmay playa role in determining the appropriate surgical and medicalmanagement. Endoscopic and extractsurface modes provide useful information on the anatomical relationship of the aneurysm for neurosurgeons and neuroradiologists. These modes provide the opportunities to extensively discussthe medicaltreatment. Particularly largebasilaraneurysms, these modesprovideuseful information.
IV-2-27I
3-D Neuroendoscope and CM-cube system in neurosurgery
T. Taira, H. lsakl, H. Kawamura, T Tanikawa, H. Kawabatake, K. Takakura. Deptof Neurosurgery, Tokyo WomensMedicalCollege Tokyo, Japan Introduction: Although three dimensional (3-D) visualization is essential in rnlcronsurosurqery, it is notcommonin neuroendoscopic surgery. Wedeveloped a system that consists of a single lens 3-D neuroendoscope and a computer aided micro-multichannel manlpulation device (CM-CUBE). Description of the System: The 3-D neuroendoscope is a 4 mm diameter single rod lens type with a specialsemi-lucent mirrorprism. The prismsplitsthe imagewith a certain angle of visionand the split imagesentertwo independent CCD cameras. There are two methods to observe3-D images. One is a liquid crystal (LC) shutter method. Images for each eye are alternatively (1/60 sec) displayed on a TV screen and surgeonswear glasseswith an LC shutter synchronized by infrared signalswith a TV screen. Another methodusesLCdisplay with a special flat lens. The flat lens separates the imagesfor individual eyes, The formermethodallows sharperimagesbut wearingthe glassesis awkward. Video images are stored in W-VHS video tape. The CM-CUBE consists of a cylindrical retractorof 10 mm in diameterwith multipleworkingchannels including one for the endoscope. This can be gUided with a stereotactic method. The working channelsare for a coaxialultrasonicimagingprobe, bipolarcoagulator, Laser knife optical fiber, surgicalforceps and facilities. These are manipulated manuallyat present, but a computerdriven systemis now under development. Future Perspective: In developing the 3-D imageneuroendoscope and the CM-CUBEsystem, we have future tele-surgery in mind. With further introduction of high quality TV images (Hi-vision) and full-controlled tele-manipulation system, a highly skilled surgeon can perform operations in his office even for patientsin distantisolated places.
'V-2-28! Navigated neuroendoscopy C. Matula, K. Roessler, A. Reinprecht, W.Th.Koos. Neurosurgical Departement, University of Vienna, Austria Due to the rapid technical developments in neuroendoscopy and in neuronavigation systems both techniques are nowadays established in modern neurosurgery. The combination of both technologies appears the next logical development in the effort to be as much minimal invasive as possible and to hold the risk thereby as minimallyas possible. The results and experiences of the existing work are based on more than 350 operations under application of a "neuroendoscope" and by more than 100 employments of three differentneuronavigational systems (MKM, SPOCS, EASY GUIDE). The neuroendoscopic experiences shows, that the most main complications are the traumatization of the CNSand the orientation of surgery. The neuronavigation with its nowadays satisfactory accuracyof referenciation and intraoperative reproducible precision seemsto be a perfect way to give a controlled orientation. Basedon that there seem to be two different concepts for the application of both techniques together. On one handthe simultaneous application, each one as a separateunit and on the other hand the real combinedapplication as one unit. For the combinedapplication an own adaptation for the pointerwas developed whichwill be
Monda y, 7 July 1997 presented and demonstrated in a short videoclip. From a group of 14 patients we treated in that way, we report our clinicalexperiences and discuss possible areasof application and indications as well as the personnel and organizational expense. Using that combined technique helps a lot to minimize the traumatization of surgery. The control and the effectiveness of surgery are raised clearly. The neuronavigation in neuroendoscopy brings essentially more orientation. The safetyin neuroendoscopy is raised therebysignificantly. The additional time for referenciation lay between 20 and 30 minutes, which surelyappearsacceptable withthe beforenamedadvantages. Theimplementation of neuroendoscopy and neuronavigation appearsfor the futureas absolutelynecessarilyand meaningfully. The creation of differenttechnical requirements is absoluteto push as well as the implementation of intraoperative ultrasound and intraoperative computer tomography as realtime intraoperative imagingwhich we wouldlike to present.
IV-2-29I
Development of an endoscopic navigation system on the base of an automatic visual control system
M. Scholz1, W. Konen2, M. von DOring 3, M. Hardenack1 , A.G. Harders1. of Neurosurgery. Ruhr-University Bocbum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892 Bochum, Germany. 2 ZN (Centerfor Neuroinformatics), Bochum, Germany, 3 Instituteof Neuroanatomy, Ruhr-University Bochum, Germany 1 Department
Introduction: During neuroendoscopy the endoscopic picture appears on the screenand is lost in the next momentwhen it is not recorded by tape or photo. But also in these cases the endoscopic picture can not be brought into exact correlation to a position in an 3-dimensional space. The aim of this study was to combine an endoscopic navigation system with a new visual control system based on video data in order to increasesafety and flexibility of endoscopical interventions. Materials and Methods: A humancadaveric head(phantom) was examined by MR(CT)with2 mmslices. Thesedataweretransferred to a navigationsystem (Easy GuideTM Neuro, Philips). A rigid endoscope (Wolf) was adaptedto the navigation system by combining it with an LED setup suitable to record the endoscopic position in 3D. The Video image was digitiZed by a frame grabber and used for different options of image control. 1) localization and display of anatomical landmarks in the endoscopic image and in the MR (CT), 2) an alarm system for standstill control, 3) the development of a virtual surrounding of the endoscopic image, 4) a measurement tool for intraoperative recalibration of preoperative MRdata, 5)the possibility of virtualbackmovements to avoidtissue damageand 6) the construction of a virtual background in case of bleeding. Results: The rigid Wolf endoscope connected to the Easy Guide System is a very precise tool for neuroendoscopical navigation. The described options weretested in 10 cadaveric specimen and several phantoms. Option 1}-3) are developed in a suitable way for neuroendoscopical interventions and can be transferred to clinical studies. Options 4)~) need further softwareimprovai. Conclusion: Development of an endoscopic navigation systemon the base of an automatic visualcontrol systemis possibleand offersthe neurosurgeons multipleoptionsof instrument controlwhich increasethe safetyand flexibilityof neuroendoscopic interventions.
IV-2-30 I Clinical experience of spinal endoscopy T. Yonemitsu , C. Ochiai, T. Takizawa,M. Matsumoto Jr.. Tokyo General Hospital, Tokyo, Japan The clinical use of endoscopes has become popular in various fields of less invasive surqsry, We have employed malleableendoscopes to observe spinal lesionssince 1993. The aim of this paper is to presentour clinical experiences. AHer positioning the patientlaterallyunderlocalor generalanesthesia an endoscope of small caliber (0.75-2.8 mm in diameter. Medical Science Co. Japan) is introduced from the L3-4or L4-5 regionthroughan introducing device for angiography, by which leakage of the cerebrospinal fluid (CSF) is avoidedduring the procedure. Images are displayed on CRT. Combined use of KTP-Iaser is availableby inserting a glass fiberthrougha channel parallelto the endoscope. A total of twelve patients underwent endoscopy. Representative findings were as follows; rapid to-and-fro movements of the CSF in canal stenosis (1 case), hypervascularity of the cauda equina in spinal AVM (1 case), thickening and adhesions of the arachnoid membrane in arachnoiditis (2 cases), and deformity of the spinal cord in spinal tumor (3 cases). In Hirayama disease (1 case) upward movement of the spinal cord along with the dural canal was prominent especially whenthe patientflexedthe neck anteriorly. In a case withneurinoma, anatomical relationship between lhe tumorand the root was well visualizedand the mass was, though partially, well evaporated by KTP-Iaser w~hout sequelae. In conclusion, spinal endoscopy is a safe and efficacious tool to examine the dynamic aspects of spinal pathology. Although the KTP-laserhas already been applicable to some endoscopes, development of equipment proper for spinal endoscopy such as a bipolar coagulator and an irrigation system is still mandatory for achieving surgerywithouta risk.