Image-Guided Surgery Through Internet of Things

CHAPTER

Image-Guided Surgery Through Internet of Things

4

S. Vijayalakshmi, Savita SCSE, Galgotias University, Greater Noida, India

4.1 ­Introduction Image-guided surgery (IGS) is also known as stereotactic computer-assisted navigation. IGS as used by surgeons is a technique to navigate through the body using three-dimensional images as their guidance. It is an advanced technology to help surgeons to see with (1) better resolution, (2) better orientation and context setting, (3) higher contrast, and (4) visibility inside solid objects. The importance of IGS [1] is growing day by day in minimally invasive surgery procedures and therapeutic interventions. IGS functioning is similar to a global positioning satellite (GPS) system used to track vehicle location and direction at any point on the globe. As in GPS, IGS is used to capture a 3D image of human anatomy before and during surgery. A target is detected, localized, and characterized for diagnosis and therapy in real-time 3D. IGS is a procedure of modifying advanced imaging techniques to accomplish operative interventions inside the body that normally need an open procedure with direct observation of the target area. Before using IGS, first the effectiveness and constraint of modalities must be checked. But by using this advanced IGS technology, surgeons [2] are able to operate on solid and working organs like the heart. In medical education, the medical Internet of Things (IoT) system has significant potential to change the way of doing things (learning). In the medical field, to model novel approaches for real-time collaboration safely and efficiently, with the help of big data analysis and training, IoT-based systems are beginning to be used. IoT technology is a nexus (network) of devices connected with sensors to share information between devices. In the fields of medicine and healthcare, the Internet of Medical Things (IoMT) improves the quality of responses and reduces the time and cost of surgical procedures. In the medical field, especially for surgical procedures, the IoT framework impacts on two broad application areas: (1) surgical training for students and residents from different locations by using a smart technology interface, and (2) IoT-based tele-medicine services that help in planning and postsurgical processing of patients with surgeons in remote locations.

Internet of Things in Biomedical Engineering. https://doi.org/10.1016/B978-0-12-817356-5.00005-X © 2019 Elsevier Inc. All rights reserved.

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4.2 ­Literature Review IGS is a process in which the surgeon uses a tracked surgical device in conjunction with preoperative images to guide them during surgery. This is a medical process that uses a computer system to obtain an image to help surgeons precisely visualize the target surgical site. IGS provides support to the surgeon during performance of a demanding operation for the treatment of disease. The clinical use of IGS systems includes neurosurgery, orthopedic, sinus surgery, dental implant, spinal surgery, and endoscopy sinus surgery. Various surgical navigation systems are available for the treatment of different diseases. A StealthStation navigation system is used for neurosurgery, biopsy, stimulation, and lesion. For knee replacement, three different navigation systems are used: Precision Knee, Express Knee, and Versatile Hip navigation. ClaroNav’s Navident is an advanced-technology navigation system for dental implants. In a navigation system, a tracking tool is used to find the position of the medical instrument at the time of surgery. A number of wired and wireless tracking systems are used. In a wired tracking system, two components are used: field generator and a set of wired sensors. Many tracking techniques are available, such as optical video tracking, mechanical tracking, and electromagnetic tracking [3, 4]. Optical tracking systems have two cameras and an active/passive marker that is placed on the medical instrument. An ultrasound tracking system uses ultrasonic waves. For tracking motion and virtual reality, mechanical pointers are used, but for medical use electromagnetic tracking systems are used, which have three main components: a field generator, sensor, and system control unit. Polhemus FASTRAK, microBIRD, Calypso, and NDI Aurora are some of the electromagnetic tracking systems available. In spinal surgery, IGS provides a 3D view of the spine for preoperative planning and navigation. There are various methods of spinal image guidance, such as fluoroscopy, CT-based, and 3D fluoroscopy. IGS system software in deep brain simulation is used to track the surgical device [3]. An open source tool for IGS is NEURONAV, which allows surgical planning, rigid and nonrigid image registration, atlas registration [5–9] and real-time tracking of a microelectrode device in deep brain simulation. In [4] the authors have presented a pattern recognition system based on spikes analysis to identify microelectrode signals from subcortical. A dental implant, which is an artificial piece for replacing missing teeth, is a standard surgical process. For dental implants, site preparation is needed in which a piece of the jawbone is removed through a surgical process for inserting the implant. This is done by a dental surgeon. The traditional way of doing this depended on the surgeon’s experience and there was a lack of accuracy as a result. The development of image-guided navigation for dental implants gives a better result as compared to the traditional method. [5, 6] In 1980 robots were introduced in the field of surgery and are still in use because of their flexibility and stability. They also reduce errors caused by humans. In [7] the author presents a 5-axes robotic system for dental implants to create the drill template. Innovations in the hardware and software of IGS systems for endoscopy sinus [10, 11] surgery are under development. IGS systems are very helpful in surgery like

4.4 ­ Performance evaluation of IGS

hip and knee replacement, which falls under orthopedic surgery. IGS navigation systems help surgeons in planning the surgery and in selecting the appropriate implant. The [8] authors discuss an IGS system for navigation at the time of spinal surgery and CT-scan images are used for guidance. They have also described technology for anterior cruciate ligament reconstruction, which uses a workstation and 3D optical localizer to display images. In [9] the authors introduced the benefits of interactive navigation of a surgical device for fixation of a spinal implant. [11] To diagnose liver abnormality, a tissue sample is required. These tissue samples are taken by inserting a needle through a small cut in the upper right abdomen. This is a surgical process under anesthesia in which images of the target area are taken using an ultrasound imaging technique for guidance and for navigation. Core biopsy and fine needle aspiration are two common surgical treatments for liver disease.

4.3 ­Evolution Medical IGS intervention has been employed over the last 20 years and makes use of preoperative data as an assisting image. The first X-ray image was discovered by Wilhelm Conrad Roentgen in 1895, but the concept and subprocesses have been tested for over 100 years. It is interesting to know that the use of the first X-ray image in medicine was for therapeutic and not for diagnostic purposes: a surgeon in Birmingham, England, J.H. Clayton, used an X-ray print to remove a needle from a woman’s hand. Approximately a month later, a physics professor at McGill University in Montreal, John Cox, removed a bullet from the leg of a man by using radiography of the limb and later it was used as evidence.

4.4 ­Performance Evaluation of IGS To evaluate [12–14] the performance of IGS, the following aspects are to be considered: • • • • •

Safety of patient and result of surgical procedure Surgery duration Situation awareness Workload and stress Acquisition and maintenance of surgical skills

4.4.1 ­Safety of Patient and Result of Surgical Procedure Safety and results are the two most important aspects of surgery. According to the IOM (Institute of Medicine), patient safety is “The prevention of harm to patient.” According to a patient safety report in 1990, studies show that many patients are harmed by medical errors, which include system failure, powerful drugs, and complicated technology that results in death or serious injury. According to the World

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Health Organization (WHO), 1 out of 10 patients is affected by these errors. The second aspect is the quality of the results of the surgical procedure. As per the IOM, “Health care quality is the degree to which health care service for individual and populations increase the desired health outcome and are consistent with current knowledge.”

4.4.2 ­Surgery Duration Surgery duration is directly related to the efficiency of the surgeon; it is essentially the system interaction that measures the performance of surgeons to accomplish a particular task using IGS or without IGS.

4.4.3 ­Situation Awareness Situation awareness is the awareness of environmental factors with respect to time or space, their comprehensive meaning, and future scope. Prior knowledge and understanding of anatomical structure can be considered a feature of situation awareness.

4.4.4 ­Workload and Stress The main objective of IGS is the reduction of workload and stress of surgeons during the surgical process. But it can have the opposite effect in the situation where a new technology is complex and requires an auxiliary tool.

4.4.5 ­Acquisition and Maintenance of Surgical Skills In training new surgeons, IGS may develop their skills or it can degrade the knowledge of experienced surgeons when IGS is not available for some reason. All variables that are used to evaluate the performance of IGS on maintenance of skills are contained in this group.

4.5 ­System Functionality and Components At a time of demanding operations, IGS [15, 16] presents an advanced technique to support the surgeon’s decisions. Its objective is to focus on technical issues and clinical outcome. But it is not clear that IGS really has an impact on the performance of the surgeon during the operation and that it can reduce stress and duration of surgical procedures. For example, medicine can learn from the field of computer-based simulation that are used for continuous training on complex equipment that are not only provides benefits but also creates new risks and challenges for the users, which are also considered at the time of the evaluation of the system. IGS delivers not only the benefits of navigational performance but also creates new cognitive challenges for the surgeons. The result of these factors is not reflected in the clinical outcome directly but cannot be ignored during the evaluation of system performance. So, the

4.5 ­ System functionality and components

performance of IGS not only depends on the clinical outcome. To know the real performance of IGS, other factors are also important, including human factor issues in complex surgical systems. Fig. 4.1 depicts the IGS system functionality. The surgeons use IGS on the basis of their skills, knowledge, attitude, and experience. In reverse, the IGS system used by the surgeon affects their workload and skill acquisition. The IGS system interaction with the surgeon and the anatomy of the patient have an effect on the surgical result. The classification of the IGS system is shown in Fig. 4.2. The main functionalities of IGS systems are divided into two broad classes: i. IGS system that supports only acquisition and analysis of information by providing navigation information. ii. IGS system that supports surgeon decisions and actions. There are various IGS system functions that support information acquisition. PB-IGS (Pointer Based) This system helps surgeons by providing information about the position of the instrument under triplanar image [17–22] by using a pointer that gives information about the instrument position. i. IN-IGS (Instrument Navigation) is used to track the surgical instrument directly and continuously. ii. DV-IGS (Distance Visualization) is used to visualize the distance between instrument and human anatomy structure that need to be protected during surgery [2]. iii. PV-IGS (Process Visualization) and UV-IGS (Uncertainty Visualization) provide information about visualization of instrument position to remove tissue and providing process over time during surgery.

Surgeon IGS system

Skill Expectation Surgeon Workload Awareness

Patient Anatomical feature

FIG. 4.1 Interaction between IGS, surgeon, and the patient.

Clinical outcome Safety, time Quality of result

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FIG. 4.2 IGS system classification.

iv. PW-IGS (Proximity Warning) gives acoustic and ocular alert when the instruments reach the sensitive area. Some IGS system functions are available that cross the limitation of only providing information acquisition and supporting the surgeon’s decision making and directly intervene in the surgeon’s action. These are: i. ID-IGS (Instrument Disable) used in slowing down the speed of the surgical instrument or to disable it entirely when sensitive structure is too close. ii. MR-IGS (Movement Restriction) controls the movement of the instrument attached to the robotic arm. iii.STS-IGS (Semiautomatic Trepanation) controls the movement of the navigation when the surgeon moves the tool on the skull surface. The work flow of IGS includes the following steps: i. Creates topography image in the form of preoperative data for surgical treatment [23, 24]. ii. Tracks the therapeutic device position during surgery. iii. Records the measured volume with preoperative data. iv. Shows the position of instrument device according to preoperative data with regard to medically important structure. v. Registers the differences between intrareality and preoperative data [25]. Image-guided intervention (IGI) can be applied on any part of the body but it is mostly used in neurosurgery because the skull has a rigid stable frame in comparison to other body parts [26]. The workflow of the IGS system is shown in Fig. 4.3.

4.5 ­ System functionality and components

FIG. 4.3 IGS components.

The patient dataset is compiled as three-dimensional anatomical maps on which the surgical tracking tool is displayed and the image dataset information and tracker information are stored into different referenced frames, which are aligned by registration into a single frame. After registration, the physicians can manipulate the data for further processing. During surgery, directions for guidance can be achieved by updating the position of the tracking tool with respect to the patient dataset. Components of IGS are: • Imaging [17–26] • Registration [14] • Planning • Tracking tool [27–30] • Navigation system [31] A short summary of each of the components is presented in next.

4.5.1 ­Imaging Image is a key component of IGS because it gives a three-dimensional view of the patient’s body. To create a 3D view of patient anatomy, various imaging modalities are used, such as X-ray, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound. The CT scan uses computer and X-ray to create cross-­sectional images of the body part. It is preferred for lungs, organ, bones, and tissues. CT scan uses radiation to create an image of the body part, which is harmful to the body. Ultrasound uses a sound wave to create the image of the body part; this is also known as sonography or ultrasound scanning. This device is operated in the range from 20 kHz to several gigahertz, which lies above the range of human audible range, hence it is not harmful for the patient. It is also less costly, noninvasive, and painless, but its imaging resolution is less than CT scans and MRI scans. MRI is a noninvasive tool to create a cross-sectional image without using radiation. MRI uses a magnetic field and radio waves to see the structures inside the body such as soft tissue, blood vessels, and organs that are not clearly seen in the other modalities like X-ray, CT, and ultrasound. MRI gives a clear and detailed image of the tissue and it

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can create more than 100 images from any direction and orientation. It is mostly used in the treatment of heart, stroke, cancer, and vascular disease. However, it is costly as compared to other imaging modalities.

4.5.2 ­Image Registration Image registration, [32, 33] an important component of image-guided intervention, is a procedure to carry different sets of data into one coordinate system. The main objective of the registration process is to integrate common features of different images into a single image that helps in providing accurate surgery results and good navigation for the surgeons during surgery. The images of the target area in human anatomy are acquired from different modalities like MRI, CT scan, X-ray, ultrasound, and PET scan [34–38] into different time frames and angles. Before the surgical process it is very important to align the preoperative data to the patient data. Image registration can be rigid and nonrigid; rigid registration is used in commercial IGS and nonrigid registration is used in research. Objects that are interconnected with rotation and translation are registered by rigid registration, as shown in Fig. 4.4, using six

Original image

Before registration

FIG. 4.4 Rigid registration.

Rotated and translated

After registration

4.5 ­ System functionality and components

d­ egrees of freedom in a three-dimensional image. Three rotation and three translation vectors are applied but deformation is not considered in this process. The various steps in the image registration process are shown in Fig. 4.5. Image registration processes steps: The image registration process [39] follows the steps listed here and the outcome of these steps provides the resultant images from the input image. • Input image: At this step two images are taken, the patient’s preoperative image (source image) and the patient’s intraoperative image (target image). These two images give the resultant registered image that helps the surgeons during the surgical process. • Attribute detection: In attribute detection some important features from preoperative and intraoperative images are identified because they contain the diagnostic details of the human anatomy. The identification of desired features helps in providing a good result from the surgery. • Features matching: At this step the detected features of source and target images are matched based on some similarity measurement, which is a very typical step in the image registration process. If the features are not matched, this means that there is an error and the result will provide the wrong position for surgery. • Transform model: Transformation of the model maps the relative features into source and target images, which is carried out by locating points on the patient’s target images, then correlating with the source image and computing

Start Source image

Target image

Input image Attribute detection Features matching Transform model Resampling

Final image

FIG. 4.5 Image registration process.

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the transformation between these images. The transformation model can be rigid or nonrigid as per the situation. Splines, optical flow based, and finite element models are some transformation methods which are used in image registration. • Resampling: The various preoperative and intraoperative images of the patient are acquired on different rotations and angles and in this step these points are coordinated into a single frame. Resampling is a final step that geometrically converts the coordinates of the preoperative image into the intraoperative image. • Final image: This is the last step, in which the registered image means the final output is provided.

4.5.3 ­Planning In the planning phase, for the surgical procedure to make its 3D model of the human anatomy, all preoperative images are uploaded into the image guidance navigation system. All the information about the patient’s anatomy provided by the system helps the surgeons to plan the surgery. This information also helps surgeons to identify the target area during surgery so that they can focus only on the target area and avoid the rest of the healthy area. It also reduces the surgical risk.

4.5.4 ­Tracking Tool An important element of image-guided intervention is the tracking device, also known as a localizer. Development of image-guided systems totally depends on the continuous improvement of navigation devices. The tracking device is used to locate the position of the instrument into the patient’s anatomy. Tracking devices that have been used previously are mostly mechanical digitizers. Various types of tracking devices are used in image-guided navigation and they are different from each other in their functionality. Some different tracking devices are: • • • •

Optical video metric Optical active and passive infrared Mechanical position pointers Electromagnetic tracking

4.5.4.1 ­Optical Tracking System

Optical tracking systems utilize infrared lights to manifest the location and situation of the target via active and passive marker, as shown in Fig. 4.6. An active marker radiates its own infrared light (IR) and a passive marker throws back IR given by an outer source. Light-emitting diodes (LEDs) are the most common active marker and charge-coupled device (CCD) cameras that provide a two-dimensional view of an image are used in passive markers.

4.5 ­ System functionality and components

OptiTrack

MicronTracker

•

3D and motion capture system

•

Used for virtual reality, robotics, animation, and video game design.

•

Stereoscopic vision to track special marked object

•

Used in biopsy, IGS, augmented reality, and ablation.

•

Head tracking input device, control camera as well as game.

•

Specially for video games

•

To track active and passive marker attached device

•

Hands free cursor control

•

Control computer through moving head, can be used at the place of mouse.

TrackIR

Polaris tracking system

SmartNav

FIG. 4.6 Different optical devices.

4.5.4.1.1 ­Optical Video Metric Optical video metric identifies a marker pattern on a video sequence image by using one or more calibrated video cameras. This type of tracking system is commonly used on crash test dummies, the video metric solution applied on the VISLAN system (VISible LANDmark), and AR toolkits (Augmented Reality). MicronTracker of ClaroNav in Canada is a commercial system that uses optical video metric that has a 157 × 36 × 47 mm form factor.

4.5.4.1.2 ­Optical Infrared This system consists of more than one camera and a special marker beacon placed on the object to be tracked and it continuously releases infrared waves in every direction. These waves are recognized by an IR receiver that is rotated in different locations. This type of system can track multiple objects and its high frequency rate, high accuracy, and isotropic measurement error make it useful for medical applications. It maintains a line of sight between the tracking tool and the instrument to be tracked, which makes it unusable for tracking flexible instruments inside the body. Active and passive are two different types of infrared optical markers and both are used mostly in

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medical clinical applications. LEDs that operate in the near-infrared range are used as an active marker and are tracked by two or three CCDs. Passive markers are similar to the video metric system and they are wireless. Varian Real-time Position Management is one of the commercial applications of optical infrared tracking for clinical use. Fig. 4.6 shows different optical devices employed in IGS. The benefits of an optical tracking system are: i. ii. iii. iv.

Optical tracking is less sensitive to the environmental noise. Tracking devices may be wired and wireless. It can track multiple objects at the same time. These devices can be used for different purposes like gaming, virtual reality, and golf swing.

4.5.4.2 ­Mechanical Position Pointer

Mechanical position pointers (MPPs) are most widely used for motion capture and virtual reality applications. The three-dimensional boundary captures give a 3D view of patient anatomy and for this a 3D positioning pointer is used. MPPs were used in medical applications before the development of optical tracking instruments.

4.5.4.3 ­Electromagnetic Tracking System

For medical applications the electromagnetic tracking system (EMTS) is a new tracking instrument in which no line of sight is required between the tracking system and instrument to be tracked [27]. Three elements of EMTS are the field generator (FG), sensor unit, and central control unit. To produce a position-varying magnetic field, FG uses various coils. A current is moved by the magnetic field into small coils contained in the sensor unit, which is attached to the object. The direction and position of the object can be decided by analyzing the behavior of the coils and also by detecting the position of the sensor. The FG and data captured by the sensor element are controlled by the central control unit. This technique is mostly used in motion capture and virtual reality. The EMTS can be divided into three categories based on medical application requirements: active current driven tracking, direct current driven tracking, and passive tracking systems. Some commercial wired and wireless commercial tracking systems are used in the medical field. They are Ascension microBIRD, NDI Aurora, Calypso, and Polhemus FASTRAK as shown in Fig.  4.7. Calypso is a wireless EMTS tracking system and the rest of these are wired tracking systems.

4.5.5 ­Navigation In IGS treatment, visualization of the dataset is a very important task. There is no need for surgeons to navigate with only a single MRI/CT scan image, because they can access 3D or even 4D data, augmented from different modalities. Patient anatomy images are taken from different modalities and it is important that this dataset is presented to the surgeon very clearly. The quality of the surgery results and the whole surgical procedure depends on good visualization.

4.6 ­ Software

Vinyl encapsulated cable

ODU connector

Sensor

Ascension microBIRD

Electromagnetic tracking system

Calypso

Polhemus Fastrak

NDI aurora

FIG. 4.7 EMTS commercial tracking systems.

4.6 ­Software Software is a component that combines the tracking system information, associates the data with corresponding images, and presents the real-time information of the device and the patient. Many open source software applications are used. Open source means the source code can be changed according to application needs. But before open source software, researchers used a Berkley Software Distribution (BSD) licensed model. The major open source software packages available for IGS currently are: • 3D Slicer • Image Guided Surgery Toolkit (IGSTK)

4.6.1 ­3D Slicer As shown in Fig. 4.8, 3D Slicer is an open source software platform for IGS and for detailed examination of image registration, segmentation, and visualization of medical. It is used for different medical applications such as autism, prostate cancer, orthopedics, schizophrenia and many more. Some of the features of 3D Slicer are: • Can be used on Linux, Mac OSX, and Windows operating systems. • Supports different imaging modalities: MRI, CT scan, ultrasound, nuclear medicine, and fluoroscopy. • Can be used for multiple organs of the human body from head to toe. An interactive navigation system is used for surgical treatment. The navigation system includes an imaging device, tracking tool, and a workstation for image

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FIG. 4.8 3D Slicer software.

s­ egmentation and other computational functions. The patient images are taken using an imaging device and are sent to the system to reconstruct the 3D model. The position of the surgical device is read by a tracking tool that guides the surgeons during surgery as to the correct position of the target. This navigation process is controlled by 3D Slicer.

4.6.2 ­Image-Guided Surgery Toolkit IGSTK is a high-level open source software toolkit that provides functionality for IGS applications; the IGSTK system is shown in Fig.  4.9. This software was developed with the support of the US National Institute of Biomedical Imaging and Bioengineering and was developed with the collaboration of Georgetown University and Kitware in 2003. The first version of IGSTK software was released in 2006. The components of the IGSTK architecture are a scan dataset, spatial object representation, image reader component, and tracking tool. The tracking tool is the key component that manages the communication between computer system and medical instrument. This Toolkit is a component-based toolkit and was developed during 2005. It is a special toolkit to track the needle using an electromagnetic field. The toolkit has the following components. • 2D and 3D viewers • Tracker interface • Registration modules

4.7 ­ IGS tracking tools

FIG. 4.9 IGSTK system.

• Open source libraries • Application programming interface (API) The toolkit incorporates the principles of the Insight Segmentation and Registration Toolkit (ITK) and the Visualization Toolkit (VTK). The Fast Light Toolkit (FLTK) is used for the graphical user interface (GUI).

4.7 ­IGS Tracking tools In computer-assisted surgery, a device is inserted into the patient’s body to see the internal structure that provides information about the target area for surgical guidance. The device tracking system in IGS, as previously discussed, is a key enabling technology. Various types of tracking systems are used to track the medical instrument without any restrictions. These are optical video, optical infrared, mechanical position pointer, and electromagnetic tracking system. Commercially available tracking systems include: • Ascension microBIRD tracker • NDI Aurora electromagnetic tracking system

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• Calypso navigation system • NDI Polaris optical tracking surgical navigation • Polhemus FASTRAK navigation tool

4.7.1 ­Ascension Micro BIRD Tracker IGS system during the surgical process depends on the tracking of the medical instrument in a 3D environment. By using information provided by the medical device, surgeons can present an overlay of device coordinates on real-time or preoperative data. The combination of imaging modalities and tracking device helps the surgeons to see inside the body for guidance and navigation during surgery. The tracking device must be natural, accurate and unaffected by other environmental factors. A popular tracking device that fulfills these conditions is a microBIRD tracking tool, as shown in Fig. 4.10. It consists of a miniature sensor for internal body navigation and gives accurate and quick positioning of the instrument device. It is used in 3D ultrasound, telerobotics, electrophysiology, brachytherapy, image-guided therapy, and intrabody navigation. Features of the microBIRD tracker include: • Tracking without ionizing radiation: The two-dimensional X-ray imaging provides the real-time position of a medical instrument without radiation exposure. • Affordable: Reasonable cost compared to other systems. • Accurate measurement: Advanced sensor technology that provides accurate tracking strength.

Vinyl encapsulated cable

ODU connector

Sensor

FIG. 4.10 MicroBIRD trackers.

4.7 ­ IGS tracking tools

• Degree-of-freedom tracking: A needle-guided process requires free movement during surgery; microBIRD is an appropriate tool for this purpose because it provides six degrees of freedom under a 3D environment. • No occlusions: Without any restrictions, it can transfer the data on full range even when sensors are fixed into the device or inside the body.

4.7.2 ­NDI Aurora Electromagnetic Tracking System A commonly used tracking system that uses electromagnetic techniques is the NDI Aurora, as shown in Fig. 4.11. It is a navigation system used in various medical applications like neurosurgery, oncology, interventional radiology, anesthesia, endoscopy, cardiology, and laparoscopy surgery. This tracking system gives information about real-time position and degree of miniature sensors, in five or six degrees of freedom (DOF). These sensors are integrated at the tip of the devices, such as needles and catheters, used during the surgical process for navigating the instrument inside the body. Features of the Aurora tracking system: • No line of sight: it can freely track the device into six or six degrees of freedom without any restriction. • Track more sensors at a time: it can track up to 16 sensors at a time or it can be customized for up to 32 sensors. • Cost-effective sensor and small in diameter, as small as 0.3 mm for integration into needle. • NDI field generator types that have plug-and-play feature with system.

FIG. 4.11 NDI Aurora system.

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4.7.3 ­Calypso Navigation System Calypso is an electromagnetic system based on real-time tracking and treatment, shown in Fig. 4.12. It is also called a “GPS for the Body. This tracking system is used in the treatment of cancer. For cancer treatment, radiotherapy is the most effective method. At the time of radiation therapy, however, internal organs like the prostate, liver, pancreas, and adrenal gland can move inside the body, making it difficult to locate the target area using currently available imaging methods. Under these conditions, the Calypso navigation system provides a better result. In Calypso, to localize the target area a very small-size Beacon transponder is used as shown in Fig. 4.13. These are wireless and look like a large grain of rice. These transponders are inserted into the body and emit radiofrequency signals to identify the location of the prostate or other organ. This helps to locate the organ throughout the treatment process. The Beacon generates a sound when the organ moves outside the set parameters and the treatment is stopped. ­Benefits of Calypso system: • This system helps in applying higher radiation doses specifically to the prostate (or other target organ) and saves the healthy tissues.

FIG. 4.12 Calypso tracking system.

4.7 ­ IGS tracking tools

Bladder Transponder

Prostate gland

FIG. 4.13 (A) Beacon transponder, (B) position of Beacon transponder into prostate.

• It provides continuous motion and location of the prostate to ensure the delivery of the prescribed radiation doses only to the prostate. • There is no need for X-ray images to locate the prostate daily before treatment.

4.7.4 ­NDI Polaris and Vicra Optical Tracking Surgical Navigation Another advanced technology product in surgical navigation is the Polaris tracker, which provides integration with computer-assisted surgery. Two optical tracking systems, Polaris Spectra and Vicra, give accurate, real-time 3D positioning of the markers placed on the medical tool during computer-assisted surgery. These markers can be active or passive. The markers are tracked under the predefined parameters that provide visualization in different medical applications such as orthopedics, neurosurgery, and spinal surgery. The system and its components are shown in Fig. 4.14. ­System components include: Sensor: Tracks passive marker and its position, emitting infrared light, and also tracks the 3D position of a single marker.

●

(A)

(B)

FIG. 4.14 (A) Optical tracking system, (B) system control unit, (C) strobe.

(C)

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Spectra: Suitable for cross-platform applications due to its flexibility and reliability. Host USB converter: USB converter is common to both Polaris Spectra and Vicra systems, which provides a link to the sensor. System control unit: This is an interface between computer, sensor, tools, and strobes. A general port (GPIO) is also available to connect other devices. Strobe: Connects three active marker tools with GPIO port.

●

●

●

●

4.7.5 ­Polhemus FASTRAK Navigation Tool The FASTRAK navigation tool from Polhemus is an electromagnetic tracking tool, shown in Fig. 4.15, that provides accurate information about 3D digitizer and quad sensor motion as shown in Fig.  4.16. The FASTRAK tool provides information from more than one sensor into a single magnetic source. The source generates an ­electromagnetic field and within this field if any sensor is available then it is tracked by FASTRAK in six degrees of freedom without any line of sight. Various medical applications where the FASTRAK navigation system is used are: eye tracking, neuroscience, biomechanics, and electroencephalography (EEG) localization.

FIG. 4.15 Polhemus FASTRAK system control unit.

FIG. 4.16 (A) Micro sensor 1.8, (B) 3D digitizer.

4.8 ­ Imaging modalities

­Some features of the FASTRAK tracking system are: • It provides real-time data continuously without line of sight. • Very simple and intuitive set-up and provides information up to four sensors at a time with user interference.

4.8 ­Imaging Modalities During image-guided neurosurgery, imaging [40] is the most essential step because it is very difficult to reach the surgery target object when it is surrounded by the cranium and critical tissues. Second, imaging provides the real-time update of the surgical instrument location, which affects the procedure result. The combination of imaging and planning, postoperative phase is known as IGN (image-guided neurosurgery). Various imaging modalities are used in IGN, but the selection of imaging modality depends on its speed of acquisition, image quality and comfort during surgery. Various imaging modalities are: • Computed Tomography • Ultrasound • Magnetic Resonance Imaging • Positron Emission Tomography • Fluoroscopy • Optical method • Nuclear medicine • Biophotonics

4.8.1 ­Computed Tomography A CT scan involves a large, box-like machine with a short tunnel. Computer tomography is a medical test that creates multiple 2D and 3D images of internal parts of the body, which can be viewed on a computer system. For the treatment of any internal part of the body, an image of the target area is required to analyze the abnormality in an area. The CT scan provides detailed information on the target area, such as an organ, soft tissue, blood vessels, and many more. In comparison to X-ray, it is very helpful in finding diseases like cancer, infectious diseases, and cardiovascular diseases. Some of its special features are: • Best for pelvic and abdomen because it gives a detailed view of inside the body by using cross-sectional views. • Best for finding cancer in chest, lung, ovary, kidney, and pancreas. • Can examine kidney tumor, cystic fibrosis, and severe injuries. Benefits: • Painless and noninvasive. • Fast, simple, and cost effective.

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• Insensitive to environmental noise. • Provides detailed image of soft tissue, bone, lung, liver, and blood vessels. • Gives real-time images to guide invasive surgeries such as core biopsy and fine needle biopsy. It is the best modality that uses cross-sectional imaging, which can be used in the planning stages such as needle guidance and biopsies. CT scans create a twodimensional image of any body part.

4.8.2 ­Ultrasound Ultrasound [41] or sonography is a portable, very low-cost, easy-to-use, and noninvasive process that does not use any ionizing radiation. The time range is seconds to minute and it can be used in the guidance stage with images of another modality. However, with ultrasound it is difficult to take images through hard bones. Sound waves are used in ultrasound to create a picture of the internal body parts. A special Doppler ultrasound method is a technology used to examine the blood flow in arteries, arm, legs, and in all body parts, as given in the following list: • Color Doppler: shows speed and direction of blood flow by converting Doppler measurement into array of colors. • Power Doppler: Does not show the direction of flow of blood, more sensitive than color Doppler and provides detailed information when blood flow is minimum. • Spectral Doppler: Shows graphical representation of blood flow and can create a sound for blood flow that can be heard with every heartbeat. Benefits: • • • • •

Analyzes the reason for pain, swelling, and infection. Examines kidney, bladder, spleen, eyes, uterus, and brain, hip, and spine in infant. Guides surgical needle biopsy to collect sample of tissue from abnormal area. Echocardiogram (ultrasound of heart) can diagnose heart cancer and failure. Analyzes baby movement in mother’s womb.

4.8.3 ­Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is a radio technology scanner that uses radio waves and magnetic field and a computer system to produce a detailed picture of the tissue and organs. It is a strong magnetic field that provides a high-resolution image of soft tissue, which can be used in every stage of IGS. The first MRI of the full body was created by Raymond Damadian, an American physician. Usages and benefits of MRI are as follows: • No radiation in MRI as with CT scan and X-ray. • Noninvasive and painless.

4.8 ­ Imaging modalities

• Scans the abnormalities in brain, spinal cord, heart, injuries, liver, breast, blood vessels, and internal organs. • Finds the reasons for infertility in women. • It is not generally used for cochlear implant, kidney disease, or with cardiac pacemakers and artificial heart valves (although MRI can now be performed safely in many patients with cardiac implanted devices).

4.8.4 ­Positron Emission Tomography and Single Photon Emission Computed Tomography Positron emission tomography (PET) and single photon emission computed tomography (SPECT) are the nuclear medicine imaging modalities in which a radioactive tracer is used to create a picture of body parts. Radioactive tracers are carrier molecules and are specially used for scanning. SPECT: SPECT creates a 3D view of radiotracer molecules in the human body. To create 3D images, many projection images of the body at different time frames are needed. When the tracer is injected inside the body it emits gamma rays and these gamma rays are detected by special camera to create the image. PET: PET is also a nuclear medical imaging technique that uses radiopharmaceuticals to make a 3D image. The difference between PET and SPECT depends on the type of tracer. The tracer used for PET emits particles known as positrons. These are the same as electrons but oppositely charged. They are destroyed when the electron and positron integrate with each other and at that time they emit energy in the form of photons. The camera used in PET detects this energy and produces an image. On guidance and resection for the core biopsy stage of tumor planning treatment, PET/SPECT can be combined with CT and MRI imaging modalities so that PET gives information about tumor margin and CT gives information about anatomical referencing. A small amount of radioactive drug is used in PET to show the difference between healthy and diseased tissue. The most commonly used tracer drug is fluorodeoxyglucose and for this reason it is sometimes called an FDG-PET scan.

4.8.5 ­Fluoroscopy Fluoroscopy is an X-ray movie that shows X-ray images in a continuous form on the system. It is very useful at the time of surgery to navigate an intraoperative surgical instrument. During a fluoroscopy process, an X-ray beam is moved across the body and these images are transferred to the system to see the movement of the body parts and the instrument. Fluoroscopy helps in the treatment and diagnosis of various diseases. Some of its uses are: • In orthopedic surgery for joint and knee replacement and for treatment of fracture. • Provides an image of the gastrointestinal tract to analyze the stomach, esophagus, and intestine.

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• Treatment of heart-related disease. • To open blocked blood vessels. The use of radiation in the fluoroscopy process makes it harmful for the human body, because the high dose of radiation can induce skin cancer and burn tissues.

4.8.6 ­Optical Method The optical method is a noninvasive technique to look inside the body to acquire images of organs and tissue as well as cells and molecules using visible lights and special properties. The two most common optical methods are bioluminescence (production of light by living organism) and fluorescence.

4.8.7 ­Nuclear Medicine Nuclear medicine is an imaging technique in which radioactive material called radiotracers is injected into the human blood to take a picture inside the body. This material moves around the target area and emits gamma rays and these gamma rays are captured by camera and system to create the image. Nuclear medicine is a noninvasive procedure used in various medical applications. The types of nuclear medical scans are: • Bone scan: Takes an image of bones to check for the presence of tumor and infection in bone. • Gallium scan: Takes picture of the specific tissue to look for infection or tumor. • MIBG scan: Metaiodobenzylguanidine scan for both bone and soft tissue to check for cancer. ­Some of the applications of nuclear medicine are: • • • • •

Analysis of the heart function after chemotherapy. Visualizing heart blood flow, spinal fluid flow, etc. Location of infection of unknown reason. Planning for cancer treatment. Discovery of sites for biopsy.

4.8.8 ­Biophotonics Biophotonics is a combination of biology and photonics, or the study of light. It can help surgeons to see how the cells and tissues are working. This light technique provides a sample of diseased and healthy tissue for diagnosis, treatment, and during surgery. This connection between photons and living cells was suggested by Alexander Gurswitch in 1923 based on emission of ultraweak photons from onion and yeast. After 20 years, German scientists found the same emission from living organisms and they called it biophotonics. Some of the applications of biophotonics are: • In biology, to analyze the function of proteins and DNA with other chemicals. • To view living organisms and study how cells communicate with each other.

4.9 ­ Applications of IGS

• To help in finding infectious disease (HIV). • To provide information about moving parts inside the body. • To provide noninvasive treatment for various diseases.

4.9 ­Applications of IGS IGS plays an important role in making many complex surgeries easier and more successful. Some of the applications are: • Neurosurgery • Parkinson’s disease • Dental implants • Endoscopy sinus surgery • Liver surgery • Spinal surgery • Cochlear implant

4.9.1 ­Neurosurgery Neurosurgery [42–44] is used for removal of tumors, biopsies, and treatment of epileptic and vascular conditions. When IGS is used in neurosurgery, three steps are involved: 1. Planning phase, 2. Intraoperative phase, and 3. Postoperative phase.

4.9.1.1 ­Biopsy

Biopsy is the process of taking a tissue sample to diagnose diseases like tumors, cancer, and other brain diseases. These tissues are taken with the help of a needle by inserting it into the tumor. Before that, a target area is scanned with the help of imaging modality.

4.9.1.2 ­Tumor Resection

A resection in medicine is the process of removing part or all of an organ, structure, and tissue. This process is very difficult due to sensitive and critical areas, vascular anatomy, and white tract matter.

4.9.1.3 ­Epilepsy

Epilepsy is a neurodisorder in which brain cell activity is disturbed and which can cause unpredictable seizures. If these seizures are not controlled by medication, then surgery is required. Image-guided neurosurgery (IGN) plays a very important role in identifying and removing the seizure focus. MRI, CT, PET, SPECT, and EEG can be used in the treatment of epilepsy. In epilepsy surgery, ictal SPECT is often used to find the region of seizure for surgery planning.

4.9.1.4 ­Vascular Conditions

Blood clots, hypertension, aneurysms, and stroke are some of the vascular diseases. Irregular conditions of the blood vessels, i.e., arteries and veins, can cause disability and death. Surgical treatment of veins and arteries with complete excision of the

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lesion use IGS. CT scan, angiography and fluoroscopy are used for the planning and surgical phases with image registration and navigation instruments.

4.9.2 ­Parkinson’s Disease Parkinson’s is a progressive neurodisorder that affects movement. Signs and symptoms of Parkinson’s disease (PD) [45, 46] can be different in different patients. Tremor, bradykinesia, rigid muscles, speech changes, and writing changes are the most common symptoms of Parkinson’s disease. There is no standard treatment for Parkinson’s disease currently. Symptoms can be controlled by medicine and surgery. Deep brain stimulation (DBS) is one of the surgical options for treatment of PD patients. In DBS, a microelectrode is placed over the subthalamic region that reduces the PD symptoms. For complex surgery, an IGS system that is able to track the surgical instrument during an intraoperative process is used. During DBS, a tool is required to plan and to navigate the microelectrode device. NEURONAV [45] is a tool for IGS that helps in surgery planning, image registration, atlas registration, 3D image viewing, and real-time location of microelectrodes for DBS. It is a supportive tool for surgeons to accurately identify microelectrodes over the subthalamic region in 3D view.

4.9.3 ­Dental Implants A historical development in dentistry has been the dental implant [47–49], which is now considered the standard of care for missing teeth. Fig. 4.17 shows the dental implant system. Missing teeth affect eating ability, speech, and alimentation. Three parts make up a dental implant: • Implant: Artificial piece that resembles a screw and forms the root for the new tooth. • Abutment: Connector that holds the tooth. • Crown: Upper part of tooth, made of porcelain. With the latest advanced technology, computer-guided surgery is available for dental implant surgery. The surgical procedure requires the following: • Cone-beam CT: Special type of X-ray equipment to make a 3D image of bone, soft tissue, and teeth. • Implant kit • Implant planning software (NobelGuide, coDiagnostiX): Planning software for surgical implementation. Use of IGS in dental implant surgery reduces the time, complexity, and discomfort and improves predictability and safety. Yomi from Neocis Inc. is changing implant dentistry as the world’s first robot-assisted dental surgical system.

4.9 ­Applications of IGS

FIG. 4.17 Dental implant system software.

4.9.4 ­Endoscopy Sinus Surgery The cavities, or sinuses, inside a human’s skull that are located around the eyes and nose produce mucus that helps keep out dirt, pollutants, and infectious particles. The sinuses are lined with cilia (very fine hair-like cells) that help to drain mucus through the sinuses. Sinus surgery is a procedure to clear blockages and control any abnormal growth and structure in the sinus. Before the development of IGS, this type of surgery was done with the help of cuts on the face and mouth, with other materials required to control the bleeding after surgery that caused pain and discomfort. But now with advanced technology the surgery is performed by nasal endoscopy, which is a small lighted metal telescope. Using an endoscope with a video camera attached allows the surgeon to look inside the nose, making the surgery much easier. For this surgical procedure a 3D mapping system is used to see the surgical instrument position and the surgery is carried out with the help of the following list of equipment/technology.

4.9.4.1 ­Balloon Sinuplasty

Balloon Sinuplasty is US Food and Drug Administration (FDA) approved technology to open the blockage of sinuses and restore normal sinus function by using a small and flexible sinus balloon catheter, shown in Fig. 4.18A. It is placed inside the nose and inflated to widen the wall to remove the blockage and restore the normal drainage.

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A balloon catheter is inserted into the inflamed sinus

1 The balloon is inflated to expand the sinus opening

2 Saline is sprayed into the inflamed sinus to flush out the pus and mucus

3 The system is removed, leaving the sinuses open

4 (A)

(B)

FIG. 4.18 (A) Balloon Sinuplasty, (B) Fusion ENT Navigation System.

4.9.4.2 ­Fusion ENT Navigation System

The Fusion ENT Navigation System is an IGS system that provides a great deal of information about patient anatomy and helps to locate the surgical instrument tip during sinus surgery. An electromagnetic ENT system incorporates a touchscreen, portable and convenient, that provides digital video of input and output and gives better results and accuracy as compared to other navigation systems. This is shown in Fig. 4.18B.

4.9.5 ­Liver Surgery To diagnose an abnormality or disease in liver, a small quantity of tissue is needed. These tissues are taken by a needle that is inserted from the right upper abdomen and this procedure is called liver biopsy. For accurate and correct needle positioning (placing), images of the stomach area are required. Ultrasound and CT are the two important imaging methods used for this procedure. The liver biopsy [35–39] can be divided into two parts: core biopsy and fine needle aspiration (FNA). Core needle biopsy: Core biopsy is a medical process that is used to remove tissues from a lesion to find out what it is. It is mostly used for detection of diseases in breast, bone, and lymph nodes. This method can take away more tissue as compared to fine needle aspiration and thus gives more information about the tissues. The core biopsy needle size is under 11–18 gauge and appears as shown in Fig. 4.19A.

4.9 ­Applications of IGS

FIG. 4.19 (A) Core biopsy, (B) fine needle biopsy.

Fine needle aspiration: Fine needle aspiration is used to diagnose abnormalities like lumps and masses by taking a small sample of cells from the affected area in the body. For removing a sample of cells, a very thin needle is used. The needle size of FNA is 21–27 gauge and appears as shown in Fig. 4.19B. Table 4.1 shows the differences between a core biopsy and fine needle aspiration biopsy. Procedure: A simple procedure is shown in Fig. 4.20 is to be followed for taking a tissue sample. In the first step, imaging modalities such as ultrasound or CT scan are used to take a preimage before surgery to make the process easier and correct. To reduce pain where the needle will be inserted, anesthesia is given. In the next step, the doctors make a small cut for inserting a core needle to take the tissue. A core biopsy needle makes a short and sharp sound at the time of taking Table 4.1  Differences between core biopsy and fine needle aspiration biopsy. 1. 2. 3. 4. 5.

In most cases it eliminates small lesions Needle size 11–18 gauge Invasive and time consuming Has strong ability to specifically diagnose benign injury

1. Removes only small section of the lesion 2. Needle size is 21–27 gauge 3. Inexpensive, very safe and quick 4. Has a limited ability to specify lesion 5.

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Prescan

Anesthesia

Small cut (lesion)

Core biopsy or fine needle biopsy

FIG. 4.20 IGS working process in liver biopsy.

a tissue sample, whereas in FNA the needle moves quickly up and down and side by side. To reduce bleeding during biopsy, a gel form substance that is absorbed by the body is also inserted.

4.9.6 ­Spinal Surgery Spinal surgery [50–53] is a surgical process used to treat degenerative conditions or diseases of the spine, such as isthmic spondylolisthesis and others. The traditional method of spinal surgery takes too much time and has increased blood loss and pain. The use of IGS for spinal surgery has been increasing over the last 20 years. The method of spinal surgery can be divided into two types, invasive and noninvasive, and the difference between these is shown in Table  4.2. In open spinal surgery, a 5- to 6-in.-long incision is made by surgeons to see inside the spine area but this process is time-consuming as well as very painful. In comparison to this open spinal surgical process, a minimally invasive procedure with an image-guided navigation system provides a supportive tool to surgeons that helps reduce complications during surgery. Table 4.2 lists the comparative analysis between invasive and noninvasive spinal surgery methods. Procedure of spinal surgery: At the time of the operation, a small incision, about 1–1.5 in. is made by the surgeons and a tubular retractor device is inserted to hold the muscles open and to allow insertion of the other medical devices required for the process, avoiding the need to cut the surrounding tissue of the affected area. Here, fluoroscopic imaging modalities help the surgeons to decide on the area for incision for the tubular retractor and the real-time images of the spine are displayed on the system. After completing the surgery process, the retractor and other devices are removed and the incision is closed. Table 4.2  Differences Between Invasive and Noninvasive Surgical Methods. Invasive

Noninvasive

• • • • •

• • • • •

Small incision, about 1–1.5 in. Fast recovery time No blood loss No chance of muscle damage Lower risk of infection

Longer incision, about 5–6 in. Long recovery time High blood loss risk High chance of muscle damage High risk of infection

4.9 ­ Applications of IGS

Types of back surgery: • Laminectomy: a process in which the lamina part of the bone is removed to relieve compression on the spine. • Discectomy: a process of removing part or whole of an abnormal disc (intervertebral) that creates pain by stressing the spinal cord. • Spinal fusion: a welding process that joins two vertebrae to reduce pain in the spine.

4.9.7 ­Cochlear Implant The human ear has three parts: outer, middle, and inner. Damage in any part of the hearing path creates a hearing loss. Different types of tests are used to compute the degree of hearing loss. Hearing loss in the outer or middle ear is described as conductive hearing loss and inner ear hearing loss is described as sensorineural hearing loss. An electronic device developed for people with severe hearing loss is known as a cochlear implant (Fig. 4.21). This system has two main parts: • Internal part: A receiver inserted into temporal bone by a surgical process. • External part: Sound processor placed behind the ear and connected via an antenna. This antenna is connected to the skin over the internal part. The cochlear implant works as follows: i. The external part captures and digitizes the sound. ii. The antenna that is attached to the skin transmits the sound to the receiver. iii. Magnetic receiver inside the skin changes the digital information into an electronic signal and it is sent to the cochlea. iv. Auditory nerves transmit the sound and this sound is received by the brain.

Speech processor

Transmeter

Battery pack

FIG. 4.21 Cochlear implant.

Microphone

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4.10 ­IGS Navigation Systems In IGS, various navigation systems are used during surgical processes, including: • • • •

StealthStation surgical navigation system Stryker navigation system ClaroNav Navident NEURONAV navigation system

4.10.1 ­StealthStation Surgical Navigation System This system is an advanced navigation system to track the surgical instrument during surgical procedures (Fig. 4.22). It has an instinctual interface and is used where stereotactic surgery is suitable. A stereotactic surgery is a nominally invasive surgery in which a 3D coordinate system is used to locate the target area, such as skull, bone or vertebra, inside the body to perform some actions such as injection, biopsy, lesion, and stimulation. The StealthStation S8, the advanced version of the system, is an integration of software, 3D camera, electromagnetic sensor tracking tool, data merging technique, and special instrument; it has the capabilities to merge the optical and EM tracking with other devices like ultrasound and microscope for guidance. The working flow of this system is shown in Fig. 4.23. This navigation system has the following features: • 27″ two touch screen monitors to support multitouch like zooming and dragging. • Provides 2D and 3D visualization and blending tools. • Different image registration methods to identify the location of patient can be used at the same time as touch and trace. • Tools to get more information and to enhance surgical planning. Some additional features are: • • • • •

Two electromagnetic emitters with large tracking volume 1 TB (terabyte) drives to store patient’s examination report 16 GB RAM for fast image manipulation Optical camera that provides flexibility in line-of-sight issue. Wireless connectivity of medical devices to import and export patients report within hospital • O-arm imaging system for automatic registration • Analog and digital output

4.10.2 ­Stryker Navigation System The Stryker navigation system is an interactive monitoring system for hip replacement that improves the surgical performance and result (Fig. 4.24). There are three navigation systems for total hip replacement: they are Precision Knee, Express Knee,

4.10 ­ IGS navigation systems

FIG. 4.22 StealthStation S8 navigation system

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CT and MRI scan of patient by radiologist

Image guided system

3D model made by surgeon

Image registration (mapping of 3D model with patient’s anatomy)

FIG. 4.23 Workflow of StealthStation navigation system.

FIG. 4.24 Stryker navigation system.

4.11 ­ Merits and demerits of IGS

and Versatile Hip navigation system software. • Precision Knee Navigation Software helps to make accurate decisions at the time of preoperative, intraoperative, and postimplantation assessment and balancing soft tissue. It provides the benefits of automatic positioning, balancing, and analysis. • Express Knee Navigation Software is a well-organized, intuitive navigation system that supports a less invasive approach to distal and tibial resections in total knee replacement. • Versatile Hip Navigation Software is used in total hip arthroplasty and also provides real-time intraoperative and postimplantation assessment of joint, leg length, and offset.

4.10.3 ­ ClaroNav Navident ClaroNav Navident is an advanced navigation technology designed for the dental implant in real time by using information provided by various modalities that helps to track the real-time position of the dental drill throughout the process. In this system, sensors are placed on both surgical instrument and patient to get 3D information, and this information is calculated by computer to display the position of the instrument; the system is shown in Fig. 4.25. There are some advanced navigation systems in the dental implant field: DenX Image-Guided Implantology, X-Guide Dynamic 3D Navigation.

4.10.4 ­ NEURONAV Navigation System Parkinson’s disease is a nervous system disorder that affects movement. For the treatment of neurodisorders DBS is required, which is a surgical treatment in which microelectrodes are fixed on to the subthalamic region. It is a complex surgical process where IGS is used, because IGS can track the surgical instrument throughout the process. A sequence of specialized modules is used for developing software, as shown in Fig. 4.26. Open source toolboxes were used to develop this powerful system: VTK (for image processing and visualization), ITK (for segmentation and registration), IGSTK (for microelectrode tracking) and FLTK (building graphic interface). NEURONAV is a tool for image-guide surgery, as shown in Fig.  4.27. It has the abilities of planning, image registration, and 3D image viewing, and can track ­microelectrode instruments. Different image-guided navigation systems are used for different surgical treatments. Table 4.3 shows the different navigation systems.

4.11 ­Merits and Demerits of IGS In medical applications, IGS is very helpful in the treatment of various diseases in which surgery is the only treatment. But IGS also has some merits and demerits, which are described in the following text.

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FIG. 4.25 ClaroNav Navident navigation system.

Patient’s data for medical history

Brain structure module

Deformable registration Labeling and surgery planning

Microelectrodes information

Analysis of images

Communication module (ISIS MER)

FIG. 4.26 NEURONAV system modules.

User interface

FIG. 4.27 NEURONAV system.

Table 4.3  Different Navigation Systems. Sr.·No

Tools

Description

1

1. StealthStation ENT 2. FUSION Compact 1. Precision Knee Navigation Software 2. Express Knee Navigation Software 3. Versatile Hip Navigation Software 1. NEURONAV 1. Stealth Computer Navigation 1. ClaroNav Navident

ENT Navigation System

2

3 4 5

Orthopedic Surgical

Parkinson’s Disease Brain Tumor Surgery Dental Navigation System

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4.11.1 ­Merits of IGS By using IGS, surgeons are able to find the real-time location of the exact area inside the human body for surgery, which makes the surgery easier and reduces the time complexity. Here are some advantages of IGS:

4.11.1.1 ­Real-Time Visualization

IGS systems provide a 3D visualization of the human body that helps in planning a surgery in real time and also helps to track the real position of the surgical instrument. A sensor is used during surgery placed on the medical device that is inserted inside the body to visualize the internal structure. When a device is inserted inside, all the activities can be seen on the computer display that is attached to the surgical navigation system and provides the real-time position and information on the medical instrument.

4.11.1.2 ­High Success Rate

If protocol is followed precisely on each step, IGS provides better accuracy and improves precision. If surgeons use IGS during surgery, IGS provides all the information on each step to the surgeons about the inside of the structure and the movement of the medical instrument, and it targets only a specific area.

4.11.1.3 ­Reduced Complications

IGS reduces complications during surgery by providing step-by-step information to the surgeons about internal structure through navigation; the results are also improved.

4.11.1.4 ­Increased Confidence

When surgical treatment is done with the help of an IGS, it improves the confidence of surgeons that the outcome will be good.

4.11.2 ­Drawbacks of IGS Before the use of IGS, it was very important for the surgeons to have all the knowledge necessary to be able to operate to make the surgery successful. IGS has some benefits in medical applications, but it also has some drawbacks, like cost, set-up time, and training, which make the process a little more complex.

4.11.2.1 ­High Cost

IGS is a very costly procedure because of the high cost of the equipment. All the apparatus used during IGS, and the maintenance, is very costly.

4.11.2.2 ­Long Set-Up Time

Treatment time may be longer because of the multiple steps used in radiography template fabrication. Many steps musts be followed before surgery can take place, such as patient preparation for surgery and the patient’s image registration using various modalities. Setting parameter values for specific surgical procedures and checking all the devices before the actual surgery takes a great deal of time and makes the surgical procedure very long.

­References

4.11.2.3 ­Training

Before using an IGS system, it is important to know about all the devices used during surgery, i.e., which system is used for the required specific purpose, how to operate the system, and how to make the best use of the system. Training must be provided to new surgeons without much surgical experience.

4.11.2.4 ­Equipment May be Cumbersome

All equipment used in IGS is very large and heavy, so it is not possible to move it easily from one place to another. Due partly to the size and weight, maintenance of these devices is also very costly.

4.11.2.5 ­Can’t Replace Surgeons

The use of IGS is increasing steadily in treatments like cancer, neurosurgery, sinus surgery, and orthopedic surgery [54]. IGS depends on the skill of the surgeons, because they know about the treatment procedure. An IGS system can act as an assistant but cannot take the place of surgeons [55, 56].

4.12 ­Conclusion Many innovations are being introduced in the computer and medical fields. Physicians are focusing on how to make surgeries simpler, 100% accurate, and painless. One such innovation area is IGS, where the medical field and computer field are integrating through the IoT [57]. The IoT finds applications in every field and it especially plays an important role in IGS, thereby helping to minimize the work of and pressure on physicians. A decade ago IGS was not very popular but now it has been introduced in many types of surgery. Because of its efficiency it is now implemented in more than 50% of the surgery types and it wouldn’t be too surprising if it finds 100% implementation in the coming decade. Even though IGS can be employed to perform almost any type of surgery, it is not a replacement for a surgeon at this time. However, we could see even that happen at some point, with the help of unexpected innovations going in on the IoT.

­References [1] K.  Cleary, et  al., Image-guided interventions: technology review and clinical applications, Ann. Rev. Biomed. Eng. (2010) 119–142. online at bioeng.annualreviews.org. [2] M. Luz, et al., Impact of image-guided surgery on surgeons’ performance: a literature review, Int. J. Hum. Factors Ergon. 4 (3/4) (2016) 229–263. [3] W. Birkfellner, J. Hummel, E. Wilson, K. Cleary, Tracking devices, in: T. Peters, K. Cleary (Eds.), Image-Guided Interventions, © Springer Science + Business Media, LLC, 2008, pp. 23–44. [4] M.C. Yip, et al., Tissue tracking and registration for image-guided surgery, IEEE Trans. Med. Imaging 31 (11) (November 2012) 2169–2182.

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