Control Architectures for Robotic Assistance in Beating Heart Surgery

Tese de doutoramento em Engenharia Electrotécnica e de Computadores, no ramo de especialização em Automação e Robótica, apresentada ao Departamento de Engenharia Electrotécnica e de Computadores da Faculdade de Ciências e Tecnologia da Universidade de CoimbraDoenças cardiovasculares são a primeira causa de morte no mundo. Todos os anos mais de 17 milhões de pessoas morrem, representando 29% do número total de mortes. As doenças coronárias são as mais críticas, atingindo mais de 7.2 milhões de mortes. Para reduzir o risco de morte, o "bypass" coronário é a intervenção cirúrgica mais comum. Atualmente este procedimento envolve uma esternotomia mediana e um "bypass" cardiopulmonar, permitindo que uma máquina externa implemente as funções de oxigenação e bombeamento de sangue. Contudo, esta máquina externa é fonte de muitas complicações pós-operatórias, incluindo a morte de pacientes. Estes problemas motivam o estudo e desenvolvimento de técnicas cirúrgicas sem parar o funcionamento do coração. Nestes casos, os batimentos cardíacos e a respiração representam as principais fontes de perturbação. Foram desenvolvidos estabilizadores mecânicos para diminuir localmente o movimento cardíaco. Colocado numa região de específica (por exemplo, na artéria coronária), estes estabilizadores limitam o movimento por pressão e sucção. Apesar dos melhoramentos feitos ao longo dos anos, ainda existe um movimento residual considerável, e o cirurgião tem que os compensar manualmente. Torna-se então natural incluir dispositivos robóticos para ajudar na prática médica, melhorando a precisão, segurançae conforto de tarefas cirúrgicas. O sistema cirúrgico da Vinci é atualmente o sistema robótico mais avançado para a prática médica, com elevado desempenho em tarefas de destreza, precisão e segurança, apesar de não fornecer soluções de realimentação táctil, nem de compensação automática de movimentos fisiológicos. O trabalho desta tese é na área da robótica para cirurgias cardíacas com o coração a bater. Baseada na realimentação da força, esta tese explora novas arquiteturas de controlo com compensação automática dos movimentos cardíacos. São feitos testes experimentais em cenários muito realistas, sem utilizar seres vivos. Um robô denominado "Heartbox" equipado com um coração real reproduz movimentos cardíacos, enquanto que outro robô manipulador aplica forças cirúrgicas nesse coração com batimento artificial. As forças de interação fornecem realimentação de contacto ao cirurgião. O principal desafio científico deste trabalho é a ligação de técnicas de compensação autónoma de movimentos fisiológicos com controlo de força e realimentação haptica.Cardiovascular diseases are the first cause of mortality in the world. More than 17 million people die every year, representing 29% of all global deaths. Among these, coronary heart diseases are the most critical ones, reaching up to 7.2 million deaths. To reduce the risk of death the coronary artery bypass grafting (CABG) is the most common surgical intervention. Currently, the procedure involves a median sternotomy, an incision in the thorax allowing a direct access to the heart, and a cardiopulmonary bypass (CPB), where heart and lung functionalities are performed by an extracorporal machine. Unfortunately the heart-lung machine is the greatest source of complications and post-operatory mortality for patients. Problems involved have motivated beating heart surgery that circumvent CPB procedure. Heartbeats and respiration represent the two main sources of disturbances during off-pump surgery. Mechanical stabilizers have been conceived for locally decreasing heart motion. Placed around a region of interest (e.g., coronary artery), these stabilizers constraint the motion by suction or pressure. Despite many improvements done over the years, considerable residual motion still remains and the surgeon have to manually compensate them. Robotic assistance has the potential to offer significant improvements to the medical practice in terms of precision, safety and comfort. Theda Vinci surgical system is the most popular and sophisticated. Although it has considerably improved dexterity, precision and safety, no solution for restoring tactile feedback to the surgeon exists and physiological motion compensation still needs to be manually canceled by the surgeon. The work presented in this thesis focus on robotic assistance for beating heart surgery. Based on force feedback, we designed new control architectures providing autonomous physiological motion compensation. Experimental assessments have been performed through a realistic scenario. A Heartbox robot equipped with an \textit{ex vivo} heart reproduces heart motion and a robot arm generates desired surgical forces on the moving heart. Interaction forces provide the haptic feedback for the surgeon. Merging autonomous motion compensation techniques with force control and haptic feedback is a major scientific challenge that we tackle in this work.FCT - SFRH/BD/74278/201

Coronary Artery Segmentation and Motion Modelling

Conventional coronary artery bypass surgery requires invasive sternotomy and the use of a cardiopulmonary bypass, which leads to long recovery period and has high infectious potential. Totally endoscopic coronary artery bypass (TECAB) surgery based on image guided robotic surgical approaches have been developed to allow the clinicians to conduct the bypass surgery off-pump with only three pin holes incisions in the chest cavity, through which two robotic arms and one stereo endoscopic camera are inserted. However, the restricted field of view of the stereo endoscopic images leads to possible vessel misidentification and coronary artery mis-localization. This results in 20-30% conversion rates from TECAB surgery to the conventional approach. We have constructed patient-specific 3D + time coronary artery and left ventricle motion models from preoperative 4D Computed Tomography Angiography (CTA) scans. Through temporally and spatially aligning this model with the intraoperative endoscopic views of the patient's beating heart, this work assists the surgeon to identify and locate the correct coronaries during the TECAB precedures. Thus this work has the prospect of reducing the conversion rate from TECAB to conventional coronary bypass procedures. This thesis mainly focus on designing segmentation and motion tracking methods of the coronary arteries in order to build pre-operative patient-specific motion models. Various vessel centreline extraction and lumen segmentation algorithms are presented, including intensity based approaches, geometric model matching method and morphology-based method. A probabilistic atlas of the coronary arteries is formed from a group of subjects to facilitate the vascular segmentation and registration procedures. Non-rigid registration framework based on a free-form deformation model and multi-level multi-channel large deformation diffeomorphic metric mapping are proposed to track the coronary motion. The methods are applied to 4D CTA images acquired from various groups of patients and quantitatively evaluated

Medical Robotics

The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt. Minimally Invasive Surgery (MIS) is a revolutionary approach in surgery. In MIS, the operation is performed with instruments and viewing equipment inserted into the body through small incisions created by the surgeon, in contrast to open surgery with large incisions. This minimizes surgical trauma and damage to healthy tissue, resulting in shorter patient recovery time. The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently “medical roboticists” or not

Foetal echocardiographic segmentation

Congenital heart disease affects just under one percentage of all live births [1]. Those defects that manifest themselves as changes to the cardiac chamber volumes are the motivation for the research presented in this thesis. Blood volume measurements in vivo require delineation of the cardiac chambers and manual tracing of foetal cardiac chambers is very time consuming and operator dependent. This thesis presents a multi region based level set snake deformable model applied in both 2D and 3D which can automatically adapt to some extent towards ultrasound noise such as attenuation, speckle and partial occlusion artefacts. The algorithm presented is named Mumford Shah Sarti Collision Detection (MSSCD). The level set methods presented in this thesis have an optional shape prior term for constraining the segmentation by a template registered to the image in the presence of shadowing and heavy noise. When applied to real data in the absence of the template the MSSCD algorithm is initialised from seed primitives placed at the centre of each cardiac chamber. The voxel statistics inside the chamber is determined before evolution. The MSSCD stops at open boundaries between two chambers as the two approaching level set fronts meet. This has significance when determining volumes for all cardiac compartments since cardiac indices assume that each chamber is treated in isolation. Comparison of the segmentation results from the implemented snakes including a previous level set method in the foetal cardiac literature show that in both 2D and 3D on both real and synthetic data, the MSSCD formulation is better suited to these types of data. All the algorithms tested in this thesis are within 2mm error to manually traced segmentation of the foetal cardiac datasets. This corresponds to less than 10% of the length of a foetal heart. In addition to comparison with manual tracings all the amorphous deformable model segmentations in this thesis are validated using a physical phantom. The volume estimation of the phantom by the MSSCD segmentation is to within 13% of the physically determined volume

Twentieth Annual Conference on Manual Control, Volume 1

The 48 papers presented were devoted to humanopeator modeling, application of models to simulation and operational environments, aircraft handling qualities, teleopertors, fault diagnosis, and biodynamics