Engineering precision surgery: Design and implementation of surgical guidance technologies

In the quest for precision surgery, this thesis introduces several novel detection and navigation modalities for the localization of cancer-related tissues in the operating room. The engineering efforts have focused on image-guided surgery modalities that use the complementary tracer signatures of nuclear and fluorescence radiation. The first part of the thesis covers the use of “GPS-like” navigation concepts to navigate fluorescence cameras during surgery, based on SPECT images of the patient. The second part of the thesis introduces several new imaging modalities such as a hybrid 3D freehand Fluorescence and freehand SPECT imaging and navigation device. Furthermore, to improve the detection of radioactive tracer-emissions during robot-assisted laparoscopic surgery, a tethered DROP-IN gamma probe is introduced. The clinical indications that are used to evaluate the new technologies were all focused on sentinel lymph node procedures in urology (i.e. prostate and penile cancer). Nevertheless, all presented techniques are of such a nature, that they can be applied to different surgical indications, including sentinel lymph node and tumor-receptor-targeted procedures, localization the primary tumor and metastatic spread. This will hopefully contribute towards more precise, less invasive and more effective surgical procedures in the field of oncology. Crystal Photonics GmbH Eurorad S.A. Intuitive Surgical Inc. KARL STORZ Endoscopie Nederland B.V. MILabs B.V. PI Medical Diagnostic Equipment B.V. SurgicEye GmbH Verb Surgical Inc.LUMC / Geneeskund

Novel PET Systems and Image Reconstruction with Actively Controlled Geometry

Positron Emission Tomography (PET) provides in vivo measurement of imaging ligands that are labeled with positron emitting radionuclide. Since its invention, most PET scanners have been designed to have a group of gamma ray detectors arranged in a ring geometry, accommodating the whole patient body. Virtual Pinhole PET incorporates higher resolution detectors being placed close to the Region-of-Interest (ROI) within the imaging Field-of-View (FOV) of the whole-body scanner, providing better image resolution and contrast recover. To further adapt this technology to a wider range of diseases, we proposed a second generation of virtual pinhole PET using actively controlled high resolution detectors integrated on a robotic arm. When the whole system is integrated to a commercial PET scanner, we achieved positioning repeatability within 0.5 mm. Monte Carlo simulation shows that by focusing the high-resolution detectors to a specific organ of interest, we can achieve better resolution, sensitivity and contrast recovery. In another direction, we proposed a portable, versatile and low cost PET imaging system for Point-of-Care (POC) applications. It consists of one or more movable detectors in coincidence with a detector array behind a patient. The movable detectors make it possible for the operator to control the scanning trajectory freely to achieve optimal coverage and sensitivity for patient specific imaging tasks. Since this system does not require a conventional full ring geometry, it can be built portable and low cost for bed-side or intraoperative use. We developed a proof-of-principle prototype that consists of a compact high resolution silicon photomultiplier detector mounted on a hand-held probe and a half ring of conventional detectors. The probe is attached to a MicroScribe device, which tracks the location and orientation of the probe as it moves. We also performed Monte Carlo simulations for two POC PET geometries with Time-of-Flight (TOF) capability. To support the development of such PET systems with unconventional geometries, a fully 3D image reconstruction framework has been developed for PET systems with arbitrary geometry. For POC PET and the second generation robotic Virtual Pinhole PET, new challenges emerge and our targeted applications require more efficiently image reconstruction that provides imaging results in near real time. Inspired by the previous work, we developed a list mode GPU-based image reconstruction framework with the capability to model dynamically changing geometry. Ordered-Subset MAP-EM algorithm is implemented on multi-GPU platform to achieve fast reconstruction in the order of seconds per iteration, under practical data rate. We tested this using both experimental and simulation data, for whole body PET scanner and unconventional PET scanners. Future application of adaptive imaging requires near real time performance for large statistics, which requires additional acceleration of this framework

How molecular imaging will enable robotic precision surgery: the role of artificial intelligence, augmented reality, and navigation

Molecular imaging is one of the pillars of precision surgery. Its applications range from early diagnostics to therapy planning, execution, and the accurate assessment of outcomes. In particular, molecular imaging solutions are in high demand in minimally invasive surgical strategies, such as the substantially increasing field of robotic surgery. This review aims at connecting the molecular imaging and nuclear medicine community to the rapidly expanding armory of surgical medical devices. Such devices entail technologies ranging from artificial intelligence and computer-aided visualization technologies (software) to innovative molecular imaging modalities and surgical navigation (hardware). We discuss technologies based on their role at different steps of the surgical workflow, i.e., from surgical decision and planning, over to target localization and excision guidance, all the way to (back table) surgical verification. This provides a glimpse of how innovations from the technology fields can realize an exciting future for the molecular imaging and surgery communities.Imaging- and therapeutic targets in neoplastic and musculoskeletal inflammatory diseas

A Review on Advances in Intra-operative Imaging for Surgery and Therapy: Imagining the Operating Room of the Future

none4openZaffino, Paolo; Moccia, Sara; De Momi, Elena; Spadea, Maria FrancescaZaffino, Paolo; Moccia, Sara; De Momi, Elena; Spadea, Maria Francesc

Intraoperative Endoscopic Augmented Reality in Third Ventriculostomy

In neurosurgery, as a result of the brain-shift, the preoperative patient models used as a intraoperative reference change. A meaningful use of the preoperative virtual models during the operation requires for a model update. The NEAR project, Neuroendoscopy towards Augmented Reality, describes a new camera calibration model for high distorted lenses and introduces the concept of active endoscopes endowed with with navigation, camera calibration, augmented reality and triangulation modules

Entwicklungen und Untersuchungen zur Bildgebung der Schilddrüse: 124Iod-PET/CT, 3D-Ultraschall und nuklearmedizinisch-sonographische Bildfusion

In der etablierten Schilddrüsenbildgebung existieren trotz des bereits hohen Standards begrenzende Faktoren. Methodische und technische Neuerungen erscheinen mithin sinnvoll und geboten. Die vorliegende Habilitationsschrift stellt die Entwicklung und Erprobung neuer Konzepte der Schilddrüsendiagnostik in drei Teilgebieten vor: *Durch die 124Iod-Niedrigaktivitäts-PET/Niedrigdosis-CT wird (i) die Ortsauflösung der herkömmlichen Szintigraphie übertroffen und die Detektierbarkeit kleinerer Strukturen sowie anatomischer Details verbessert. Durch den parallel akquirierten CT-Datensatz können (ii) zusätzliche Erkenntnisse zur Schilddrüse sowie deren Beziehung zu Nachbarorganen gewonnen werden. Darüber hinaus sind (iii) im Rahmen der Vorbereitung von Radiojodtherapien prätherapeutische Uptake-Messungen möglich. *Der 3D-US ermöglicht (i) den lückenlosen Scan der Schilddrüse und (ii) die vollständige digitale Archivierung des Untersuchungsvolumens im PACS. Dadurch ergeben sich auf Schnittbildworkstations die Vorteile (iii) des Second Readings, (iv) des Side-by-Side-Vergleichs mit vorangegangenen 3D-US-Studien und anderen Schnittbildverfahren. Darüber hinaus kann (v) eine nachträgliche Datenverarbeitung (Processing) erfolgen. *Die Einbeziehung des Ultraschalls in das Konzept der Fusions- bzw. Hybridbildgebung hat gezeigt, dass die räumliche Verknüpfung und bildliche Überlagerung der morphologisch-sonographischen Informationen mit den nuklearmedizinisch-funktionellen Bilddaten erfolgen kann. Aus dem klinischen Potential der Methoden einerseits, sowie den geschilderten Limitationen andererseits ergeben sich Implikationen für die Zukunft. Zunächst sind die apparativ-technische Weiterentwicklung der Verfahren sowie eine Optimierung der informationstechnischen Einbindung notwendig. Darüber hinaus muss eine Entwicklung hin zu einer zeitsparenden und einfachen Anwendbarkeit erfolgen, um einen rationellen klinischen Workflow zu ermöglichen und personelle Ressourcen zu schonen

Intraoperative Navigation Systems for Image-Guided Surgery

Recent technological advancements in medical imaging equipment have resulted in a dramatic improvement of image accuracy, now capable of providing useful information previously not available to clinicians. In the surgical context, intraoperative imaging provides a crucial value for the success of the operation. Many nontrivial scientific and technical problems need to be addressed in order to efficiently exploit the different information sources nowadays available in advanced operating rooms. In particular, it is necessary to provide: (i) accurate tracking of surgical instruments, (ii) real-time matching of images from different modalities, and (iii) reliable guidance toward the surgical target. Satisfying all of these requisites is needed to realize effective intraoperative navigation systems for image-guided surgery. Various solutions have been proposed and successfully tested in the field of image navigation systems in the last ten years; nevertheless several problems still arise in most of the applications regarding precision, usability and capabilities of the existing systems. Identifying and solving these issues represents an urgent scientific challenge. This thesis investigates the current state of the art in the field of intraoperative navigation systems, focusing in particular on the challenges related to efficient and effective usage of ultrasound imaging during surgery. The main contribution of this thesis to the state of the art are related to: Techniques for automatic motion compensation and therapy monitoring applied to a novel ultrasound-guided surgical robotic platform in the context of abdominal tumor thermoablation. Novel image-fusion based navigation systems for ultrasound-guided neurosurgery in the context of brain tumor resection, highlighting their applicability as off-line surgical training instruments. The proposed systems, which were designed and developed in the framework of two international research projects, have been tested in real or simulated surgical scenarios, showing promising results toward their application in clinical practice

Left ventricular remodeling and function in ischemic heart disease and aortic valve disease

Background: Cardiac remodeling is a broad term that refers to structural and functional alterations of the heart in response to chronic changes in loading conditions or left ventricular (LV) contractile performance. Different loading conditions will affect the heart in different ways, some leading to impaired heart function, symptoms of heart failure, or even death. However, the process of remodeling may not be permanent. If the heart is relieved of the underlying cause of the remodeling, the heart function and structure may normalize in a process referred to as reverse remodeling. The complex interplay of factors that determine the process of reverse remodeling is not fully elucidated. Cardiac remodeling can be evaluated by many different diagnostic modalities, but the most widely used diagnostic tool is two-dimensional echocardiography (2DE). In recent years, three-dimensional echocardiography (3DE) has emerged with possible advantages in the assessment of LV volume and function. The thesis aimed to evaluate 3DE in the assessment of LV function and remodeling, and to study different aspects of remodeling in response to pressure and volume overload in patients with aortic stenosis (AS) and aortic regurgitation (AR), respectively. Methods: Studies I and II investigated patients with ischemic heart disease (n = 15 and n = 32, respectively). In Study I, the assessments of LV volume and ejection fraction (EF) were compared using 3DE, cardiac magnetic resonance (CMR), and single-photon emission computer tomography (SPECT). Study II compared the performance of 2DE, contrast-enhanced 2DE, 3DE, and contrast-enhanced 3DE in the assessment LV volumes and EF, using CMR as a reference standard. In Studies III and IV, 65 patients with severe AR and 120 patients with severe AS, respectively, were examined using 2DE and 3DE before and at one year after aortic valve replacement (AVR). In Study III, LV volumes, systolic and diastolic LV function, and left atrial strain (LAS) were analyzed to identify predictors of impaired LV reverse remodeling in AR. Study IV assessed LV functional indices, including 2D global longitudinal strain (GLS) and 3D strain, to assess predictors of incomplete reverse remodeling in AS. Results and conclusions: There were significant differences among 3DE, SPECT and CMR regarding the measurement of LV volumes. However, the estimation of EF showed good agreement. 3DE was more accurate and showed more favorable reproducibility than 2DE for the assessment of EF and LV volumes. Contrast enhancement improved accuracy and reproducibility for both 2DE and 3DE. One-third of patients with AR had signs of impaired LV diastolic function. After AVR, diastolic LV functional indices improved, LV and left atrial (LA) volumes decreased, and indices of LA function increased. LA conduit strain had an incremental prognostic value for the prediction of impaired LV functional and structural recovery. In patients with AS, AVR was associated with a decrease in LV mass, an improvement in 2D GLS, and a decrease in LV twist. 2D GLS and left ventricular mass index were predictive of incomplete reverse remodeling during the follow-up period. 3D GLS did not add discriminatory or predictive information over 2D GLS