Virtual and Augmented Reality Techniques for Minimally Invasive Cardiac Interventions: Concept, Design, Evaluation and Pre-clinical Implementation

While less invasive techniques have been employed for some procedures, most intracardiac interventions are still performed under cardiopulmonary bypass, on the drained, arrested heart. The progress toward off-pump intracardiac interventions has been hampered by the lack of adequate visualization inside the beating heart. This thesis describes the development, assessment, and pre-clinical implementation of a mixed reality environment that integrates pre-operative imaging and modeling with surgical tracking technologies and real-time ultrasound imaging. The intra-operative echo images are augmented with pre-operative representations of the cardiac anatomy and virtual models of the delivery instruments tracked in real time using magnetic tracking technologies. As a result, the otherwise context-less images can now be interpreted within the anatomical context provided by the anatomical models. The virtual models assist the user with the tool-to-target navigation, while real-time ultrasound ensures accurate positioning of the tool on target, providing the surgeon with sufficient information to ``see\u27\u27 and manipulate instruments in absence of direct vision. Several pre-clinical acute evaluation studies have been conducted in vivo on swine models to assess the feasibility of the proposed environment in a clinical context. Following direct access inside the beating heart using the UCI, the proposed mixed reality environment was used to provide the necessary visualization and navigation to position a prosthetic mitral valve on the the native annulus, or to place a repair patch on a created septal defect in vivo in porcine models. Following further development and seamless integration into the clinical workflow, we hope that the proposed mixed reality guidance environment may become a significant milestone toward enabling minimally invasive therapy on the beating heart

Optical techniques for 3D surface reconstruction in computer-assisted laparoscopic surgery

One of the main challenges for computer-assisted surgery (CAS) is to determine the intra-opera- tive morphology and motion of soft-tissues. This information is prerequisite to the registration of multi-modal patient-specific data for enhancing the surgeon’s navigation capabilites by observ- ing beyond exposed tissue surfaces and for providing intelligent control of robotic-assisted in- struments. In minimally invasive surgery (MIS), optical techniques are an increasingly attractive approach for in vivo 3D reconstruction of the soft-tissue surface geometry. This paper reviews the state-of-the-art methods for optical intra-operative 3D reconstruction in laparoscopic surgery and discusses the technical challenges and future perspectives towards clinical translation. With the recent paradigm shift of surgical practice towards MIS and new developments in 3D opti- cal imaging, this is a timely discussion about technologies that could facilitate complex CAS procedures in dynamic and deformable anatomical regions

AUGMENTED REALITY AND INTRAOPERATIVE C-ARM CONE-BEAM COMPUTED TOMOGRAPHY FOR IMAGE-GUIDED ROBOTIC SURGERY

Minimally-invasive robotic-assisted surgery is a rapidly-growing alternative to traditionally open and laparoscopic procedures; nevertheless, challenges remain. Standard of care derives surgical strategies from preoperative volumetric data (i.e., computed tomography (CT) and magnetic resonance (MR) images) that benefit from the ability of multiple modalities to delineate different anatomical boundaries. However, preoperative images may not reflect a possibly highly deformed perioperative setup or intraoperative deformation. Additionally, in current clinical practice, the correspondence of preoperative plans to the surgical scene is conducted as a mental exercise; thus, the accuracy of this practice is highly dependent on the surgeon’s experience and therefore subject to inconsistencies. In order to address these fundamental limitations in minimally-invasive robotic surgery, this dissertation combines a high-end robotic C-arm imaging system and a modern robotic surgical platform as an integrated intraoperative image-guided system. We performed deformable registration of preoperative plans to a perioperative cone-beam computed tomography (CBCT), acquired after the patient is positioned for intervention. From the registered surgical plans, we overlaid critical information onto the primary intraoperative visual source, the robotic endoscope, by using augmented reality. Guidance afforded by this system not only uses augmented reality to fuse virtual medical information, but also provides tool localization and other dynamic intraoperative updated behavior in order to present enhanced depth feedback and information to the surgeon. These techniques in guided robotic surgery required a streamlined approach to creating intuitive and effective human-machine interferences, especially in visualization. Our software design principles create an inherently information-driven modular architecture incorporating robotics and intraoperative imaging through augmented reality. The system's performance is evaluated using phantoms and preclinical in-vivo experiments for multiple applications, including transoral robotic surgery, robot-assisted thoracic interventions, and cocheostomy for cochlear implantation. The resulting functionality, proposed architecture, and implemented methodologies can be further generalized to other C-arm-based image guidance for additional extensions in robotic surgery

SLAM-based Dense Surface Reconstruction in Monocular Minimally Invasive Surgery and its Application to Augmented Reality.

While Minimally Invasive Surgery (MIS) offers considerable benefits to patients, it also imposes big challenges on a surgeon's performance due to well-known issues and restrictions associated with the field of view (FOV), hand-eye misalignment and disorientation, as well as the lack of stereoscopic depth perception in monocular endoscopy. Augmented Reality (AR) technology can help to overcome these limitations by augmenting the real scene with annotations, labels, tumour measurements or even a 3D reconstruction of anatomy structures at the target surgical locations. However, previous research attempts of using AR technology in monocular MIS surgical scenes have been mainly focused on the information overlay without addressing correct spatial calibrations, which could lead to incorrect localization of annotations and labels, and inaccurate depth cues and tumour measurements. In this paper, we present a novel intra-operative dense surface reconstruction framework that is capable of providing geometry information from only monocular MIS videos for geometry-aware AR applications such as site measurements and depth cues. We address a number of compelling issues in augmenting a scene for a monocular MIS environment, such as drifting and inaccurate planar mapping. Methods A state-of-the-art Simultaneous Localization And Mapping (SLAM) algorithm used in robotics has been extended to deal with monocular MIS surgical scenes for reliable endoscopic camera tracking and salient point mapping. A robust global 3D surface reconstruction framework has been developed for building a dense surface using only unorganized sparse point clouds extracted from the SLAM. The 3D surface reconstruction framework employs the Moving Least Squares (MLS) smoothing algorithm and the Poisson surface reconstruction framework for real time processing of the point clouds data set. Finally, the 3D geometric information of the surgical scene allows better understanding and accurate placement AR augmentations based on a robust 3D calibration. Results We demonstrate the clinical relevance of our proposed system through two examples: a) measurement of the surface; b) depth cues in monocular endoscopy. The performance and accuracy evaluations of the proposed framework consist of two steps. First, we have created a computer-generated endoscopy simulation video to quantify the accuracy of the camera tracking by comparing the results of the video camera tracking with the recorded ground-truth camera trajectories. The accuracy of the surface reconstruction is assessed by evaluating the Root Mean Square Distance (RMSD) of surface vertices of the reconstructed mesh with that of the ground truth 3D models. An error of 1.24mm for the camera trajectories has been obtained and the RMSD for surface reconstruction is 2.54mm, which compare favourably with previous approaches. Second, \textit{in vivo} laparoscopic videos are used to examine the quality of accurate AR based annotation and measurement, and the creation of depth cues. These results show the potential promise of our geometry-aware AR technology to be used in MIS surgical scenes. Conclusions The results show that the new framework is robust and accurate in dealing with challenging situations such as the rapid endoscopy camera movements in monocular MIS scenes. Both camera tracking and surface reconstruction based on a sparse point cloud are effective and operated in real-time. This demonstrates the potential of our algorithm for accurate AR localization and depth augmentation with geometric cues and correct surface measurements in MIS with monocular endoscopes

INTERFACE DESIGN FOR A VIRTUAL REALITY-ENHANCED IMAGE-GUIDED SURGERY PLATFORM USING SURGEON-CONTROLLED VIEWING TECHNIQUES

Initiative has been taken to develop a VR-guided cardiac interface that will display and deliver information without affecting the surgeons’ natural workflow while yielding better accuracy and task completion time than the existing setup. This paper discusses the design process, the development of comparable user interface prototypes as well as an evaluation methodology that can measure user performance and workload for each of the suggested display concepts. User-based studies and expert recommendations are used in conjunction to es­ tablish design guidelines for our VR-guided surgical platform. As a result, a better understanding of autonomous view control, depth display, and use of virtual context, is attained. In addition, three proposed interfaces have been developed to allow a surgeon to control the view of the virtual environment intra-operatively. Comparative evaluation of the three implemented interface prototypes in a simulated surgical task scenario, revealed performance advantages for stereoscopic and monoscopic biplanar display conditions, as well as the differences between three types of control modalities. One particular interface prototype demonstrated significant improvement in task performance. Design recommendations are made for this interface as well as the others as we prepare for prospective development iterations

Developing Ultrasound-Guided Intervention Technologies Enabled by Sensing Active Acoustic and Photoacoustic Point Sources

Image-guided therapy is a central part of modern medicine. By incorporating medical imaging into the planning, surgical, and evaluation process, image-guided therapy has helped surgeons perform less invasive and more precise procedures. Of the most commonly used medical imaging modalities, ultrasound imaging offers a unique combination of cost-effectiveness, safety, and mobility. Advanced ultrasound guided interventional systems will often require calibration and tracking technologies to enable all of their capabilities. Many of these technologies rely on localizing point based fiducials to accomplish their task. In this thesis, I investigate how sensing and localizing active acoustic and photoacoustic point sources can have a substantial impact in intraoperative ultrasound. The goals of these methods are (1) to improve localization and visualization for point targets that are not easily distinguished under conventional ultrasound and (2) to track and register ultrasound sensors with the use of active point sources as non-physical fiducials or markers. We applied these methods to three main research topics. The first is an ultrasound calibration framework that utilizes an active acoustic source as the phantom to aid in in-plane segmentation as well as out-of-plane estimation. The second is an interventional photoacoustic surgical system that utilizes the photoacoustic effect to create markers for tracking ultrasound transducers. We demonstrate variations of this idea to track a wide range of ultrasound transducers (three-dimensional, two-dimensional, bi-planar). The third is a set of interventional tool tracking methods combining the use of acoustic elements embedded onto the tool with the use of photoacoustic markers

Registration of ultrasound and computed tomography for guidance of laparoscopic liver surgery

Laparoscopic Ultrasound (LUS) imaging is a standard tool used for image-guidance during laparoscopic liver resection, as it provides real-time information on the internal structure of the liver. However, LUS probes are di cult to handle and their resulting images hard to interpret. Additionally, some anatomical targets such as tumours are not always visible, making the LUS guidance less e ective. To solve this problem, registration between the LUS images and a pre-operative Computed Tomography (CT) scan using information from blood vessels has been previously proposed. By merging these two modalities, the relative position between the LUS images and the anatomy of CT is obtained and both can be used to guide the surgeon. The problem of LUS to CT registration is specially challenging, as besides being a multi-modal registration, the eld of view of LUS is signi cantly smaller than that of CT. Therefore, this problem becomes poorly constrained and typically an accurate initialisation is needed. Also, the liver is highly deformed during laparoscopy, complicating the problem further. So far, the methods presented in the literature are not clinically feasible as they depend on manually set correspondences between both images. In this thesis, a solution for this registration problem that may be more transferable to the clinic is proposed. Firstly, traditional registration approaches comprised of manual initialisation and optimisation of a cost function are studied. Secondly, it is demonstrated that a globally optimal registration without a manual initialisation is possible. Finally, a new globally optimal solution that does not require commonly used tracking technologies is proposed and validated. The resulting approach provides clinical value as it does not require manual interaction in the operating room or tracking devices. Furthermore, the proposed method could potentially be applied to other image-guidance problems that require registration between ultrasound and a pre-operative scan

Exploiting Temporal Image Information in Minimally Invasive Surgery

Minimally invasive procedures rely on medical imaging instead of the surgeons direct vision. While preoperative images can be used for surgical planning and navigation, once the surgeon arrives at the target site real-time intraoperative imaging is needed. However, acquiring and interpreting these images can be challenging and much of the rich temporal information present in these images is not visible. The goal of this thesis is to improve image guidance for minimally invasive surgery in two main areas. First, by showing how high-quality ultrasound video can be obtained by integrating an ultrasound transducer directly into delivery devices for beating heart valve surgery. Secondly, by extracting hidden temporal information through video processing methods to help the surgeon localize important anatomical structures. Prototypes of delivery tools, with integrated ultrasound imaging, were developed for both transcatheter aortic valve implantation and mitral valve repair. These tools provided an on-site view that shows the tool-tissue interactions during valve repair. Additionally, augmented reality environments were used to add more anatomical context that aids in navigation and in interpreting the on-site video. Other procedures can be improved by extracting hidden temporal information from the intraoperative video. In ultrasound guided epidural injections, dural pulsation provides a cue in finding a clear trajectory to the epidural space. By processing the video using extended Kalman filtering, subtle pulsations were automatically detected and visualized in real-time. A statistical framework for analyzing periodicity was developed based on dynamic linear modelling. In addition to detecting dural pulsation in lumbar spine ultrasound, this approach was used to image tissue perfusion in natural video and generate ventilation maps from free-breathing magnetic resonance imaging. A second statistical method, based on spectral analysis of pixel intensity values, allowed blood flow to be detected directly from high-frequency B-mode ultrasound video. Finally, pulsatile cues in endoscopic video were enhanced through Eulerian video magnification to help localize critical vasculature. This approach shows particular promise in identifying the basilar artery in endoscopic third ventriculostomy and the prostatic artery in nerve-sparing prostatectomy. A real-time implementation was developed which processed full-resolution stereoscopic video on the da Vinci Surgical System