Navigation System in Minimally Invasive Surgeries

Minimally invasive procedures continue to increase in popularity since these techniques mean substantially less trauma for the patient, less expensive for them, and less workload for the surgeons. “The field of image-guided procedures is one subset of minimally invasive procedures in which medical images are used to provide guidance during the treatment. Technologies such as computer-aided surgery can be used to provide image guidance during these interventions, which can result in better outcomes.” (Kevin. et al. 2005. p. 6748). Going through the history of the majority of surgical procedure shows an obvious process of modification in them over the time on the basis of the outcome. Procedures have turned into very limited and minimal invasive procedures from the ones literally called radical surgeries in majority of the cases. “Minimally invasive surgery has gained enormous popularity because delicate structures at risk can be identified safely even when reliable landmarks are missing (tumors, revision, bleeding, etc)” ( Schlöndorff, pp.187-190., Anon, pp. 901-905) Almost any surgery in this era is possible to be dealt with either endoscopically, minimal invasive approaches, Laparoscopy, Natural Orifice Endoscopic Surgery, Single port Access surgery, Endoscopic Ultrasound-guided surgery, endoscopic Ct guided surgeries a lot more to come. “The use of endoscopy for diagnosing and treating ailments of the alimentary tract has evolved steadily over the past few decades, with tremendous growth and innovation in the past few years. Initially, endoscopy relied on rigid telescopes, direct visualization, and dangerously exothermic sources of illumination. The introduction of fiber optics, charge-coupled-device cameras, and increasingly efficient light sources has enabled researchers to investigate areas of the human gastrointestinal tract through flexible endoscopy not previously thought to be reachable without formal surgical exploration” (Kevin, 2008).

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There have been procedure done through different natural orifices, but “The first report of oral peritoneoscopy done in animals was published by Kalloo et al (Kalloo, 2004) in 2004. Since then, multiple investigators have used transluminal flexible endoscopy in animal models to perform various intraperitoneal procedures, ranging from tubal ligation to splenectomy (Kantsevoy, 2006). If we see it’s a modified form of EGD that is done as a routine procedure in our everyday life. These Natural Orifice Transluminal Endoscopic Surgery (NOTES) techniques are currently in their infancy (Hochberger, 2005., Kalloo, 2004.) in gynecology, the use of natural orifice is very common now. In gynecology, almost all the surgeries are possibly done through NOTES. For progress to be made, a new set of tools will need to be developed (ASGE, 2006., Swanstrom, 2008). Deconstruction of the endoscope and reconstruction in a NOTES-friendly manner will be an important long-term contribution (Kochman, 2007). In endoscopic or natural orifice access surgeries, closure of the point of intervention also becomes a issue, but there are advancements happening on day-today basis in that as well like The techniques described for access closure are also applicable for the actual site of surgery. So there have been different techniques designed and tested for that as well some have shown promising results, but this area is still not standardized yet, and it still needs further research work. “T-fasteners could be easily applied to close an enterotomy. A technique using the pre-placement of T-fasteners before full-thickness bowel resection appears safe and feasible “(Ikeda, 2006). The G-Prox could also be used provided an adequate working channel (4.5mm) is available (Swanstrom., 2008 Swanstrom, 2005 , Sclabas, 2006)]. An overtube with suture (NDO applicator) is another possible approach. The Eagle Claw does not appear precise and gentile enough for most applications (Hu B, 2006). “The more recent advances in scope platforms, devices, and techniques have allowed researchers to push the envelope of endoscopic diagnostics and therapeutics to greater heights”(Kevin, 2008).

There are different navigation systems specific for the types of surgeries performed, and there have been studies on them by the particular specialties. There was a study from neurosurgery group who studied all the 3-D navigation system used in neurosurgery and they also compared them. Since minimal access mean a limited window of access for which there should be means to configure it in an appropriate way. “Computer-assisted surgery (CAS), also known as image-guided surgery, surgical navigation, and 3-D computer surgery, is any computer-based procedure that uses technologies such as 3D imaging and real-time sensing in the planning, execution and follow-up of surgical procedures. CAS allows for better visualization and targeting of sites as well as improved diagnostic capabilities, giving it a significant advantage over conventional techniques”. (Brown University, 2005) “Computer-aided surgery, in which computers are used to provide image guidance to physicians for minimally invasive procedures, is still a relatively new field. There are different navigation system the ones that have been studied well have shown promising results and that has created a hope of getting a lot more navigation system in future. Systems they have been studies and used are, “ISG Viewing Wand, Philips Easy Guide, Zeiss STN, and ISG/ELEKTA Free-hand, ARTMA System, Zeiss MKM System” (Andreas, 2000).

Viewing Wand: “The Viewing Wand (ISG Technologies, Mississauga, Ontario) mainly consists of a position-sensitive mechanical measuring arm with a localizing stylus of varying shapes at the end. The arm has 6 degrees of freedom and can be moved inside the operating field”. (Andreas, 2000) “The joints’ positions are converted to position and orientation in space, which are shown as crosshairs in the preoperative CT/MR images. This allows searching of preplanned paths or identification of anatomical structures during surgery.( Sandeman, 1994., “To improve functionality further tools have been added to the existing system,( Freysinger, 1997., Gunkel, 1997) thus providing straight and bent probes, suction devices, power instrumentation, needles, cannulae, etc. Other than for ear, nose, and throat surgery, we have successfully used this system for interstitial brachytherapy to place hollow radiation in optimal preplanned positions inside inoperable tumor masses of the head and neck region.( Auer, 1998)

Philips Easy Guide, Zeiss STN, and ISG/ELEKTA Free-hand: “These systems (Philips Easy Guide [Philips, Eindhoven, the Netherlands], Zeiss STN [Carl Zeiss], and ISG/ELEKTA free-hand [ELEKTA, Stockholm, Sweden]) use pointers that are equipped with infrared light-emitting diodes. The position and orientation of the light-emitting diodes are detected with 2 or 3 infrared cameras close to the operative field, and the position of the probe is indicated as crosshairs in the 3-D data sets. These systems require stable intraoperative patient fixation, and the registration procedures are nearly identical”. (Andreas, 2000) These systems have also been mainly used for head and neck minimal invasive surgeries like procedures to petrous bone, frontal skull base, and paranasal sinuses.

ARTMA System: “This virtual patient system (ARTMA, Vienna, Austria) is considerably different from the latter, apart from the fact that it uses magnetic digitizing. Sensors fixed to the instrument, the endoscope (microscope), and the patients provide 3-D data for navigation. In addition—and this is the unique feature of this navigation system—the positions, access paths, and additional graphical structures can be visualized on the live video. This allows us to directly superimpose 3-D information into the video sequence. For example, a predefined path can be shown by a sequence of colored frames, similar to a tunnel, floating as permanent information over the video and the data set at the same time, guiding the surgeon to the planned target” (Andreas, 2000). “To that end, digital photographs of the patient (lateral and frontal views), the medical image data sets (2-dimensional and 3-D) are registered to the patient. The optical function of the endoscope (microscope) has to be determined, and thereafter navigation is possible: pathways are faded into the live video, and navigation in CT/MR is possible” ( Gunkel, et al.1995:257-261)

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Zeiss MKM System: “The Zeiss MKM system (Carl Zeiss) is mainly designed for neurosurgical and otologic operations. The microscope is mounted on a high-precision robotic arm. The patient is rigidly mounted to the operating table, where the reference emitter of the digitizer is mounted too. This emitter is referenced with the robot. The position of the focal point inside the patient can be displayed relative to the patient’s 3-D image data sets after a standard patient-image registration procedure. The Zeiss MKM system can superimpose contours, targets, or diagnostic images to the microscopic view, showing the actual position of the autofocus point inside the patient” (Andreas, 2000)

Endoscopic, augmented reality (AR) navigation system: “The system consisted of a rigid endoscope with light-emitting diodes, an optical tracking system, and a controller. The operation of the optical tracking system was based on two sets of infrared light-emitting diodes, which measured the position and orientation of the endoscope relative to the patient’s head. It helped surgeons perform accurate, safe, endoscope-assisted operations to treat pituitary tumors; for which a very limited window of access is available and this more specifically useful for reoperations, in which midline landmarks may be absent” (Kawamata, 2002). This navigation system was superior to the other conventional one due to its ability to generate different color images on the basis of the tumor distance from the endoscope, which was helping fully localizing the tumors even further.

There has been an advancement in the endoscopic platform and that has lead to the invention of new navigation system at a rapid speed. “The introduction of ColonoSight and mother-daughter endoscopes including the ShapeLock TransPort and the SpyGlass direct visualization system have extended the reach to which endoscopic instruments can be used for advanced therapies. (Kevin, 2008). “Specific new platforms include Colono- Sight and mother-daughter endoscopes such as the ShapeLock TransPort and the SpyGlass direct visualization system. Specific devices include the EndoCinch suturing system, the full-thickness Plicator procedure, Esophyx, the Stretta system, and the HALO360 system”. (Kevin, 2008). All these navigation systems are mostly surgery and site-specific and they all have different outcome. “Most developments have come over the last a decade. Systems based on bony landmarks for applications such as the brain, spine, and ear/nose/throat are now commercially available, and some institutions use them as the standard for care. However, systems for abdominal interventions and for other procedures with substantial organ motion and deformation have not yet been developed, and constitute an area of current research” (Kevin. et al. 2005. pp. 6748).

From different research work, it has been concluded that a computer-assisted minimal invasive surgery needs to have three components in the system to work: first of all it should have a control unit through a computer, there should also be a tracker that can localize the flow, direction and also the extent of going ahead of the surgical instrument and once the information is taken there should also be a system to accumulate data and organize it purposefully. The localizers used these days are mostly Optical but some are CT/ MRI based as well. The ones most in use are optical, but the electromagnetic ones is a good hope for the future which is safer and more comprehensive. Despite a lot of advancement in the field of NOTES and other endoscopic procedures, surgical routine is still limited to diagnostics, surgical planning, and interventions on mostly rigid structures and soft tissue surgery is still a challenging task for most of the surgeons. In order to expedite this process, there have been interventions in the recent years. The way planning is done for radiation therapy in oncological management similar planning schemes is being designed for localizing the target points before surgery as well. All of this advancement is done through navigation, and different tracking systems, and the aim is to support surgeons in localizing anatomical targets, observing critical structures, and sparing healthy tissue and over all producing a system that is safer and more promising for the patients. “Furthermore, the state-of-the-art positron emission tomography (PET) offered a new opportunity to find out the lung tumor in the very early stage” (Thompson, 2002).

To identify lesion which are smaller in size are internal in location and are softer consistency lying in soft tissues is hard task for the surgeons to identify. So if PET is used while operating for localizing the lesions an then existing them with a margin as has been mentioned in a study by Thompson where they say “However, such fine lesions are often too small to be found out under the video scope, and too soft to be distinguished with the surgeons’ finger touch. In these cases, we generally use several kinds of marking techniques, such as dyeing, wiring and barium injection through bronchoscope, but their accuracy is unsatisfying. To solve this problem, a magnetic navigation system that could identify the location of a micro-magnetic marker (a permanent magnet), which was embedded near or at the tumor site before surgery, based on the three-dimensional measurement with micro-fluxgate sensors was developed” (Thompson, 2002). This is very important to know how much margin the surgeon has to go ahead further and how much tumor safe margin to leave behind; all this concept of visual-spatial orientation needs a lot of technology to assist the surgeon. “The virtual image of the transmitter is then generated and superimposed on the endoscopic image monitor through the down-scan converter in real-time” (Shimada, 2003). Here this tracking and of the whole thing and bringing a visually interpreted view out of all the images makes a clear picture for the surgeon to operate, reopen if needed and configure the events in a healthy sequence. “The sensor-to-grid transformation is known and fixed in advance. The grid-to-mini camera transformation depends on the surgical situation and is estimated using Bouquet’s camera calibration technique”. (Bougue, 2007).

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