1. Field of the Invention
The present invention relates to robotic devices and methods for instrument targeting. In particular, the invention relates to systems and methods for computer assisted image-based instrument targeting used in computed tomography (CT) guided interventions.
2. Description of the Related Art
Minimally invasive and noninvasive procedures for surgery are gaining increased popularity mainly due to reduced trauma to patients and improved recovery time. One of the main problems encountered in minimally invasive procedures is, in contrast to open surgical procedures, a dramatic reduction in the surgeon's visual ability. Accordingly, radiological, ultrasonic, and magnetic resonance imaging techniques are employed to map anatomical geometry during intra-operative procedures.
CT and CT fluoroscopy (CTF) are among these imaging techniques. Systems and methods for using CT and CTF in guided interventions have been developed.
CT interventions have been further enabled by the development of CT CTF imagers [Daly B, Krebs T L, Wong-You-Cheong J J, Wang S S: Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance. AJR (1999) 173:637-644 and Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette P C: Value of CT fluoroscopy for percutaneous biopsy procedures. JVIR 2000 (2000) 11:879-884], which in addition to classic CT capabilities, allow for fluoro-imaging of a CT slice. The radiologist manually orients and inserts the instrument while keeping it in the fluoro slice by observing the fluoro monitor [Silverman S G, Tuncali K, Adams D F, Nawfel R D, Zou K H, Judy P F: CT fluoroscopy-guided abdominal interventions: techniques, results, and radiation exposure. Radiology (1999) 212:673-681]. In experienced hands the procedure is fast and normally successful. [Kato R, Katada K, Arno H, Suzuki S, Ida Y, Koga S.: Radiation dosimetry at CT fluoroscopy: physician's hand dose and development of needle holders. Radiology (1996) 201:576-578]. The major limitations of CTF interventions are the relatively high radiation exposure [Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C; Milette P C: Effect of the learning process on procedure times and radiation exposure for ct fluoroscopy-guided percutaneous biopsy procedures. JVIR (2000) 11:1217-1221; Nawfel R D, Judy P F, Silverman S G, Hooton S, Tuncali K, Adams D F: Patient and personnel exposure during ct fluoroscopy-guided interventional procedures. Radiology (2000) 216:180-184; and Nickoloff E L, Khandji A, Dutta A: Radiation doses during ct fluoroscopy. Health Physics (2000) 79:675-681], the constraint of operating in a CT slice [Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette P C: Value of CT fluoroscopy for percutaneous biopsy procedures. JVIR 2000 (2000) 11:879-884 and Nawfel R D, Judy P F, Silverman S G, Hooton S, Tuncali K, Adams D F: Patient and personnel exposure during ct fluoroscopy-guided interventional procedures. Radiology (2000) 216:180-184], and the reduced resolution of the CTF compared to the CT images [Daly B, Krebs T L, Wong-You-Cheong J J, Wang S S: Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance. AJR (1999) 173:637-644 and Patriciu A, Mazilu D, Stoianovici D, Stanimir A, Susil R, Masamune K, Fitchinger G, Taylor R H, Anderson J, Kavoussi L R: CT-Guided Robotic Prostate Biopsy, (2000), 18th World Congress on Endourology & SWL, September 2000, Sao Paulo, Brazil].
CT fluoroscopy (CTF) offers many advantages to performing interventional procedures. With CT fluoroscopy the trajectory of a needle can be tracked in real time allowing the physician to make adjustments as necessary. This advance has made procedures faster with equivalent or better success rates. Gianfelice et al. reported faster biopsy procedure times with mean times significantly declining from 43 minutes with conventional CT to 28 minutes with CTF, and procedure success rates increasing from 88% to 94% [Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette P C. Value of ct fluoroscopy for percutaneous biopsy procedures. JVIR 2000; 11:879-884]. Likewise, Silverman et al. reported mean needle placement times significantly decreasing from 36 minutes with conventional CT to 29 minutes with CTF and with equivalent success rates between the two modalities [Silverman S G, Tuncali K, Adams D F, Nawfel R D, Zou K H, Judy P F. CT fluoroscopy-guided abdominal interventions: techniques, results, and radiation exposure. Radiology 1999; 212:673-681]
CTF has made interventional procedures faster with equivalent or better success rates [Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette P C. Value of ct fluoroscopy for percutaneous biopsy procedures. JVIR 2000; 11:879-884 and Silverman S G, Tuncali K, Adams D F, Nawfel R D, Zou K H, Judy P F. CT fluoroscopy-guided abdominal interventions: techniques, results, and radiation exposure. Radiology 1999; 212:673-681]. However, the major limitation to the modality is the relatively high radiation exposure to patient and physician [Nawfel R D, Judy P F, Silverman S G, Hooton S, Tuncali K, Adams D F. Patient and personnel exposure during ct fluoroscopy-guided interventional procedures. Radiology 2000; 216:180-184 and Kato R, Katada K, Anno H, Suzuki S, Ida Y, Koga S. Radiation dosimetry at ct fluoroscopy: physician's hand dose and development of needle holders. Radiology 1996; 201:576-578]. Robots have been used in surgery to solve problems of holding and controlling instruments [Paulson E K, Sheafor D H, Enterline D S, McAdams H P, Yoshizumi T T. CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Radiology 2001; 2-20:161-167; Kavoussi L R; Moore R G, Adams J B, Partin A W. Comparison of robotic versus human laparoscopic camera control. J Urol 1995 December; 154(6):2134-6; Fadda M, Marcacci M, Toksvig-Larsen S, Wang T, Meneghello R. Improving accuracy of bone resections using robotics tool holder and a high speed milling cutting tool. J Med Eng Technol 1998 November-December; 22(6):280-4; and Koyama H, Uchida T, Funakubo H, Takakura K, Fankhauser H. Development of a new microsurgical robot for stereotactic neurosurgery. Stereotact Funct Neurosurg 1990; 54:462-467].
The major limitation of CTF is the relatively high radiation exposure to patient and physician. In order to make the real time adjustments in needle trajectory the physician's hand is in proximity to the scanning plane. Physician hand exposure has been theoretically and empirically determined to be approximately 2 mGy per procedure [Nawfel R D, Judy P F, Silverman S G, Hooton S, Tuncali K, Adams D F. Patient and personnel exposure during ct fluoroscopy-guided interventional procedures. Radiology 2000; 216:180-184]. Kato et al. have calculated that on the basis of an annual dose limit of 500 mSv for the hands, a physician with continuous hand exposure would be limited to performing only four CTF procedures per year. As such, a number of procedural techniques and shields have been suggested to minimize radiation exposures. Kato et al. and Daly et al. have used needle holders and Nawfel et al. have; used lead drapes all to minimize hand exposure [Kato R, Katada K, Anno H, Suzuki S, Ida Y, Koga S. Radiation dosimetry at ct fluoroscopy: physician's hand dose and development of needle holders. Radiology 1996; 201:576-578; Nickoloff E L, Khandji A, Dutta A. Radiation doses during ct fluoroscopy. Health Physics 2000; 79:675-681; and Daly B, Krebs T L, Wong-You-Cheong J J, Wang S S. Percutaneous abdominal and pelvic interventional procedures using ct fluoroscopy guidance. AJR 1999; 173:637-644]. Others have noted that experience and training may lead to a reduction in exposure [Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette P C. Effect of the learning process on procedure times and radiation exposure for ct fluoroscopy-guided percutaneous biopsy procedures. JVIR 2000; 11:1217-1221]. Paulson et al. recently reported lowering radiation exposure by lowering mA and taking intermittent spot images during the procedure [Paulson E K, Sheafor D H, Enterline D S, McAdams H P, Yoshizumi T T. CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Radiology 2001; 2-20:161-167]. Intermittent “spot check” images has gained greater acceptance as it generally can allow successful completion of the intervention with significant reduction of radiation exposure.
A number of procedural techniques [Nawfel R D, Judy P F, Silverman S G, Hooton S, Tuncali K, Adams D F: Patient and personnel exposure during ct fluoroscopy-guided interventional procedures. Radiology (2000) 216:180-184], shields [Nickoloff E L, Khandji A, Dutta A: Radiation doses during ct fluoroscopy. Health Physics (2000) 79:675-681], and needle holders [Bishoff J T, Stoianovici D, Lee B R, Bauer J, Taylor R H, Whitcomb L L, Cadeddu J A, Chan D, Kavoussi L R: RCM-PAKY: Clinical Application of a New Robotic System for Precise Needle Placement, (1998), Journal of Endourology, 12:82 and Stoianovici D, Cadeddu J A, Demaree R D, Basile H A, Taylor R H, Whitcomb L L, Sharpe W, Kavoussi L R: An Efficient Needle Injection Technique and Radiological Guidance Method for Percutaneous Procedures, (1997), LNCS, Springer-Verlag, 1205:295-298] have been proposed to reduce radiation exposure. Robotic systems have also been pursued for their unique capability of collectively eliminating the limitations of the manual procedure [Stoianovici D: Robotic Surgery, (2000) World Journal of Urology, 18:4:289-295]. Unlike manual interventions, robotic CT guided procedures are not necessarily limited to the use-of CTF [Patriciu A, Stoianovici D, Whitcomb L L, Jarrett T, Mazilu D, Stanimir A, lordachita I, Anderson J, Taylor R, Kavoussi L R, (2000), “Motion-Based Robotic Instrument Targeting Under C-Arm Fluoroscopy”, LNCS, Springer-Verlag, Vol. 1935, pp. 988-998 and Solomon S, Patriciu A, Masamune K, Whitcomb L, Taylor R H, Kavoussi L, Stoianovici D, 2001, “CT Guided Robotic Needle Biopsy: A Precise Sampling Method Minimizing Radiation Exposure”, Radiology, in press]. This approach, however, requires specialized robotic hardware, image registration, and guidance algorithms.
Robots have been introduced into the operating room to hold and move instruments precisely. Robots allow greater precision, allow greater accuracy, and lack tremor when compared to humans [Kavoussi L R; Moore R G, Adams J B, Partin A W. Comparison of robotic versus human laparoscopic camera control. J Urol 1995 December; 154(6):2134-6 and Fadda M, Marcacci M, Toksvig-Larsen S, Wang T, Meneghello R. Improving accuracy of bone resections using robotics tool holder and a high speed milling cutting tool. J Med Eng Technol 1998 November-December; 22(6):280-4]. Neurosurgeons have used robots to perform stereotactic biopsies using previously acquired CT images [Koyama H, Uchida T, Funakubo H, Takakura K, Fankhauser H. Development of a new microsurgical robot for stereotactic neurosurgery. Stereotact Funct Neurosurg 1990; 54:462-467; Kwoh Y S, Hou J, Jonckheere E A, Hayati S. A robot with improved absolute positioning accuracy for ct guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988; 35:153-160; and Fankhauser H, Glauser D, Flury P, Piguet Y, Epitaux M, Favre J, Meuli R A. Robot for ct-guided stereotactic neurosurgery. Stereotact Fund Neurosurg 1994; 63:93-98]. Cardiac surgeons use robots to translate gross movements on a magnified image into fine robotic movements in the body [Autschbach R, Onnasch J F, Falk V, Walther T, Kruger M, Schilling L O, Mohr F W. The Leipzig experience with robotic valve surgery. J Card Surg. 2000-January-February; 15(1):82]. One of the advantages of robots capitalized on in telesurgical applications is the fact that the surgeon does not need to be in the same location as the patient [Lee B R, Png D J,—Liew L, Fabrizio M, Li M K, Jarrett J W, Kavoussi L R. Laparoscopic telesurgery between the United States and Singapore. Ann Acad Med Singapore 2000 September; 29(5):665-8]. Multiple reports of remote surgery exist [Link R E, Schulam P G, Kavoussi L R. Telesurgery. Remote monitoring and assistance during laparoscopy. Urol Clin North Am 2001 February; 28(I):177-88; Cheah W K, Lee B, Lenzi J E, Goh P M. Telesurgical laparoscopic cholecystectomy between two countries. Surg Endosc. 2000 November; 14(11):1085; and Marescaux J, Smith M K, Folscher D, Jamali F, Malassagne B, Leroy J. Telerobotic Laparoscopic Cholecystectomy: Initial Clinical Experience With 25 Patients. Ann Surg 2001 July; 234(1):1-7]. This advantage of operating remotely may be used to limit radiation exposure in CTF guided interventional procedures.
Specialized algorithms have been proposed for robot-image registration and/or instrument guidance [Stoianovici D: Robotic Surgery, (2000) World Journal of Urology, 18:4:289-295]. A servoing method using the procedure needle as a marker under CT-fluoroscopy was reported by Loser and Navab [Loser M-I, Navab N: A new robotic system for visually controlled percutaneous interventions under CT fluoroscopy, MICCAI 1999, LNCS, Springer-Verlag (2000) 1935:887-896]. Susil et al. [Susil R C, Anderson J, Taylor R H: A Single Image Registration Method for CT Guided Interventions, LNCS, Springer-Verlag (1999) 1679:798-808] reported a registration method using a localization device (a modified Brown-Roberts-Wells frame [Brown R A, Roberts T S, Osborne A G: Stereotaxic frame and computer software for CT directed Neurosurgical localization. Invest. Radiol. (1980), 15: 308-312]) attached to the robot's end-effector, which was further perfected by Masamune [Masainune K, Patriciu A, Stoianovici D, Susil R, Taylor R H, Fichtinger G, Kavoussi L R, Anderson J, Sakuma I, Dohi T: Development of CT-PAKY frame system—CT image guided Needle puncturing manipulator and a single slice registration for urological surgery, Proc. 8th annual meeting of JSCAS, Kyoto 1999:89-90] and Patriciu [Fichtinger G, DeWeese T L, Patriciu A, Tanacs A, Mazilu D, Anderson J H, Masamune K, Taylor R H, Stoianovici D, (2001), “System For Robotically Assisted Prostate Biopsy And Therapy With IntraOperative CT Guidance”, Academic Radiology, in press and Patriciu A, Mazilu D, Stoianovici D, Stanimir A, Susil R, Masamune K, Fitchinger G, Taylor R H, Anderson J, Kavoussi L R: CT-Guided Robotic Prostate Biopsy, (2000), 18th World Congress on Endourology & SWL, September 2000, Sao Paulo, Brazil].
Initially, investigators used industrial robots [Kwoh Y S, Hou J, Jonckeere E A, H&yati S:—A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery, IEEE Transactions on Biomedical Engineering, 35(2), pp. 153-160, 1988] to prove the feasibility of robotic CT-guided procedures. Specialized image-guided robots have then been developed following the innovative trend of surgical robotics in general [Stoianovici D: Robotic Surgery, (2000) World Journal of Urology, 18:4:289-295].
The PinPoint™ system manufactured by Marconi Medical Systems is an example of a passive system that highly enhances CT navigation capabilities [Cook A, Ravenna O, Cook A, Yanof J, Cavnah P, Hines J, Chaturvedi A: Interactive Computer User Interface for Planning Robotic Assisted Interventions, Radiology, 1999, Vol. 213, pp. 577]. PinPoint is a frameless stereotactic arm using joint encoders to provide the position of its end-effector instrument with respect to the CT gantry thus allowing for-the visualization of the instrument in the CT image space. The PinPoint arm can also be locked at the desired location to serve as a guide for needle placement.
Minerva (Laboratory of Microengineering at the Swiss Federal Institute of Technology in Lausanne, Switzerland) is a CT-guided, multi-function neurosurgical robot [Fankhauser H, Glauser D, Flury P, Piguet Y, Epitaux M, Favre J, Meuli R A: Robot for CT-guided Stereotactic Neurosurgery, Stereotact Funct Neurosurg, 63(1-4), 93-8]. It operates inside a CT gantry with free longitudinal movement allowing cranial scans at any level. Under the physician's remote control, Minerva can manipulate two instruments in addition to the tool for automatic penetration of the skin, skull, and meninges [Glauser D, Fankhauser H, Epitaux M, Hefti J L, Jaccottet A: Neurosurgical robot Minerva—first results and current developments. J Image Guid Surg, 1(5), 266-72].
Another neurosurgical robot, NeuroMate™ (Integrated Surgical Systems, Davis, C A), originally developed at the University 6.f Grenoble, France [Benabid A L, Cinquin P, Lavalle S, Le Bas J F, Demongeot J, de Rougemont F: Computer-driven robot for stereotactic surgery connected to CT scan and magnetic resonance imaging. Technological design and preliminary results. Appl Neurophysiol, 50(1-6), 153-4 and Benabid A L, Lavallee S, Hoffmann D, Cinquin P, Demongeot J; Danel F: Potential use of robots in endoscopic neurosurgery. Acta Neurochir Suppl, 54, 93-7] is a frameless stereotactic system capable of carrying-out surgical procedures under image-guided remote physician control.
The components of many other surgical robot designs (such as the Intuitive Surgical daVinci™ robot [Blumenkranz S J, Rosa D J, “Manipulator Positioning Linkage for Robotic Surgery”, U.S. Pat. No. 6,246,200, Jun. 12, 2001]) are based on the Remote Center of Motion (RCM) principle [Taylor R H, Funda J, Grossman D D, Karidis J P, LaRose D A, “Remote Center-of Motion Robot for Surgery”, U.S. Pat. No. 5,397,323, Mar. 14, 1995] invented by Taylor in 1995 and originally implemented on the LARS robot for laparoscopy developed at IBM [Taylor R H, Funda J, Eldridge B, Gruben K, LaRose D, Gomory S, Talamini M, Kavoussi L R, Anderson-J, (1995): “A Telerobotic Assistant for Laparoscopic Surgery”, IEEE Engineering in Medicine and Biology Magazine, Vol. 14, pp. 279-287]. The RCM is perhaps the most common architecture used in surgical robotics [Stoianovici D: Robotic Surgery, (2000) World Journal of Urology, 18:4:289-295]. An example of an RCM mechanism is the prototype surgical robot designed for needle alignment inside a CT gantry reported in 1999 by Loser and Navab [Loser M-I, Navab N: A new robotic system for visually controlled percutaneous interventions under CT fluoroscopy, MICCAI 1999, LNCS, Springer-Verlag (2000) 1935:887-896]. The robot presents a small distal part made of radiolucent materials implementing a rigid-link parallelogram RCM. This is capable of actively orienting a procedure needle about the fixed location of its tip. The investigators derived a visual servoing algorithm for needle orientation. A needle guide is used for trajectory enforcement and insertion is performed manually.
Another RCM based experimental robot designed for Neuro-CT interventions was developed in 1998 by Masamune et al. [Masamune K, Ji L H, Suzuki M, Dohi T, Iseki H, Takakura K: A newly developed stereotactic robot with detachable driver for neurosurgery, Proc. MI CCAI 1998, pp. 215-222, 1998] at the University of Tokyo evolving from Dohi's 1993 design [Yamauchi Y, Ohta Y, Dohi T, Kawamura H, Tanikawa T, Iseki H: A needle insertion Manipulator for X-Ray CT image guided neurosurgery, J. of LST, vol. 5-4, 814-821, 1993]. This is a special RCM construction using a goniometer arc and a second revolute axis pointing towards its center. The system has a relatively small size and mounts on the mobile table of the CT scanner.
Our URobotics Laboratory [Stoianovici D, (2002): “URobotics—Urology Robotics at Johns Hopkins”, Computer Aided Surgery, in press] has reported the development of three modular robotic components and two image registration/targeting methods related to X-Ray guided operations. A radiolucent needle driver PAKY [Cadeddu J A, Stoianovici D, Chen R N, Moore R G, Kavoussi L R: Stereotactic mechanical percutaneous renal access, (1998), Journal of Endourology, 12:2:121-126 and Stoianovici D, Cadeddu J A, Demaree R D, Basile H A, Taylor R H, Whitcomb L L, Sharpe W, Kavoussi L R: An Efficient Needle Injection Technique and Radiological Guidance Method for Percutaneous Procedures, (1997), LNCS, Springer-Verlag, 1205:295-298] was reported in 1997, the RCM robot reported in 1998 is a small surgical robot operating on the RCM principle [Stoianovici D, Whitcomb L L, Anderson J H, Taylor R H, Kavoussi L R: A Modular Surgical Robotic System for Image Guided Percutaneous Procedures, (1998) LNCS, Springer-Verlag, 1496:404-410], and the G_ARM [Lerner, G, Stoianovici D, Whitcomb, L, L, Kavoussi L, R, (1999), “A Passive Positioning and Supporting Device for Surgical Robots and Instrumentation”, LNCS, Springer-Verlag, Vol. 1679, pp. 1052-1061] reported in 1999 is a sturdy passive positioning arm In 2000 we used the PAKY-RCM-G_ARM system with a new fluoro-servoing algorithm [Patriciu A, Stoianovici D, Whitcomb L L, Jarrett T, Mazilu D, Stanimir A, lordachita I, Anderson J, Taylor R, Kavoussi L R, (2000), “Motion-Based Robotic Instrument Targeting Under C-Arm Fluoroscopy”, LNCS, Springer-Verlag, Vol. 1935, pp. 988-998] for percutaneous renal access under C-Arm guidance. In 2001 we reported a laser based registration method [Patriciu A, Solomon S, Kavoussi L R, Stoianovici D, (2001): “Robotic Kidney and Spine Percutaneous Procedures Using a New Laser-Based CT Registration Method”, LNCS, Vol. 2208, pp. 249-258] for robotic CT interventions and implemented it on the PAKY-RCM robot. With this system we performed a comprehensive clinical study [Solomon S, Patriciu A, Masamune K, Whitcomb L, Taylor R H, Kavoussi L, Stoianovici D, 2001, “CT Guided Robotic Needle Biopsy: A Precise Sampling Method Minimizing Radiation Exposure”, Radiology, in press] of kidney, spine, liver, and lung procedures of biopsies and radio-frequency (RF) ablation.
Thus, there is a need for new and improved robot systems and methods that take advantage of commonly available imaging technology and solve problems with the prior art.
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