Research progress in application of artificial intelligence to intraoperative navigation assisted by an orthopedic robot / 中华创伤骨科杂志

Orthopedic robots, as intelligent medical devices, have achieved good outcomes in clinical application in some orthopedic surgeries. Artificial intelligence (AI) has played an important role in the development of orthopedic robots due to its powerful capabilities of information processing and decision-making. The developing trends of orthopedic robotics are automation and intelligentization. Since AI has demonstrated great advantages in preoperative planning, an increasing number of researchers have been devoted to AI application in intraoperative navigation by an orthopedic robot. This paper outlines the exploratory efforts in applying AI technology to the intraoperative navigation assisted by an orthopedic robot, describes the advantages of AI in improving accuracy and reducing radiation, and forecasts research prospects in application of AI technology to orthopedic robots based on the current situation.

O-arm real-time guidance in cervical pedicle screw fixation / 中国骨伤

OBJECTIVE@#To explore the technical aspects of the accuracy of cervical pedicle screw placement with O-arm guidance.@*METHODS@#The clinical data of 21 patients who underwent cervical pedicle screw fixation by O-arm real-time guidance from December 2015 to January 2020 were analyzed retrospectively. There were 15 males and 6 females, aged from 29 to 76 years old with an average of (45.3±11.5) years. The postoperative CT scan was utilized to evaluate the placement of the pedicle screw and classified according to the Gertzbein and Robbins classification.@*RESULTS@#A total of 132 pedicle screws were implanted in 21 patients, 116 at C3-C6 and 16 at C1 and C2. According to Gertzbein & Robbins classification, the overall breach rates were found to be 11.36% (15/132) with 73.33% (11 screws) Grade B, 26.67% (4 screws) Grade C, and no Grade D or E screw breaches. There were no pedicle screw placement related complications at final follow-up.@*CONCLUSION@#The application of O-arm real-time guidance technology can make cervical pedicle screw placement reliable. High accuracy and better intra-operative control can increase surgeon's confidence in using cervical pedicle instrumentation. Considering the high-risk nature of anatomical area around cervical pedicle and the possibility of catastrophic complications, the spine surgeon should have sufficient surgical skills, experience, ensures stringent verification of the system, and never relies solely on the navigation system.

Application of extended reality technology for real-time navigation in clinical operation / 南方医科大学学报

OBJECTIVE@#To explore the application of extended reality (XR) technology in clinical surgeries for improving the success rate of surgeries.@*METHODS@#To assist the surgeons to better understand the location, size and geometric shape of the lesions and reduce potential radiation exposure in minimally invasive surgical navigation based on two-dimensional images, we constructed three-dimensional models based on CT data and used XR technology to achieve intraoperative navigation. An improved quaternion method was used to improve the accuracy of electromagnetic positioning, with which the system error of positioning accuracy was reduced to below 2 mm. A 5G network was used to optimize the server GPU programming algorithm, and real-time video stream coding strategy and network design were adopted to reduce data transmission jam and delay in the remote surgery network, which achieved an average delay of less than 60 ms. A Gaussian distribution deformation model was used to simulate collision detection and stress deformation of the tissues to achieve a tactile perception effect.@*RESULTS AND CONCLUSION@#The intraoperative navigation system based on XR technology allowed more accurate determination of the location of the lesions, effectively reduced the surgical risk, and avoided the risk of intraoperative radiation exposure. The low latency and high fidelity of 5G network achieved real-time interaction during the surgery to provide a technical basis for multi-terminal remote cooperative surgery. The combination of force feedback technology and XR technology enables the surgeons to conduct deep immersion preoperative planning and virtual surgery to improve the success rate of surgery and shorten the learning curve.

Application value of three dimensional imaging fusion navigation system in laparoscopic pan-creatic surgery / 中华消化外科杂志

Objective:To investigate the application value of three dimensional (3D) imaging fusion navigation system (hereinafter referred as navigation system) in laparoscopic pan-creatic surgery.Methods:The retrospective and descriptive study was conducted. The clinical data of two volunteers, including volunteer 1 undergoing laparoscopic pancreaticoduodenectomy for cholangiocarcinoma and volunteer 2 undergoing laparoscopic pancreaticotomy + splenectomy for pancreatic cancer, who were admitted to the Second Hospital of Hebei Medical University from December 2020 to May 2021 were collected. The 2 volunteers were females, aged 68 years and 40 years, respectively. The self-developed navigation system was applied in laparoscopic simulator model test, including in rigid-body model and prosthesis model, and clinical test. Observation indicators: (1) results of model test; (2) results of clinical test. Measurement data with normal distribution were represented as Mean± SD. Results:(1) Results of model test. The rigid-body model or prosthesis model with occlusion can be seen in the laparoscopic visual field of the initial laparoscopic simulator. The rigid-body model or prosthesis model with occlusion and rigid-body model or prosthesis model without occlusion can be seen in the 3D visual reconstruction image of enhanced computer tomography (CT) examination. The rigid-body model or prosthesis model with occlusion can be seen in the laparoscopic visual field of the initial laparoscopic simulator after the 3D visual reconstruction image was superimposed and fused with the real-time laparoscopic image. Both of the rigid-body model and prosthesis model were in high consistency, with the distance error of marker points were (0.26±0.11)mm and (0.29±0.18)mm, respectively. (2) Results of clinical test. The abdominal organs and blood vessels with occlusion of the 2 volunteers can be seen in the initial laparoscopic visual field. The location of tumor, important organs and blood vessels can be seen in the navigation system using the 3D visual reconstruction image of enhanced CT examination. The location of tumor, important organs and important blood vessels can be seen in the laparoscopic visual field after the 3D visual reconstruction image was superimposed and fused with the real-time laparoscopic image. The distance error of marker points of the volunteer 1 was (1.36±0.57)mm and the distance error of marker points of the volunteer 2 was (1.24±0.33)mm.Conclusions:The self-developed navigation system can integrate the preoperative 3D visual reconstruction image of enhanced CT examination and the intraoperative real-time laparoscopic image with a good effect. The relationship between deep tissue and blood vessels which is not clarified in conventional laparoscopy can be shown in the navigation system assisted laparoscopic pancreatic surgery.

Thirty Cases of Front-orbital Fibrous Dysplasia: Intraoperative Optic Canal Localization with Three-bits Method and Outcomes Evaluation / 肿瘤防治研究

Objective To investigate the indications of optic canal decompression in the patients with front-orbital fibrous dysplasia and the methods of intraoperative optic canal localization and decompression. Methods We collected 30 cases of fibrous dysplasia. All patients had sufficient images assessment. Patients with symptoms underwent surgery, including front-orbital cranioplasty and optic canal decompression. The frontotemporal epidural approaches were used. If there was a proptosis, the approach was extended with the removal of superior orbital ridge. Six patients undertook intraoperative CT and MRI fusion navigation, assisting in confirming the trunk, orbital and cranial orifice of optic nerve. During the operation, the optic canals were decompressed by three-bits method, to confirm the position of optic nerve. Results There were 30 cases of optic canal decompression and one case of vision loss. The visual acuity and vision field of the remaining patients improved to varying degrees. The proptosis disappeared or alleviated after the operation. Thirteen cases were reconstructed with normal internal plate, five cases with titanium plate, nine cases without reconstruction, and two cases were paved with proliferative broken bone on the orbital top; one case recurred with exophthalmos again after five years, but the visual acuity did not decline. Conclusion For the patients with front-orbital fibrous dysplasia, active surgical treatment should be taken, optic canal decompression should be chosen for diminution of vision, craniofacial anaplasty and orbital decompression should be performed in patients with facial deformity. The epidural approach is a good option to locate the optic nerve from the orbital orifice or cranial orifice. Combined with the three-bits method, we can achieve safe and meticulous optic nerve decompression.

Cavernoma Paraventricular / Paraventricular Cavernoma

Introducción: Los cavernomas representan el 5 al 13% de las malformaciones cerebrales y suelen tener una localización supratentorial. Clínicamente pueden permanecer asintomáticos o presentar síntomas neurológicos progresivos. Para estos últimos, así como los que presentan hemorragia recurrente, la resección quirúrgica es el tratamiento de elección. Sin embargo, para aquellos que presentan una localización profunda es menester estudiar la relación que existe entre la lesión y las estructuras cerebrales adyacentes. La tractografía (DTI) y las técnicas de navegación intraoperatoria son herramientas fundamentales para planificar y guiar el abordaje a la lesión y realizar un mapeo de las vías de proyección, asociación y comisurales, permitiendo un acceso seguro mediante corticotomías pequeñas y mínima retracción del parénquima cerebral. Objetivo: Describir la técnica quirúrgica guiada por neuronavegación para la resección de un cavernoma frontal derecho profundo yuxtaventricular a través de una pequeña corticotomía. Caso: Paciente de sexo masculino de 20 años de edad, deportista profesional, con parestesias miembro superior izquierdo y cefalea severa. Resonancia magnética evidencia lesión heterogénea en T1 y T2 y presencia de un halo de hemosiderina, compatible con cavernoma a nivel del techo del cuerpo en el ventrículo lateral derecho. Mide 28 mm x 31 mm x 28 mm en sus diámetros transversal, dorso-ventral y rostro-caudal. Tractografía evidencia lesión en íntima relación con el tracto corticoespinal en su recorrido por la corona radiada. Resultados: Exéresis completa de la lesión. El paciente evolucionó sin déficit neurológico y fue dado de alta a las 72 horas del postoperatorio. Conclusión: El uso de la tractografía y de la navegación intraoperatorio, permite abordar lesiones profundas, en contacto con áreas elocuentes, mediante corticotomías pequeñas con mínima retracción cerebral

Introduction: Cavernous malformation represents among 5 to 13% of brain vascular malformations, most of them have a supratentorial location. Clinically they can remain asymptomatic or present with neurological symptoms. In cavernomas with recurrent hemorrhage, located in safe areas, surgical resection is the treatment of choice. However, for those which have a deep yuxta-ventricular localization it is necessary to know the relationship between the lesion and eloquent cerebral structures. Fiber tractography and intraoperative navigation systems are essentials tools to plan and guide the surgical approach and make a mapping of the projection, association and commissural fibers in order to have a safe access to the lesion. Objective: To describe the surgical technique using neuronavigation for the resection of a right frontal yuxta-ventricular cavernous malformation through a minimal approach. Case: A 20-year-old man, professional athlete with left arm paresthesia and severe headache. Magnetic resonance shows a heterogeneous lesion in T1 and T2 with a hemosiderin in the roof of the right lateral ventricle, compatible with a cavernous malformation. Its size was 28 mm x 31mm x 28 mm in the transversal, dorsoventral and rostrocaudal diameter. The fiber tractography shows an intimate relationship with the corticospinal tract on its path through the corona radiata. Results: Complete resection of the lesion. The patient evolved without a neurological deficit and was discharged 72 hours later. Conclusion: The fiber tractography and the intraoperative navigation system allow the deep lesions approach, especially for those who have an intimal relationship with eloquent ́s areas, using minimally corticotomy with less parenchymal retraction.

Research progress of near-infrared fluorescence imaging technology in surgery / 中国肿瘤临床

Near-infrared fluorescence (NIRF) imaging is an emerging technology that aids in real-time intraoperative navigation. NIRF uses fluorescent dyes and probes to obtain real-time anatomical and functional information of blood and lymphatic vasculature and specific tissues during surgery. It can identify small cancerous growths and tumor margins that cannot be normally detected by traditional methods, thus providing the surgeons with a perioperative, anatomical guidance and identification modality to make correct intraoperative decisions. NIRF is promising owing to the following aspects: real-time, sensitive, safe, non-invasive, relatively cheap, and non-ionizing; it has the potential to bring a revolution in the existing surgical techniques. This article comprehensively reviews the basic principles of NIRF imaging technology, the clinical progress in real-time guided tumor resection, sentinel lymph node mapping for cancer staging, and protection of critical anatomical structures during surgery. Furthermore, this review discusses the advantages and limitations of NIRF technology and potential future prospects for its application.

Application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective To explore the application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma (ICC).Methods The retrospective descriptive study was conducted.The clinicopathological data of 11 patients with ICC who were admitted to Zhujiang Hospital of Southern Medical University between January and September 2018 were collected.There were 5 males and 6 females,aged (55 ± 12)years,with a range from 30 to 74 years.The data of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with gadoxetate disodium (Gd-EOB-DTPA) of the upper abdomen were respectively collected,and three-dimensional(3D) model of liver was constructed based on CT-MRI fusion images.The preoperative evaluation and surgical planning were carried out based on the different modal imaging examination technologies.The indocyanine green (ICG) molecular fluorescence imaging system and augmented reality navigation system were used to guide hepatectomy.Observation indicators:(1) preoperative evaluation;(2) intraoperative situations;(3) comparison between surgical planning based on the different model imaging technologies and actual surgical method;(4) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to November 2018.Measurement data with normal distribution were represented as Mean ± SD,measurement data with skewed distribution were represented as M (range).Count data were described as absolute number or percentage and comparisons were analyzed using the paired chi-square test.Results (1) Preoperative evaluation:the proportions of grade 3 and above branch vessels of the portal vein and hepatic vein system and tumor margin by enhanced CT examination and enhanced MRI examination were respectively 11/11,4/11 and 5/11,11/11,with statistically significant differences in above indicators (x2 =4.16,5.14,P＜0.05).The enhanced CT showed 11 liver cancer lesions and enhanced MRI showed 13 lesions (including 2 lesions not demonstrated by enhanced CT,with a maximum diameter ≤ 10 mm).The 3D model of liver based on CT-MRI fusion image:location,number,infiltrating range (tumor boundary),intrahepatic vascular distribution,variation and its spatial relationship with lesions could be stereoscopically,intuitively and comprehensively displayed.(2) Intraoperative situations:of 11 patients,11 lesions were explored with naked eyes;13 lesions were detected by ICG molecular fluorescence imaging system,including 2 lesions showing low uptake lesions in liver and gallbladder specific period by preoperative MRI examinations and intrahepatic metastasis cancer by pathologic examination.Of 11 patients,6 had naked-eye ischemia boundaries around related vessels of hepatic portal ligation;10 with anatomical hepatectomy had hepatic segments or hemihepatic boundary by ICG molecular fluorescence imaging system,including 2 using positive staining and 8 using anti-staining.Among 11 patients,3 (1 combined with local resection of hepatic segment Ⅷ metastases),2,2,1,1,1 and 1 underwent respectively left hepatectomy,left lateral lobectomy of liver,right hepatectomy,extended right hepatectomy,right lobectomy of liver,resection of partial hepatic segment Ⅷ and mesohepatectomy.Seven of 11 patients received regional lymph node dissection and 4 received simple lymph node biopsy.Of 11 patients,1 diagnosed as with bile leakage of liver section underwent suture and ligation treatment with 4-0 Prolene;10 didn't occurred bile leakage.The surgical margin of 11 patients was negative.The operation time,volume of intraoperative blood loss and duration of hospital stay were (240± 118)minutes,(275±249)mL and (13 ± 8) days,respectively.There was no blood transfusion in the perioperative period.(3) Comparison between surgical planning based on the different model imaging technologies and actual surgical method:surgical planning of 3D model based on CT,MRI and CT-MRI fusion image in 6,9 and 11 patients was respectively consistent with actual surgical method.(4) Follow-up:11 patients were followed up for 2-10 months,with a median time of 6 months.Three patients had postoperative complications,2 of which were found in Clavien-Dindo Ⅰ and Ⅱ,including 1 with pleural effusion + peritoneal effusion and 1 with pleural effusion,they were improved after conservative treatment;1 with complication of Clavien-Dindo Ⅲ (postoperative intra-abdominal bleeding) was improved by selective arterial embolization using percutaneous femoral artery puncture.There was no postoperative bile leakage,hepatic failure and death.Conclusion Multimodal image fusion technique is helpful to optimize the preoperative surgical planning,which can assist the recognition of important vessels and real-time navigation of hepatectomy during operation,and improve the safety of operation.

Application of indocyanine green fluorescence imaging in laparoscopic hepatectomy / 中华肝胆外科杂志

Minimally invasiveness and accuracy are the aim of modern hepatobiliary surgery.Under the guidance of this concept,laparoscopic hepatectomy turns to be more mature and standardized.However,there are still some limitations for laparoscopy.Indocyanine green fluorescence imaging technique can accurately locate tumors,mapping liver segments,and display biliary tract.It is an effective real-time tool to guide the parenchymal transection accurately during operation.It can also detect small lesions and bile leakage.Indocyanine green fluorescence imaging technique makes up the limitations of laparoscopic surgery,providing better conditions for accurate surgery.In this paper,we summarized the application of indocyanine green fluorescence imaging technique in laparoscopic hepatectomy.

Application of mixed reality technique in hepatobiliary tumor surgery / 中国介入影像与治疗学

Objective: To explore the application value of mixed reality technology in surgical treatment of hepatobiliary tumors. Methods: Sixteen patients with hepatobiliary tumors (study group) underwent CT plain and enhanced examination or routine MR examination of abdomen. The original data of DICOM format with layer thickness ≤1.5 mm were obtained. Then the data were imported into the computer, and 3D model reconstruction was performed using Mimics software. The calculated STL format files were imported into zSpace, and the mixed reality technology was used to process the display. The virtual model was used to for discussion of surgical planning, rehearsal operation process and intraoperative real-time navigation. Meanwhile, 31 patients with hepatobiliary tumors were enrolled in control group and underwent traditional surgical treatments. The average operative time and the mean intraoperative blood loss were compared between the two groups. Results: By constructing 3D model of CT or MR scan image data, the relative positional relationship of tissue and organs were distinguished. The lesions' site could be delineated by Mimics software, and the lesions' size were clearly measured with rendering. The mixed reality navigation system could guide the surgical procedure, accurately provide the location of lesion, show the relative relationship of surgical instruments and the lesion. The average operation time of study group and control group was (296.25±65.37)min and (391.45±79.75)min (t=2.280, P=0.029), and the mean intraoperative blood loss was (318.75±99.20)ml and (560.32±227.53)ml (t=2.080, P=0.046), respectively. Conclusion: Mixed reality technology can provide the surgeon with a very intuitive stereo image, help to clarify the surgical path and enhance the judgment of the surgeon, therefore having good application prospect in hepatobiliary tumor surgery.

Virtual surgical planning and intraoperative navigation for mandibular reconstruction: from accurate to minimal invasive / 中国修复重建外科杂志

Simultaneous restoration of function and appearance should be performed in mandibular reconstruction. Option of reconstructive techniques is determined by cause, location, extent, and classification of the mandibular defects. Vascularize bone graft is one of the most popular technique in current clinical practice of mandibular reconstruction. Fibula is the most common donor site for mandibular reconstruction. The disadvantage of low height of neo-mandible reconstructed by single fibular segment can be solved by vascularized double barrel fibula graft. Using virtual surgical planning and intraoperative navigation for mandibular reconstruction leads to simplify surgical procedure, reduce operating time and injury, and decrease donor site morbidity so that accurate mandibular reconstruction could be completed. Direction of minimal invasive surgery for mandibular reconstruction will be developed by intraoral approach and intraoral anastomosis.

Computer-Assisted Spine Surgery (CASS) / 대한정형외과학회잡지

Computer-assisted spine surgery (CASS) is a new discipline involving application of computer engineering and mechanical engineering to spine surgery. The tools used most commonly include preoperative surgical simulation, intraoperative navigation, and robot-assisted surgery. Surgical simulation has been utilized for both clinical and basic research. Navigation in spine surgery has focused on guidance of screw placement, however, due to limited accuracy and high cost, its use is somewhat sparse. CASS may be combined with minimal invasive spine surgery in the near future. Further validation of clinical accuracy issues and surgical outcomes as well as cost-benefit analysis is required.

Development and Accuracy Test of a Robot-arm Type Image-guided Surgery System for Percutaneous Screw Fixation of the Sacro-iliac Joint

PURPOSE: To develop a robot-arm type image-guided surgery system for percuatneous screw fixation of the sacro-iliac joint and to evaluate its accuracy. MATERIALS AND METHODS: We have developed an image-guided surgery system using a three-dimensional digitizer (Microscribe 3-D G2, Immersion, USA) and a personal computer. The registration error and target localization error at fiducial registration were measured 30 times for each using a phantom made with plastic pelvic bone model (Sawbones, USA). Sixteen 6.5 mm cannulated screws were inserted into four plastic bone models, and the accuracy was evaluated. RESULTS: The target localization error was 1.46+/-0.47 mm while the registration error was 0.73+/-0.23 mm. All of the 16 screws were inserted well across the sacro-iliac joint, and there was neither cortical breach nor collision between screws or washers. CONCLUSION: The accuracy of the developed system was similar to that of optical tracker-based navigation systems, and its helpfulness and usefulness was proven with simulation surgery using plastic bone models.

Development of an Intra-operative Navigation System Using an Optical Tracking System / 대한정형외과연구학회지

PURPOSE: The purposes of this study were to develop an intraoperative navigation system as the first step toward image-guided surgery and robotic surgery, and to evaluate its accuracy. MATERIALS AND METHODS: The navigation system was composed of an optical tracking system (Polaris, Northern Digital) and a personal computer. The registration error and target localization error of fiducial registration and surface registration were measured using a phantom. Each of the errors was measured 30 times, and the average values and the standard deviations were calculated. RESULTS: The registration error was 0.84 +/- 0.28 mm at fiducial registration and 0.81 +/- 0.21 mm at surface registration. The target localization error was 1.54 +/- 0.34 mm at fiducial registration and 1.46 +/- 0.32 mm at surface registration. CONCLUSION: We have developed an intraoperative navigation system using an optical tracker, and could assure ourselves that its accuracy is adequate for many orthopaedic surgeries. However, it still requires improvement in the accuracy and development of specific software and instruments for various operations.