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Kingston’s operating room of the future refines surgical techniquesBy Andy Shaw A $28.1 million Ontario grant for space redevelopment at Kingston General Hospital (KGH) has opened doors to the world’s first fully computerized operating suite. “We’re using some of the funds to build computers and tracking technology into the walls and ceilings, so that it will be easy and convenient to do any kind of image-guided procedure in our two new operating rooms,” says Dr. Randy Ellis, a computer scientist at Queen’s University who is also appointed to KGH’s surgery department. Expected to open in early 2003, the new ORs are a joint Queens-KGH project dubbed OR2010. Meant to set the standard for computer assisted surgery, OR2010 has drawn both public and private sector support, thanks to earlier successes of specialized techniques and robotic equipment developed under Ellis’s leadership. Since a casual “what if...?” chat in a coffee shop with a mechanical engineering student in 1993, Dr. Ellis has been investigating how computers can be brought to bear on orthopaedic surgery. His work and a group of willing surgeons have made Kingston a hotbed of computer-assisted surgery ever since. In 1997, for example, Dr. John Rudan performed Canada’s first computer-assisted knee re-alignment at KGH, precisely removing just a small wedge of bone instead of replacing the entire joint. In 1998, Dr. David Pichora similarly performed the first computer-assisted wrist surgery. Later came first-ever surgeries to remove painful, non-cancerous bone tumours with pinpoint precision. Now, with more than 50 computer-assisted operations to their credit, the benefits are clear to Kingston surgeons, researchers, and patients alike. Instead of chopping out large chunks of bone and inserting metal plates and screws in hugely invasive and debilitating procedures, says Dr. Ellis: “We can remove a tumour through small incisions in less than an hour. So rather than being in a cast for six to eight weeks and undergoing six months of rehab, the patient is discharged the same day and spends only a week in post-operative recovery.” Typically, the surgical team first develops a 3D computer model of the target bone or joint. Custom software then helps them prepare a plan of attack, which they refine by doing virtual surgery on the model. When ready, the plan is integrated with customized surgical and optoelectrical instruments that precisely guide surgeons through the real procedure. “We’ll be doing this in the new ORs primarily for orthopaedic, cranial-facial, and neurosurgery at first. But many other kinds can be done in the room too,” says Dr. Ellis. “The computer does necessarily make every type of surgery better,” says Dr. Dr. Rudan, now an associate professor of surgery at Queen’s and one of two principal investigators along with Dr. Pichora on the OR2010 team. “But that is what we are trying to find out – where’s its niche? What can computer assisted surgery do and what can’t it do?” Dr. Rudan says much of the OR2010 project will move from proof-of-principle to surgery’s mainstream at KGH with the opening of the new operating rooms. Dr. Rudan expects to see a lot of minimally invasive surgery done on arthritic knees. “We can replace the affected part of the joint through a two-inch incision. We can’t, of course, see the whole knee but we can visualize it very well with our 3D reconstructions and implant new components much more accurately than with conventional pictures,” says Dr. Rudan. He also says such image guided techniques will make complicated hip surgeries much less traumatic for patients. Badly mangled wrists, a common injury for the young (skateboarders) and old alike, will continue to be the focus of attention for Dr. Pichora in the new ORs. “He’s been able to do some remarkable work restoring normal joint lines in the wrist,” says Dr. Rudan. Narrowing the procedures down to those where computer assistance has proven truly superior is the next step, says Dr. Rudan. And they’ll be chosen against a range of criteria. “First of all, the procedure has to be done at least as well, and hopefully better than with conventional surgery. Then it has to allow us to do more cases exactly the way we want them done than with conventional techniques. We also have to be able to do the procedure within the normal time allotted for it. We can’t take two or three more hours for it just because we are using computers. It also has to be cost effective. In other words, we can’t just use these techniques for one operation and then have a major software or hardware modification after each one. And for the operating room crews, they have to be comfortable with the technology. It has to be reduced to the level of being as simple as sliding a CD into a player. So that you don’t need a huge technical background in order to use the techniques. Finally, it has to be possible that if the computer fails, the surgeon can go immediately back to working conventionally. We can’t have the whole procedure dependent on the computer.” New procedures in KGH’s state-of-the-art ORs will reach places where others have not gone before – into soft tissue. Northern Digital Inc. (NDI) of Waterloo, Ontario, an OR2010 collaborator much praised by Dr. Ellis, is developing tracking systems suitable for laparoscopic surgery on the likes of the heart, liver, and prostate gland. “We’re world leaders in providing localization in image guided surgery using optical technology,” says NDI president David Crouch. “That’s been very suitable for neurosurgery, spine procedures, and orthopedics where you can get a clear line of sight to the tool you need to track. But in soft tissue surgery, we’re much more likely to be tracking internal tools such as endoscopes and catheters that are becoming smaller and smaller.” To track those ever-smaller targets through the murky, fleshy environment of an organ, NDI has turned to magnetic technology that places minute sensors inside laparoscopic tools. Linked with ultrasound imaging and moving through a magnetic field generated by other NDI equipment, the sensors give very precise guidance, for instance, to a surgeon’s biopsy needle aiming for a dead centre sample of a liver tumour. Backing up these new procedures in the operating rooms of the near future will be computer-assisted record keeping. Sun Microsystems, another praised supporter of OR2010, is already supplying its multi-channel Jini network technology to a U.S. hospital in Virginia where information streaming from all devices involved in an operation can be recorded. “There’s a virtual connection to everything at work in the OR so that blood pressure and temperature monitors, for example, don’t have to be tracked individually,” explains Greg Worth, a Sun business development manager for healthcare world-wide based in California. “The data are constantly and automatically funnelled into one consolidated medical-legal record of everything that occurred during the operation.” Back in Canada, other surgical researchers and developers are also out on the leading edge. The Institute for Robotics and Intelligent Systems (IRIS), for example, is a federal national centre of excellence being managed by the non-profit Precarn Inc. Under Precarn stewardship, Dr. Tim Salcudean, an electronics engineer at the University of British Columbia in Vancouver led a team of other university researchers from Simon Fraser, Queen’s (including Randy Ellis), and McGill, as well as from the Robarts Research Institute in London, Ontario and Western Clinical Engineering in Vancouver. The three-year $1.47 million project, which wound up in April this year, aimed at using technology to improve pre-surgery diagnosis, the surgery itself, and surgical outcome assessment. At the diagnosis end, the team tackled the problem of how surgeons might cope better with the vast amounts of images and other data available to them prior to pulling on the gloves. It also went after new ways of carrying out sophisticated surgical procedures using minimally invasive techniques in the operating room. Finally, it grappled with how one can more systematically determine the effectiveness of such surgeries once the patients have gone home. Among the upshots are a new robotic-assisted ultrasound system suitable for carotid artery diagnoses, the new computer-aided orthopaedic knee techniques of Dr. Ellis described above, as well as a sensing system to measure post-operative joint performance. This research has already resulted in three spin off companies bent on commercializing these developments. In another IRIS project led by Vincent Hayward at McGill University, researchers have brought haptic feedback to angiograms. In the past, surgeons needed expensive MRI techniques to look at the shape and size of suspect blood vessels. However, MRI snapshots can take five minutes to appear on screen, so the challenge was to find a cheaper, faster way for doctors to view angiograms. The solution the team developed is software that transforms angiogram data into 3D images. Doctors can then “feel” the blockages displayed in the images using a joystick. An applied-for patent will likely protect this new Canadian technique now dubbed “skin stretch tactile display”. The team has developed four tactile display devices aimed not only at surgical use but also for the gaming, automotive, and computer aided design industries. At Simon Fraser University, Professor Shahram Payandeh has turned his mechanical engineering training to robot-assisted endoscopic and laparoscopic work – robo-surgery, in short. A specialist in mechanical grasping and manipulating, Dr. Payandeh is working on giving surgeons normal freedom of movement and sense of touch at the surgical site even when working with the long tools and endoscopes. Collaborating with other engineering and medical researchers at the University of Victoria and the University of British Columbia, Payandeh has developed a number of robotic devices that place and hold surgical tools in precise positions. This removes the need for an assistant surgeon to do the holding and reduces the strain on the operating surgeon who must often assume demanding postures while manipulating various tools and graspers. One device, for example, allows surgeons to suture internal organs without having to hold back the skin at the same time. Enabling surgeons to operate more accurately and with less stress for both surgeon and patient alike is the common goal of Payandeh, Ellis, Salcudean, and others who are supported by IRIS research and development funds. The robotic technology they are producing is quite literally cutting edge. It is also technology that has a place to grow up. IRIS links researchers at over 40 Canadian universities, hospitals, and research centres with over 90 private companies with the aim of turning their developments more quickly into marketable products. One important piece of surgical research, however, can’t be commercialized. But it is telling about surgery’s future. In 2000, an IRIS supported survey of 1,008 British Columbia surgeons on minimally invasive techniques and tools revealed that there’s still plenty of development work yet to be done. On average, the surgeons performed 150 endoscopic procedures a year with more than 73 percent of them being carried out for therapeutic reasons. Yet more than 20 percent of the surgeons surveyed said they had difficulties with, “...equipment inconsistency, tools awkward to use, tools inadequate, poor image quality, limited field of view, lack of touch feedback, and technical knowledge of the OR staff.” As impressive as Canadian innovation in surgical technology has been, it’s too soon yet to rest on our laurels. BACK TO TOP OF PAGE
London surgeons and Canadarm makers devise new technologiesBy Jerry Zeidenberg LONDON, ONT. – CSTAR has struck an alliance with MD Robotics, developer of the space station’s Canadarm, to collaborate in the creation of medical robotic technologies that will leapfrog many of the applications that are available today. The partners believe they can position Canada as a leading producer of solutions for the fast-developing, minimally invasive surgical industry. The Canadian Surgical Technologies & Advanced Robotics (CSTAR) organization was launched in 1999 by the London Health Sciences Centre and the Lawson Health Research Institute, also based in London. MD Robotics is a subsidiary of MacDonald Dettwiler and Associates. The partners plan to apply many of the advanced technologies developed for the Canadarm and space systems to medical robotics and tele-surgery. “We can jump ahead in this area,” said Dr. Reiza Rayman, director of research and business operations for CSTAR, and a surgeon who has scores of robotic-assisted operations to his credit. “We’ve got all the right ingredients in this partnership, including the aerospace technologies, advanced telecommunications technologies and a great deal of experience in medical robotics. It’s now a matter of putting it all together.” Robotic surgery has taken great strides around the world in recent years. Using computerized arms, instruments, lights and endoscopes, the technology enables surgeons to conduct delicate operations in patients through tiny incisions – often just a few millimeters in length. The result is less trauma to the patient and a faster recovery. Physicians have used robotics for a variety of procedures, from cardiac surgery to gall bladder removal. Dr. Rayman stressed that the London Health Sciences Centre is a world leader in the application of robotics to surgery, with an extensive base of experience and expertise to draw upon. Indeed, the LHSC performed the world’s first robotic-assisted, closed chest, single coronary bypass surgery on a beating heart, in September 1999. Since then, surgeons at the hospital have conducted more than 300 robotic procedures, including 92 heart bypass operations. In February 2001, surgeons at the LHSC performed robotic-assisted surgery using remote manipulation of a robotic arm, also known as “tele-surgery.” The operation also made use of telestration, a technique in which remote surgeons draw on monitors to assist local surgeons with a procedure, while all of the surgeons view the same images on the video screens. And in March 2002, the hospital conducted the world’s first thoracic robotic procedure – an apical bullectomy. “We’re a major player already when it comes to using the technologies, and we have a number of firsts to our credit,” said Marlene Le Ber, manager of CSTAR. “Now we’re going to start developing and producing our own technologies.” Dr. Rayman said there are three main areas on which the partners will concentrate, to produce solutions that improve on technologies that are currently available. First, they intend to enhance the visualization systems that are presently used. These currently tend to be two-dimensional views of the interior of the body, delivered to TV screens or computer monitors by endoscopes. Dr. Rayman said improvements can be made in this area. Secondly, a good deal of work can be done in the articulation of robotic joints, thereby giving surgeons much more dexterity when operating the instruments. “Humans have six to seven degrees of freedom, when moving joints,” said Dr. Rayman. “Medical robots need this as well.” Finally, enhancements could be made in the control systems of the robots, enabling the movements of the robot to be more fluid and more closely matching the intent of the surgeon. “We’d like to see the movements become much more natural,” said Dr. Rayman. Once the partners devise technologies in these areas, they plan to create a spin-off company to market the innovations worldwide. “One of our mandates is to commercialize the technologies, if possible,” said Dr. Rayman. For its part, CSTAR has raised $17.2 million to finance a range of activities. The organization will occupy two levels of a new, five-floor research building at University Campus, London Health Sciences Centre. It plans to move into the new quarters in the early part of 2003. CSTAR already has several research programs under way. These include: • Robotic-assisted interventional cardiology and cardiac surgery. • Robotic cancer therapy and thoracic surgery, including robotic-assisted thorascopic brachytherapy for lung cancer. The centre plans to use robotics to allow precise implantation of radioactive seeds in lung tumours. • Telesurgery and robotic telementoring. • Robotic haptics, the development of better ‘force feedback’ systems that enable a surgeon to feel as well as see what he or she is doing inside the patient’s body, through the use of endoscopes and other instruments. • Atrial fibrillation. This project team proposes to apply robotic surgery techniques to a procedure in which the electrical pathways causing uncoordinated cardiac contractions are altered. According to CSTAR, this hybrid combination will be an international first. • Pediatric/In Utero fetal program. Using robotic technologies, CSTAR surgeons will be able to correct problems while the fetus is still in the mother’s womb. For example, if there is no outflow of urine from the baby’s kidneys, the surgeons can implant a temporary drain. Similarly, if the lungs of the fetus don’t expand as expected, and fluid needs to be drained, this can again be done through precise, robotic technologies. “It’s very exciting, because it means there’s a real potential for the baby to be born perfectly normal through the use of these techniques,” said Ms. Le Ber. CSTAR is currently seeking to raise additional funds to finance joint projects with MD Robotics. It believes it will be successful in this area, partly because of the federal government’s current emphasis on inventiveness through Industry Canada’s Innovation Strategy. For its part, MD Robotics earlier this year established an alliance with the University of Calgary to develop a robotic platform for brain surgery. However, surgeons at the University of Calgary are just launching the program, with less background in the use of robotics than the physicians at CSTAR. Nevertheless, CSTAR managers have been in touch with surgeons and administrators at the University of Calgary to see if there are ways of collaborating, including joint applications for government funding. And in September, the Queen Elizabeth II hospital in Halifax announced that it had conducted a telementoring session in the area of neurosurgery, in which brain surgeons in Halifax advised surgeons at the Saint John Regional Hospital, in New Brunswick, during a live operation, using Computer Motion’s Socrates system for remote tele-surgery and tele-mentoring. BACK TO TOP OF PAGE
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Kingston’s
operating room of the future refines surgical techniques