Image Guided Surgery - Duke Universityweb.duke.edu/.../session5/imageguidedsurgeryyasufuku.pdf · Image Guided Surgery ... Image registration with surgical navigation . Optical Surgical

Image Guided Surgery

Kazuhiro Yasufuku MD, PhD

Director of Endoscopy, University Health Network

Director, Interventional Thoracic Surgery Program

Associate Professor of Surgery, University of Toronto

Division of Thoracic Surgery, Toronto General Hospital

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2017 Duke Masters of Minimally Invasive Thoracic Surgery Sep 22-23rd, 2017

Disclosure

• Industry-sponsored grants• Educational and research

grants from Olympus Corporation

• Consultant• Olympus America Inc.

• Intuitive Surgical Inc.

• Medtronic

• Johnson and Johnson

• Auris Surgical Robotics

• Concordia Healthcare

• Research Collaboration• Siemens

• Novadaq Corp

• Veran Medical Technologies

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Image Guided Surgery (IGS) – Definition?

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Image Guided Surgery (IGS) – Definition?

• General term used for any surgical procedure wheresurgeons employs tracked surgical instruments inconjunction with preoperative or intraoperative images inorder to indirectly guide the procedure

• IGS was originally developed for treatment of brain tumors

• Various applications of navigations for neurosurgery havebeen widely used for almost two decades

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Image Guided Surgery (IGS) – in Thoracic Surgery

• Fluorescence Image Guided Surgery

• Virtual/Electromagnetic Navigation Guided Surgery

• Preoperative CT Guided Surgery

• Intraoperative Cone Beam CT Guided Surgery

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Fluorescence Image Guided Surgery

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ICG and Near Infrared (NIR) Imaging

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Surv Opthalmol, 2000

820-835nm

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M.W: 775

Indocyanine green NIR thoracoscope

PinPoint, Novadaq TechnologiesTM

ICG Fluorescence-Guided Surgery

• Sentinel LN Mapping

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J Thorac Cardiovasc Surg. 2013; 146: 562-70

• A-dose escalation phase 1 clinical trial

real-time NIR imaging after peritumoral

injection of 3.8 to 2500 μg

• 26 NIR(+) SLNs identified in 15 pts with 7

NIR(+) SLNs (6 pts) harboring metastatic

disease on histologic analysis

• Metastatic nodal disease never identified

in pts with a histologically negative NIR(+)

SLN

ICG Fluorescence-Guided Surgery

• NIR Thoracoscopic Segmental Resection

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J Thorac Cardiovasc Surg. 2012; 143: 1330-5

• ICG injection into the bronchus of target pulmonary segments under GA

• NIR Thoracoscopic identification of the target segments (Hamamatsu Photonics, Hamamatsu, Japan)

• Intersegmental lines and planes identified to allow segmental resection

ICG Fluorescence-Guided Surgery

• NIR Robotic Segmental Resection

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J Thorac Cardiovasc Surg. 2014; 148: 737-8

• iv injection of ICG after division of segment bronchus, vein and artery (2.5mg/10mL, 6-8mL bolus)

• Da Vinci Firefly fluorescence imaging for identification of the target segments

Virtual/Electromagnetic Navigation Guided Surgery

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Virtual assisted Lung Mapping

• VAL-MAP

• Bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection

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J Thorac Cardiovasc Surg. 2014; 147: 1813-9

Preoperative bronchoscopic marking

• CT Fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules

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CHEST 2004; 125:1747–1752

Preoperative ENB marking (fiducial, dye)

• ENB-guided VATS wedge resection of peripheral lung nodules

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Seminars in Thoracic and Cardiovascular Surgery, 22 , 2011J Community Hosp Intern Med Perspect. 2014; 4(1): 10

GTx (Guided Therapeutics) Program

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GTx OR at Toronto General Hospital

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GTx OR Capabilities

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Cone-Beam CT Dual Source- Dual Energy CT

MIS, Endoscopic Technology

Guided Therapeutics (GTx) Core

GTx OR Capabilities

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Cone-Beam CT

Guided Therapeutics (GTx) Core

Multi-Modality Surgical Guidance

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Optical Imaging

Surgical Tool TrackingIntraoperative CBCT

Surgical Planning

Pre-Operative Imaging

Intraoperative localization Image assistance during MIS/Robotic Surgery

Real time monitoring of minimally invasive thoracic

intervention

Optical Surgical Navigation

Surgical Tool TrackingIntraoperative CBCTPre-Operative Imaging

1. Preoperative CT imaging

2. Intraoperative CBCT Imaging

3. Image registration with

surgical navigation

Optical Surgical Navigation

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Chest Wall Tumor Resection

Guided Therapeutics (GTx) Core

GTx OR – VATS localization

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GTx OR – Image guided Transbronchial Interventions

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Ujiie et al, AATS 2016 abstract

CT-guided Microcoil Placement and ICG Injection

Ujiie et al, AATS 2016 abstract

Intraoperative NIR Localization

GTx OR – CBCT localization

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Summary

• Hybrid OR with capabilities of preoperative and intraoperative real-time radiologic imaging as well as advanced endoscopic procedures will assistsurgeons during Image Guided Surgery

• Advances in imaging technology will enable intraoperative localization of small peripheral nodule during minimally invasive surgery

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AcknowledgementLatner Thoracic Surgery LaboratoryYasufuku Laboratory

Hideki Ujiie

Kosuke Fujino

Chang Young Lee

Tomonari Kinoshita

Alex Gregor

Salma Hindy

Andrew Effat

Judy McConnell

Alexandria Grindlay

Kim Hudson

TECHNA Institute

David Jaffray

Robert Weersink

Jonathan Irish

Harley Chan

Michael Dunne

Jimmy Qiu

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Thank you

Division of Thoracic Surgery

Toronto General Hospital

University Health Network

Kazuhiro Yasufuku, MD, PhD, FCCP

[email protected]