Transoral robotic surgery (TORS) is an effective minimally invasive alternative to traditional open surgery with improved surgical outcomes and reduced morbidity. However, TORS utilizes the natural orifice approach and does not provide haptic feedback, resulting in difficulty in assessing the extent of tumor or identifying critical structures. Intra-operative surgical navigation with image guidance has the potential to compensate for the sensory deficit in TORS. The authors previously enabled intra-operative image guidance for TORS and demonstrated the feasibility of electromagnetic tracking of da Vinci robotic instruments. In this paper, the authors described the development of a TORS navigation framework with real-time tracking and integration with the da Vinci surgeon’s console, assessed the system efficacy in a multi-user phantom localization study, and discussed study limitations. Five participants with various experience levels performed target localization tasks without and with navigation and all achieved significantly reduced target localization error (TLE) (p≤0.05; α=0.05), with the lowest TLE being 2.1mm. The authors successfully demonstrated the potential of the navigation system in facilitating precise target localization and enabling accurate image-guided TORS (igTORS).
Positive surgical margins are a common complication of trans-oral tumor resection, and implementation of image guidance is typically hindered by significant tissue deformation introduced by oral retractors. Recent advances have produced multiple pathways for developing intraoperative trans-oral image guidance, which must ultimately be displayed to the surgeon in real time. This work presents a pipeline for automatically displaying CT-registered three-dimensional surface structures in the surgeon console of a da Vinci surgical system and assesses image-plane projection accuracy using Dice coefficient and intersection over union metrics. While coarse accuracy is acceptable (metric averages ⪆0.5), more accurate projections were obtained using registration methods based on optically tracking the endoscope shaft. Further improvement of registration, kinematic modeling, and endoscope calibration is necessary prior to use in preclinical evaluation of image guidance strategies for trans-oral robotic surgery.
Transoral robotic surgery (TORS) has demonstrated improved surgical outcomes with reduced morbidity when compared to traditional open surgical treatments. However, it is more difficult to assess the extent of tumor and localize critical structures due to lack of haptic feedback and the natural orifice approach. Enabling image-guided TORS (igTORS) to compensate for the sensory deficit requires a surgical navigation system that is compatible with both the TORS procedures and the da Vinci surgical system. Previously, the authors developed an imaging compatible oral retractor system for TORS to allow artifact-free intraoperative CT images for use in image guidance. In this work, we developed a surgical navigation system for TORS that utilizes intraoperative images and electromagnetic (EM) tracking. A cadaver experiment simulating a standard TORS procedure was performed to examine system feasibility and accuracy. A da Vinci Bovie instrument was tracked, and its real-time location was visualized in tri-planar CT images and displayed on the surgeon’s console and on the bedside vision cart using the TilePro feature. Target localization error (TLE) was computed to be 3.46±0.77 mm. This was the first time that surgical navigation in TORS was demonstrated with intraoperative image guidance and EM tracking of da Vinci instruments in a cadaver experiment.
Currently-available metallic retractors typically used in transoral robotic surgery (TORS) cause significant artifacts in CT imaging and cannot be safely used in MRI. The lack of imaging-compatible oral retractors poses a significant challenge to enabling intraoperative imaging in TORS. This work introduces a customizable compact 3D-printed polymer retractor system that enables multiple modes of adjustability, artifact-free CT and MR images, and adequate surgical exposure. The polymer retractor design was modeled after the traditional metal FK and Crowe-Davis retractors and can be used with an acrylic suspension system that rests over the patient’s chest. Finite element analysis was conducted to evaluate the mechanical performance in relevant clinical loading conditions. Cadaver experiments followed by endoscopic, CT, and MR imaging were performed to demonstrate functionality. Artifact-free CT and MR images were obtained. An interincisive distance of 42.50 mm and 200.09 cm3 working volume were achieved, which allow the introduction of robotic arms and necessary instruments in TORS. This polymer retractor system makes it possible to acquire intraoperative images and establishes a critical step to make image-guided TORS both feasible and effective.
Tumor phantoms (TP) have been described for the purposes of training surgical residents and further understanding tissue characteristics in malignancy. To date, there has not been a tumor phantom described for the purposes of research and training in oncologic surgery of the head and neck focusing on the larynx and pharynx. With the goal of providing radiographic, visual, and physical mimicry of head and neck squamous cell carcinoma (HNSCC), a phantom was developed as a proposed training and research tool for trans-oral surgical procedures such as transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). TP’s were constructed with an agar-gelatin chicken stock base to approximate reported physical properties, then glutaraldehyde and Omnipaque-350 were used as a fixative and to enhance CT-visualization respectively. Further, to ensure heterogeneity in radiographic imaging, other materials like olive oil and condensed milk were explored. These ingredients were combined with the use of a novel, 3D printed, syringe adaptor designed to allow for the direct injection of the liquid tumor into model tissue. TP’s fixed quickly in vivo upon implantation and were imaged using CT and segmented. This injection-based model was piloted in bovine tissue and verified in porcine tissue with excess Omnipaque-350 for volumetric reliability then optimized utilizing 6 well plates. Following radiographic optimization, the viscoelastic properties of TP’s were measured through uniaxial compression. We observed a Young’s modulus similar to published literature values and consistent reproducibility. Most notably, our proposed TP can be used by multiple specialties by altering the color and concentration of agar in the base solution to approximate physical properties.
Access to the requested content is limited to institutions that have purchased or subscribe to SPIE eBooks.
You are receiving this notice because your organization may not have SPIE eBooks access.*
*Shibboleth/Open Athens users─please
sign in
to access your institution's subscriptions.
To obtain this item, you may purchase the complete book in print or electronic format on
SPIE.org.
INSTITUTIONAL Select your institution to access the SPIE Digital Library.
PERSONAL Sign in with your SPIE account to access your personal subscriptions or to use specific features such as save to my library, sign up for alerts, save searches, etc.