Robot assisted craniofacial surgery: first clinical evaluation
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1 Robot assisted craniofacial surgery: first clinical evaluation C. Burghart*, R. Krempien, T. Redlich+, A. Pernozzoli+, H. Grabowski*, J. Muenchenberg*, J. Albers#, S. Haßfeld+, C. Vahl#, U. Rembold*, H. Woern* * Institute of Process Control and Robotics, Department of Computer Science, University of Karlsruhe, Karlsruhe, Germany * Clinic of Radiology, University of Heidelberg, Heidelberg, Germany + Clinic of Cranio-Maxillo-Facial-Surgery, University of Heidelberg, Heidelberg, Germany # Clinic of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany For more than three years the surgeons of the Clinic of Craniofacial Surgery of the University of Heidelberg and the engineers of the Institute of Process Control and Robotics (IPR) of the University of Karlsruhe have been cooperating to devise an intelligent surgical robotic system for craniofacial surgery. In July 1998 a new surgical robotics system, a RX 90, was acquired, which was also used in first animal experiments in fall The experimental set up, the conducted tests, our experiences and results will be depicted in this paper. 1. INTRODUCTION Robot assisted craniofacial surgery is a great challenge to the engineer and the surgeon. The use of robots as intelligent surgical instruments promises a considerable improvement of surgical interventions. For three years engineers of the Institute of Process Control and Robotics of the University of Karlsruhe and maxillofacial surgeons of the University of Heidelberg have been cooperating to develop a robotic system to be used as surgical aid in the operating theatre. The first experimental set up consisting of a surgical robot (RX 90), an infrared navigation system, a force torque sensor, a surgical saw, a pointer, a fixation unit and a workstation was tested at the cardiac animal laboratory of the University of Heidelberg. The complete working procedure necessary to perform robot assisted surgery was evaluated starting with the data acquisition, medical image data processing, surgical planning and ending with the intraoperative support of the surgeon by an intraoperative navigation system and a surgical robot. The CT-scan and the surgery on the pig cadaver were performed at the University of Heidelberg, the surface models and the cutting trajectories of the planned osteotomies were generated at the University of Karlsruhe. * Acknowledgement This research was performed at the Clinic of Maxillofacial Surgery at the University of Heidelberg, Prof. Dr. Dr. Muehling, the Clinic of Cardiac Surgery, Prof. Dr. Hagl, and at the Institute of Process Control and Robotics, headed by Prof. Dr.-Ing. U. Rembold and Prof. Dr.-Ing. H. Wörn, at the University of Karlsruhe, Germany. The research is being funded by the German Research Foundation, as it is part of the special research programme, SFB 414, "Information Technology in Medicine - Computer and Sensor Supported Surgery".
2 Robot assisted osteotomies can be performed in two different manners: either the bone is cut autonomously by the robotic system or the surgeon guides the robotic arm along the trajectory while his movements are controlled and restricted by the robot control. The latter method was tested in the animal experiments. 2. EXPERIMENTS The studies were conducted with six pig cadavers at the laboratory of cardiac surgery. The first two times the pigs were beheaded and several different bone cuts were executed with the help of the robot on the solitary heads. Contemplating all experiments, five times the same tests were carried out: a bone cut on each side of the pig s nose up to the forehead and one opening of the skull. The cuts along the muzzle were chosen due to the differences in anatomy between pig and human Experimental Set Up The following devices were used for the robot assisted osteotomy in the animal operating room: An SGI-workstation was needed for visualizing the pig s skull, the planned bone cuts, the reference points and the position of an infrared pointer in twodimensional CT-slices and a threedimensional view. The reference points needed for the registration could be determined by our software as well. The workstation was also used for communicating with the Institute of Process Control and Robotics and transferring data. An infrared navigations system consisting of a camera array with two cameras, a pointer fitted with infrared diodes and a tool interface unit was connected to the workstation via serial link. A software developed by the IPR visualized the skull and communicated with the navigation system. A force torque sensor and a specific oszilliating pneumatic surgical saw, which was built at the IPR, were attached to the robot s flange. The sensor was connected with a PC via CAN- Bus in order to record the detected forces and torques. The forces and torques were then sent via serial port to the robot control Methods In a first step, twelve titanium mini screws were implanted into the skull of a pig to be used as artificial landmarks, then the head of the pig was scanned in a CT-scanner. The scan protocol was composed of nonoverlapping slices with a distance of 1.5 mm between the CTslices. Then the DICOM data were transformed into the tomogram format used by the Institute of Process Control and Robotics and sent to the laboratory in Karlsruhe via internet.
3 Figure 1. Generated surface model of the pig s skull. Figure 2. Planning of the bone cuts using a haptic interface. The information on the bone and the titanium miniscrews was extracted from the data set by seedpoint segmentation and threshold segmentation. Afterwards, supplementary to the volume model the segmented data were triangulated in order to obtain a surface model needed for surgical planning (Fig. 1). A haptic interface (phantom) was used to generate osteotomy lines on the surface model of the skull (Fig. 2). All data, both surface model and volume model as well as the intended bone cuts, were then transferred to the laboratory of cardiac surgery in Heidelberg via internet. (For more information about the surgical planning system refer to [1].) In the animal laboratory the head of the pig cadaver was fixed in a device resembling a combination of mayfield clamp and external fixture in oder to prevent any movement of the pig s head during robot manipulation. The bone cut to be performed by the robot was visualized on an SGI workstation using the volume model of the pig s skull. Four characteristic reference points were selected in the data set and sent to the robot control. The access to the bone to be operated on was planned with the help of the infrared navigation system (Fig. 3). After preparing the bone and fasting the pig s skull to the fixation device, the registration of the pig was repeated and the positions of the bone cuts were controlled. Then the reference point and the trajectories were sent to the robot control. The surgeon manually guided the robot arm to the four reference points for computing the transfomation.
4 Figure 3. Manual registration of the pig cadaver by infrared navigation. Figure 4. Manual guiding of the surgical saw fixed to the robot. The robot restricts the surgeon s movements. An autonomous movement of the robot along the trajectory with a 3 mm offset in direction of the z-coordinate confirmed the bone cut to be performed. The actual dissection of the bone was executed with the help of a pneumatic oszilliating craniofacial saw attached to the robot s wrist. The surgeon manually guided the robot arm along the trajectory whereby his movements perpendicular to the cutting line were restricted by the robot (Fig. 4 and Fig. 5). Only a small deviation of the trajectory (3 to 5 mm) was allowed. The force-torque-sensor detected the forces applied by the surgeon, and the robot control computed the intended movements. A software routine evaluated the movements and determined the robot s actions. Movements were only allowed within restricting cylinders around the segments of the trajectory. An approach of the edge of a cylinder resulted in increasing resistance of the robot arm. Movements outside the given tolerance were prohibited by the robot control. We experimented with varying tolerances of the force controlled restriction. The most accuracte results were achieved with a tolerance of 1.5 mm radius of the inner cylinder around a trajectory segment. The disadvantage of a small tolerances was, that it was not possible to cut bone thicker than 5 mm.
5 Figure 5. Robot supported disection of the pig s muzzle. During robot action the pig s head was fixed in a device resembling an external fixator. Intraoperatively, each performed bone cut was evaluated with the help of the navigation system. The accuracy of the bone cut depends on the quality of the registration and the tolerance permitted for manually guiding the robot arm. Postoperatively the skelettized skull of the pig was measured by a coordinate measuring machine. 3. RESULTS The studies were perfomed on six pig cadavers. Five times cuts along the muzzle and treptanations of the skull were realized. In each experiment when diseccting the bone between nose and forehead four reference points were used for registration. The registration error of the infrared navigation ranged from 0.5mm to 3mm. The registration error of the robot when manually registering the artificial landmarks ranged from 0.2 mm to 0.5 mm. Additionally, position errors resulting from the segmentation of the titanium screws in the CT data have to be contemplated. After the dissection of the bone a first evaluation was made using the infrared navigation system. Here, there never was noticed a deviation from the planned trajectory of more than 3 mm, which just is the tolerance for the sawing process. A later evaluation using a coordinate measuring machine to determine the deviation on the skelettized pig heads showed the same results. Still, the dura and the brain of the pig were never damaged when cutting an opening into the frontal bone using the presented method. All forces and torques meassured during the robot assisted surgical intervention were protocolled. When guiding the manipulator without restriction, forces between N and +1.0 N were detected. When restricting the surgeon s movements during the sawing process, the forces applied ranged from -2.5 N to N (Fig. 6). The detected torques ranged from mmnm to 1.0 mmnm when guiding the robot and form -2.3 mmnm to 3.1 mmnm when performing the bone cuts. Several features of the described method still have to be improved. The manual restricted guiding was rather hard to handle for the surgeon. The drift of the sensor is rather high (4 N), which causes some difficulties with small forces. It took a lot of force to guide the saw when
6 dissecting the bone; this feature was implemented on purpose, as otherwise the robot would move too big a distance within a time slot when a small force is applied to the surgical saw. Unintended cuts would result. Difficulties to get to know the position of the preplanned trajectory with respect to the robot when guiding the saw have meanwhile been improved. A man-machine interface depicting the deviation in x-, y- and z-direction has been developed. Figure 6. Forces detected when guiding the robot and when dissecting the bone. 4. CONCLUSION In this paper the first evaluation of a method for robot assited craniofacial surgery on pig cadavers has been presented. The manual guiding of a robot along a preplanned threedimensional trajectory while the robot restricts the surgeon s movements, offers a surgeon the opportunity to transpose an osteotomy as planned and to make the final decision on the actual position of the bone cut within a given range. Further research includes the autonomous performance of osteotomies by robot and the development of a method to decide the correct depth of the bone cut at each point of the trajectory. Additionally, a specific system architecture for the computer and robot supported operating theatre has to be devised.
7 REFERENCES 1. Münchenberg J., Haßfeld S., Raczkowsky J., Rembold U., Wörn H.: Expert supported Operation Planning in Maxillofacial Surgery. In Proceedings of Computer Assisted Radiology and Surgery (CAR'98), Tokyo (1998).
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