RICERCA ITALIANA     

ENDOCAS - Centro di eccellenza per la chirurgia assistita al calcolatore

Università di Pisa

Principal Investigator

Franco MOSCA Università di PISA

Research Objectives

$IMM_PER_0014THE EVOLVING SCENARIO OF SURGERYWhile open surgical exploration still represents the most commonly applied surgical technique, minimally invasive surgery (MIS) is becoming widely accepted in the light of the reduction of access trauma for the patient. In addition, the surgical scenario is evolving under the influences of a number of emerging technologies. Image guided surgery, robotics, augmented reality, and intelligent surgical tools are contributing to evolve the surgical procedures from a "traditional" model, based only on the surgeons' skill, to the "computer assisted" model, where surgeons and machines work together in a synergistic way (see Figure).$IMM_PER_0016 The evolution of the role of medical imaging in the operating roomFull integration of advanced imaging into interventional radiology and minimally invasive surgical methods will result in fundamental changes in therapeutic strategies and approaches. The computer-assisted model improves the QUALITY of surgical intervention providing tools and methods to assist (never substitute!) the surgeon and to exploit his/her skills. Advances in technology have already resulted in sweeping changes in diagnostic radiology, and more widespread use of modern therapeutic devices, computers and advanced imaging technologies will have a far-reaching effect on surgery as well. Image guidance, in general, can reduce the inherent invasiveness of surgery and improve localization and targeting by intra-operative imaging. Alternatively, intra-operative image guidance can be based on previously acquired images using reference frames attached to the patient (frame-based stereotaxy) or images which are registered to the patient (frameless stereotaxy). In the latter case, computers can navigate the operator through 3D coordinates and thus fulfill the need for enhanced visibility during interventional radiological and minimally invasive surgical procedures. Image-derived information for treatment can be applied to every stage of the therapeutic process, improving the quality, the accuracy and the predicatability of surgical procedures. The increasing demand for refinement of imaging and image representation for interventions and surgery requires unique methods for data acquisition, processing and display and the full understanding of the process of imaging and its applications to therapy. Image based modeling requires computerized image processing methods and image integration techniques to replace the mental process of generating 3D representation of the patient's anatomy. Although advanced imaging modalities and information processing or display methods are widely used in planning, monitoring and guiding various therapies, these imaging techniques could be integrated into interventional and surgical procedures, as depicted in Figure. $IMM_PER_0015 The scenario of computer assisted surgeryCURRENT SITUATION Research and development in the field of computer assisted surgery (CAS) is performed, in academic and industrial contexts, in a rather uncoordinated manner.Academic research in engineering and information technologies is carried on in all basic technological and methodological fields of CAS. This research yields the most advanced results in all these areas but suffers from a separate and unsystematic approach, and achievement of different teams are often hardly comparable and let alone integrable. Moreover, this research, although directed towards clinical applications, is typically not driven by correct specifications; therefore most prototypes need complete re-engineering before in-vitro validation.Industrial development of CAS systems, on the other hand, is clearly targeted towards clinical applications, but suffers from the limitations that they are targeted towards specific interventions and porting to specific medical needs is both costly and difficult. Moreover, being closed systems, it is rarely possible to interface them with other devices and use them as components for in-house research. To determine the real effectiveness, for doctors and patients, of those out-of-the box systems is another hard challenge. In Italy, basic research is being carried on by University departments and specialized Hospitals. Large, multinational medical companies have their commercial offices in Italy, but they do not make - in general - R&D activities. A few small companies are emerging, mainly as spin-offs from University research centers. Promoting the creation of new industrial initiatives in Italy for manufacturing new products for CAS would be a very important factor for the ultimate success of R&D efforts on CAS. By observing the overall world scenario, and trying to define roadmaps towards the future, we can say that significant results, both from a clinical and technological/commercial point of view, have been achieved only for applications in neurosurgery, ear-nose-throat (ENT) surgery and orthopedics. The development of systems for applications in abdominal and thoracic surgery represents a key challenge in the sector of image-guided surgery. In fact, due to the high deformability of the anatomical structures interested by the intervention, handling of soft tissue models introduces many issues related to model creation, registration with the patient's position in the operating room and intra-operative localization of anatomical structures and surgical tools. This research proposal addresses this highly innovative context, from the scientific point of view.Furthermore, some problems are emerging related to the acceptability of new technologies for surgery by the health care system, and to the education and training of surgeons and personnel for the appropriate use of these new technologies.The objective of EndoCAS is to establish a Center of Excellence for Minimally Invasive Computer Assisted Surgery, which aims at developing, in an integrated manner, research in various disciplines, such as engineering, medicine and economics, at promoting the clinical application of this research, at training the surgeons and technical personnel who will use new technologies, and at exploiting industrially the results of the process.WHY A CENTRE OF EXCELLENCE IN PISASeveral different research institutions compose the academic reality of Pisa: the University of Pisa (UNIPI) is partnered by Scuola Normale Superiore, Scuola Superiore Sant'Anna (SSSA), several institute gathered in a centre of Consiglio Nazionale delle Ricerche (CNR), Istituto Nazionale di Fisica Nucleare, etc., that are linked together by a long tradition of common research projects. This multidisciplinary entities confer to Pisa an extraordinary set of competences, which will constitute the cultural background of the proposed Centre. In this scenario, several Pisan research groups are active in the field of CAS since its origin (around the late 1980s), which are jointly proposing the establishment of the Centre.The proposers of the Centre of Excellence are a group of surgeons of UNIPI that practice research in the field of CAS in addition to clinical activities. The sectors of their activity comprise laparoscopic, ENT, endocrine and cardio-thoracic surgery. Division of Diagnostic and Interventional Radiology and Department of Business Economics complete the group of proponents. This group of main proponents is joined by other partners of Pisa, which also are essential for the achievement of the objectives of EndoCAS: the bioengineering and economics group of SSSA and a group computer scientists specialized in computer graphics of CNR.A short description of each of the partners will be presented in the following, to highlight how the research groups commonly possess all the knowledge necessary to the establishment of the Centre and to the exploitation of the results produced in the general national interest. The following figure represents schematically the organization and competence flow of the proposed Centre of Excellence.$IMM_PER_0018Competence flow of the EndoCAS CentreThe proposed Centre of Exellence has some unique advantages related to its location in Pisa:- first of all, it starts from a solid, well established and demonstrable tradition of research in the CAS field. Pisa is well known and recognized worldwide as a center of excellence for high quality surgery, imaging and medical engineering; - it arises from consolidated active collaborations between the medical and engineering partners. These already existing collaborations and shared objectives will allow to reduce drastically the duration and cost of the start-up phase of the proposed Centre of Excellence, thus obtaining a quick impact of research results on the health care system;- the proposers are well aware of the importance of evaluating the cost/effectiveness of the new procedures and tools for CAS, and have experience on these problems. EndoCAS will not only develop research and instrumentation, but provide guidelines for evaluating the new tools, to the benefit not only of our geographical area, but of the overall national health care system.The proposal of a Centre of Excellence originates from the medical component and is highly motivated by the fact that, in the field of CAS, clinical needs do determine design approach and system specifications. The opposite approach, consisting in integration of more or less independently developed technologies into highly technological devices, could lead to products that, not corresponding to any real clinical need, would remain useless. Moreover, a mere technological approach would neglect key factors that contribute to the diffusion of CAS, such as economical benefit and the young surgeons' need for training.Concerning the technical and engineering aspects of the research, EndoCAS will recourse to the competence and experience of the MiTech Lab of SSSA, one of the historical groups that has contributed to the birth and development of CAS in Italy and worldwide, demonstrated by publications in this field dated back to the end of the 1980s (e.g. Dario P., Bergamasco M.: "An advanced robot system for automated diagnostic tasks through palpation". IEEE Trans. Biomed. Eng. 35 (2) 118-126, 1988) and by coordination and participation to many European and international projects, which date back to 1989 (e.g. ISCAMI - Integrated System for the Management and Manipulation of Medical Images, a European concerted action). The Special Issue on Medical Robotics of the IEEE Transactions on Robotics and Automation (available online http://www.ncsu.edu/IEEE-RAS/TRA/TRA.html#calls) can be taken as additional demonstration of the worldwide recognition of the lead role of MiTech Lab in this field: the coordinator of the group, Prof. Paolo Dario, is involved as guest editor of the Special Issue, together with Prof. Russell Taylor and Dr. Jocelyne Troccaz, which are among the major authorities on CAS worldwide. The preparation and publication of this Special Issue, planned for October 2003, will allow the EndoCAS team to monitor and confront itself continuously with the most significative advances in the robotics field of CAS.In addition, EndoCAS plans to closely collaborate with selected national and international laboratories, among which: University of Dundee Scotland (Prof. A. Cuschieri, Department of Surgery), Universitat de Barcelona Spain (Prof. E. Targarona, Department of Surgery), University of Catania (Prof. D. Russello), ISBEM, University of Marseille (Prof. D.E. Henry) and Mount Sinai NY (Prof. M. Gagner). In particular, a strengthening of the research activities on anatomy and tissue characterization actually carried out at Department of Clinical Physiology of CNR of Pisa and of the activities of high education carried out at the laboratory of Economy and Management of SSSA, which, since 10 years organizes the Master in Innovation Management, are planned. Concerning formation activities, collaboration (and integration) with ENDODOC, in the scope of the organization of residential courses for surgeons at the Cisanello Hospital, is planned. An additional collaboration of particular importance for the Centre, for the technological transfer of the research activities, will be represented by institutions in southern Italy, for evaluation of the results in a different context and advanced training of qualified personnel.In the international field, collaborations with CISST-ERC (Johns Hopkins University, Baltimore MD USA, http://cisstweb.cs.jhu.edu/, coordinated by Prof. R. Taylor), TIMC (Universite de Grenoble, France, http://www-timc.imag.fr/gmcao/index.html, coordinated by Dr. J. Troccaz) and with Biorobotics Laboratory (University of Washington, Seattle WA USA http://brl.ee.washington.edu/, coordinated by Prof. B. Hannaford), with residence periods and temporary exchanges of researchers and professors. Cisanello Hospital strongly supports the establishment of the Centre and interest has been exhibited by the following companies: Ethicon Endo Surgery, Karl Storz, Tyco Health Care, Smith&Nephew and ASC. SHORT AND LONG-TERM OBJECTIVESThe objectives of EndoCAS, associated to the Department of Oncology, Transplantation and New Technologies in Medicine, will aim at carrying out activities concerning:1) frontier clinical practice with novel CAS systems of demonstrated effectiveness;2) development of basic methodological and technical components for the development and integration of CAS systems;3) analysis of the effectiveness and cost-benefit ratio of CAS systems, also in relation to the specific end-users' needs;4) training of young surgeons to traditional and computer-assisted interventions with an educational route that integrates multimedia instruments and surgical simulators;5) industrialization of acquired know-how, especially on the national territory, so to encourage production and industrialization of the developed prototypes and novel devices, thus promoting large-scale clinical employment.Otherwise stated, the goal of EndoCAS is to address key knowledge, technology, and systems design barriers that must be overcome in the development of CAS systems. Furthermore, by working closely with industry and clinician end users, our goal is to promote the rapid transfer of these results into practical use, also providing evidence of their social and economic benefits, and to help in educating a new generation of engineers, clinicians, and researchers needed to support this expanding field.Short-term objectives are the growth of basic knowledge and methodologies in all relevant areas and the realization of demonstrators that prove the applicability of the acquired knowledge.Long-term objectives are the further expansion of research activities, the porting of the acquired knowledge to novel applications of MIS (thanks to the modular approach), and the delivery of services to the scientific, industrial and medical community. Territorial development will be pursued as a key strategy to promote dissemination of the achievements at national level. The successful achievement of the proposed objectives will contribute to establish the necessary bases to progressively raise the level of the national Health Care System to a relevant place in the world-wide scenario of new technologies in surgery.Thematic keywords of EndoCAS, i.e. the areas of CAS that are addressed by the Centre are:- Basic research in the field of; medical imaging and image-based modeling; surgical planning and simulation; robotic and mechatronics; augmented reality systems;- Frontier clinical practice in the following surgical domains: laparoscopic, ENT, endocrine, cardio-thoracic;- Service delivery: validation of commercial and custom-made devices and systems for CAS; surgical training with innovative educational materials and simulators. <<<