Diagnostic Imaging Techniques & Robotic Surgery

Computed

Tomography Magnetic Resonance Imaging Positron Emission Tomography Ultrasonography X-Ray Bone Scan

Computed Tomography
CT uses a computer and a rotating x-ray device to create detailed, cross-sectional images, or slices, of organs and body parts. A CT machine resembles a large, square doughnut. A flat "patient couch" is situated in the circular opening, which is about 24 to 28 inches in diameter. The patient lies on the couch, which can be moved up, down, forward, and backward to position the patient for imaging.

Computed Tomography
The CT scanner itself is a circular, rotating frame with an x-ray tube mounted on one side and a banana-shaped detector mounted on the other. A fan-shaped beam of x-rays is created as the rotating frame spins the x-ray tube and detector around the patient. For each complete rotation, one cross-sectional slice of the body is acquired. As the scanner rotates, the detector takes numerous snapshots called "profiles." Typically, about 1,000 profiles are taken in one rotation. Each profile is analyzed by computer, and the full set of profiles from each rotation is compiled into to form the slice-a two-dimensional image.

Computed Tomography

CT's primary benefit is the ability to separate anatomical structures at different depths within the body. A form of tomography can be performed by moving the X-ray source and detector during an exposure. Anatomy at the target level remains sharp, while structures at different levels are blurred.

By varying the extent and path of motion, a variety of effects can be obtained, with variable depth of field and different degrees of blurring of 'out of plane' structures.

Common CT Scan Questions

Q: Does CT hurt?
A: CT imaging itself is painless. The patient is required to remain motionless during the examination (which is difficult for some people), but the actual scan causes no bodily sensation.

Q: How long will the CT take?

A: The length of a complete CT examination varies, depending on the type of CT required. Procedures usually take between 10 and 45 minutes. Some of the more complicated CT examinations take longer than 45 minutes.

Q: Do all CT scans require the administration of acontrast agent?

A: Not all CT examinations require the use of a contrast agent. When a contrast agent is required, it is because the radiologist and referring physician determine that it is necessary for diagnosis. Contrast agents are considered to be safe and side effects are uncommon. The benefits associated with the improved imaging of particular organs generally outweigh the low risk of allergic reaction.

Common CT Scan Questions

Q: Is it all right to have a CT during pregnancy? A: Pregnant women should not have a CT, or any other x-ray examination, while in the first trimester (the first three-month period) of the pregnancy. Other exams, such as ultrasound, are available to help diagnose a medical condition in such cases. Q: What is the difference between CT and MRI? A: CT and MRI differ in two basic ways.CT uses x-rays to detect and
record the radiation absorbed by different tissues, and sends the data to a computer to transform into images. MRI does not use x-rays. Instead, MRI employs a powerful magnetic field to monitor the nuclei of hydrogen atoms in water, the most abundant element in the body. When subjected to the magnetic field of an MRI, the hydrogen protons are knocked out of alignment and emit a radiofrequency signal that is detected by the MRI machine, which then processes the signals into images.CT scans usually show little differentiation in soft tissues, but highlight solid structures, like calcium deposits or kidney stones. MRI scans emphasize detailed tissue structures due to differences in water content.

Important Facts about CTS

Computed Tomography (CT), also known as Computed Axial Tomography (CAT), is a painless, sophisticated x-ray procedure that uses a computer to provide images of soft tissue, bone, and blood vessels. CT imaging is considered a safe examination. While CT does involve xrays, the diagnostic benefits are usually considered to outweigh the risks of x-ray exposure or injections of contrast agents (or use of sedatives) during the procedure.

CT combines a computer and a rotating x-ray device to create detailed cross-sectional images, or "slices" of organs and body parts.
CT scanning has the unique ability to image a combination of soft tissue, bone, and blood vessels. Among all the other available imaging techniques, it is one of the best tools for studying the lungs and abdomen. It is also invaluable in cancer diagnosis, and is the preferred method for diagnosing lung, liver, and pancreatic cancer. The newest "multi-slice" spiral CT scanners can collect as much as eight times more data than previous state-of-the-art spiral CT scanners.

Important Facts about CTS

In general, no special preparation is required for a CT scan. Comfortable, loose clothing should be worn, and any articles of clothing or jewelry that might degrade the images, such as earrings, glasses, dentures, belts, etc., should be removed. Many CT examinations require the oral or intravenous administration of a harmless contrast agent, a liquid that enhances imaging of certain organs or blood vessels. Contrast agents for CT examinations are administered in three different ways:
Intravenous injection Oral administration Rectal administration

A relatively uncommon type of contrast that consists of a gas that is used for special lung and brain imaging. The technique is called Xenon CT and is only available at a small number of locations worldwide. It is used only for rare cases. It is very important to lie completely still during a CT examination while the scanner is taking images.

CT - Diagnostic Use
Cranial diagnosis of cerebrovascular accidents and intracranial hemorrhage CT generally does not exclude infarct in the acute stage of a stroke. For detection of tumors, CT scanning with IV contrast is occasionally used but is less sensitive than magnetic resonance

Chest CT is excellent for detecting both acute and chronic changes in the lung parenchyma. A variety of different techniques are used depending on the suspected abnormality. For evaluation of chronic interstitial processes (emphysema, fibrosis, and so forth), thin sections with high spatial frequency reconstructions are used - often scans are performed both in inspiration and expiration. This special technique is called High resolution CT (HRCT). For detection of airspace disease (such as pneumonia) or cancer, relatively thick sections and general Purpose image reconstruction techniques may be adequate.

CT Step by Step

CT step by step

Magnetic Resonance Imaging

Magnetic Resonance Imaging, or MRI, is a painless and safe diagnostic procedure that uses a powerful magnet and radio waves to produce detailed images of the body's organs and structures, without the use of X-rays or other radiation.

Magnetic Resonance Imaging

The images produced by MRI can be compared to a sliced loaf of bread. Just as you can lift each individual slice from the loaf and see both the slice and the inside of the bread, so too the image "slices" produced by the MRI show the exact details of the inside of the body. The computer is able to reconstruct all the images into a single image resembling an X-ray. This reconstruction also can be made into three-dimensional images, allowing complete and remarkable visualization of the body area scanned from all angles

How Does Magnetic Resonance Imaging Work?

The MRI scanning machine is a large donut-shaped magnet with a sliding scanning table. A person lies on this table, which then slides into the desired position in the MRI magnet. The machine produces loud, repetitive noises, like banging, during the procedure. But these noises, while unpleasant at times, aren't dangerous or indicative of a problem. In our bodies, the nuclei of hydrogen atoms (called protons) normally point randomly in different directions. However, when exposed to the magnetic field in an MRI chamber, the nuclei line up in parallel formation, like rows of tiny magnets. Nearly two-thirds of the body's hydrogen atoms are found in water and fat molecules. When the nuclei are subjected to a strong but harmless (and painless) pulse of radio waves from the MRI machine, they are knocked out of their parallel alignment. As they fall back into alignment, they produce a detectable radio signal.

How Does Magnetic Resonance Imaging Work?

The signal is recorded by the machine and transferred to a computer. The computer uses these signals to calculate an image that is based on the strength of signal produced by different types of tissue. For example, tissues that contain little or no hydrogen (such as bone) appear black. Those that contain large amounts of hydrogen (such as the brain) produce a bright image.

What Are The Risks Of An MRI?

Because MRI uses low-energy, non-ionizing radio waves, there are no known risks or side effects. In fact, since the technique uses no radiation, it can be repeated with no known adverse effects. While there are no known hazards, MRI is not proven to be safe during pregnancy. If a pregnant woman must undergo an MRI, she will be asked to sign a special consent form. The magnet at the center of the procedure may affect, or be affected by, any person fitted with a pacemaker, hearing aid, or other electrical device. People with such devices should advise the physician or technician. They are generally advised not to have an MRI.

MRI: Frequently Asked Questions

Q: Are the "radio waves" used in MRI like regular radio waves? A: No. While the MRI does use a radio wave antenna to send signals to the body and receive signals back during the procedure, the "radio wave signals" are actually a changing magnetic field that is much weaker than the strong magnetic field of the main magnet in the machine.

Q: Why not just get an x-ray? A: MRIs are particularly useful for looking at the non-bony parts or "soft tissues" of the body-the same types of body parts and tissues that x-ray machines are not designed to pick up
Q: Are there any disadvantages to MRI? A: Aside from those who suffer from claustrophobia, or who have implanted medical devices that prohibit the use of MRI, there are no known medical disadvantages. One financial disadvantage is that the MRI costs more than a

MRI: Frequently Asked Questions

Q: What is the main between x-ray and MRI? difference

A: Aside from the fact that MRI does not use radiation to obtain images, the biggest difference is that MRI can "see through" bone and define fluid-filled soft-tissue, while x-rays can only define bone

MRI: Putting It All Together

Magnetic Resonance Imaging, or MRI, is a painless diagnostic procedure that uses a powerful magnet and radio waves to produce high-quality, cross-sectional images of organs and body structures without the use of X-rays or other ionizing radiation. Because MRI does not involve the use of x-rays, it is safe for the majority of people. MRI uses low-energy, non-ionizing radio waves, so there are no known risks or side effects, even with repeated imaging. The MRI scanning machine is a large donut-shaped magnet with a movable scanning table on which a person lies. The machine produces loud noises, like banging, during the procedure. The noises, while unpleasant at times, aren't dangerous or indicative of a problem, but are a signal that images are being taken. The computer uses the MRI signals to create an image that is based on the strength of signal produced by different types of tissue. For example, tissues that contain little or no hydrogen (such as bone) appear black. Those that contain a large amount of hydrogen (such as the brain) produce a bright image.

MRI: Putting It All Together

In general, MRI is used to rule out certain diseases and to facilitate treatment for medical conditions. For an "ordinary" MRI, no special preparation is required. An entire MRI exam may take from 20 minutes to 1.5 hours, depending on the type of information required by the radiologist and physician, and the quality of the images needed to make a particular diagnosis. Normal activities can be immediately resumed after the images are obtained. Because the machine has a tunnel-like appearance, some people feel uncomfortable, or even claustrophobic (fearful of being closed in). Most people can overcome this feeling, but for those who need assistance, the doctor can prescribe a tranquilizer for use before the procedure. Special scanners with open magnets exist for those people who are too claustrophobic and/or too large to fit in the regular machines. Unfortunately, the image quality of these scanners is generally not as good as it is from those with closed magnets.

Positron Emission Tomography (PET)

A scanner detects radioactive material that is injected or inhaled to produce an image of the brain. Commonly used radioactively-labeled material includes oxygen, fluorine, carbon and nitrogen. When this material gets into the bloodstream, it goes to areas of the brain that use it. So, oxygen and glucose accumulate in brain areas that are metabolically active. When the radioactive material breaks down, it gives off a neutron and a positron. When a positron hits an electron, both are destroyed and two gamma rays are released.

PET Scan

Positron Emission Tomography (PET)

Advantages: Provides an image of brain activity.
Disadvantages: Expensive to use. Radioactive material used.

Ultrasound (Sonography) - Basics

It is used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. They are also used to visualize a fetus during routine and emergency prenatal care. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). It poses no known risks to the patient, it is generally described as a "safe test" because it does not use ionizing radiation, which imposes

Ultrasound how does it work?

the same principles involved in the sonar used by bats, ships and fishermen. when a sound wave (frequency 2.0 to 10.0 megahertz ) strikes an object, it bounces backward or echoes. by measuring these echo waves it is possible to determine how far away the object is and its size, shape, consistency (solid, filled with fluid, or both) and uniformity. a transducer both sends the sound waves and records the echoing waves. When the transducer is pressed against the skin, it directs a stream of inaudible, high-frequency sound waves into the body. As the sound waves bounce off of internal organs, fluids and tissues, the sensitive microphone in the

Ultrasound - Biomedical Applications

heart and blood vessels, incl. the abdominal aorta and its major branches liver gallbladder spleen pancreas kidneys bladder uterus, ovaries, and unborn child (fetus) in pregnant patients eyes thyroid and parathyroid glands scrotum (testicles)

Ultrasound limitations

Ultrasound waves are reflected by air or gas; therefore ultrasound is not an ideal imaging technique for the bowel. Ultrasound waves do not pass through air; therefore an evaluation of the stomach, small intestine and large intestine may be limited. Intestinal gas may also prevent visualization of deeper structures such as the pancreas and aorta. Patients who are obese are more difficult to image because tissue attenuates (weakens) the sound waves as they pass deeper into the body. Ultrasound has difficulty penetrating bone and therefore can only see the outer surface of bony structures and not what lies within.

Robotic Surgery

During robotic surgery, the surgeon uses the assistance of a robot to operate on the patient through tiny holes in the abdomen instead of a large open incision. The robotic technology, cited as #1 in Forbes magazine's Five Robots That Will Change Your Life, consists of a surgeon's console that controls a tower with four working arms. One arm controls the three-dimensional camera's movement inside the body, while the remaining three arms hold specialized laparoscopic instruments. The robotic arms precisely replicate the surgeon's exact hand and finger movements from the console. NewYork-Presbyterian/Columbia is one of a few select centers in the country and the first in New York City - to use the state-of-the-art High Definition daVinci-S Surgical System to peform robotic urologic surgery. We work very closely with the manufacturer of this system (Intuitive Surgical Inc, Sunnyvale, CA) to stay on the cutting edge of this technology.

Robotic Surgery
The use of a computer console to perform operations from a distance opens up the idea of telesurgery, which would involve a doctor performing delicate surgery miles away from the patient. If the doctor doesn't have to stand over the patient to perform the surgery, and can control the robotic arms from a computer station just a few feet away from the patient, the next step would be performing surgery from locations that are even farther away. If it were possible to use the computer console to move the robotic arms in real-time, then it would be possible for a doctor in California to operate on a patient in New York. A major obstacle in telesurgery has been latency -- the time delay between the doctor moving his or her hands to the robotic arms responding to those movements. Currently, the doctor must be in the room with the patient for robotic systems to react instantly to the doctor's hand movements. Having fewer personnel in the operating room and allowing doctors the ability to operate on a patient long-distance could lower the cost of health care in the long term. In addition to cost efficiency, robotic surgery has several other advantages over conventional surgery, including enhanced precision and reduced trauma to the patient. For instance, traditional heart bypass surgery requires that the patient's chest be "cracked" open by way of a 1-foot (30.48-cm) long incision. However, with the da Vinci system, it's possible to operate on the heart by making three or four small incisions in the chest, each only about 1 centimeter in length. Because the surgeon would make these smaller incisions instead of one long one down the length of the chest, the patient would experience less pain, trauma and bleeding, which means a faster recovery.

Robotic Surgery

Robotic assistants can also decrease the fatigue that doctors experience during surgeries that can last several hours. Surgeons can become exhausted during those long surgeries, and can experience hand tremors as a result. Even the steadiest of human hands cannot match those of a surgical robot. Engineers program robotic surgery systems to compensate for tremors, so if the doctor's hand shakes the computer ignores it and keeps the mechanical arm steady.

Da Vinci Surgical System

The da Vinci Surgical System, created by Intuitive Surgical, was the first robotic surgical system approved by the FDA. Since its inception in 2000, the da Vinci System has allowed surgeons to perform various procedures on the body through minimally invasive, 1 cm keyhole incisions. Operation The surgeon works at a console a few feet away from the operating table. Several controls are used while watching a magnified threedimensional image of the surgical field on the monitor. The patient-side cart refers to the robotic arms and instruments that directly contact the patient. Anywhere from two to four instrument arms can be used along with one endoscopic arm. Applications Cariothoracic mitral valve prolapse, revascularization, CABG(clinical), renal tumor removal General bariatric(obesity), surgery, gastric bypass Gynecological hysterectomy Urological prostatectomy

Advantages Due to the fact that all surgeries are minimally invasive, there is a significantly lower amount of pain, blood loss, and scarring. Recovery time is also shorter and better clinical outcomes can be achieved using the da Vinci System compared to normal laparoscopic surgery.

Disadvantages The initial capital investment, a large upfront cost, is one major deterrent of using a robotic system like da Vinci. Also, a certain learning curve is present when surgeons use equipment like this for the first time. Thus, while robotic surgery systems attempt to reduce human factors, the "practice makes perfect" moto holds true.

Medtronic StealthStation

The StealthStation, a product of Medtronic Surgical Navigation Technologies, is a three-dimensional imaging system that allows surgeons to navigate through the body. It is a next generation product that combines images from a variety of traditional sources. Some of these include X-ray, computerized tomography(CT), magnetic resonance imaging(MRI), and ultrasound. By combining such a variety of imaging techniques, the StealthStation allows for more precise three-dimensional images so the surgeon can focus on the exact location desired

Operation The StealthStation analyzes pre-operative diagnostic scans to create threedimensional images used by the surgeon to map out the safest and least invasive surgical path. Real time images are continually produced throughout the surgery. By merging images from multiple sources, the Stealth Station allows surgeons to view their targets from any angle. Lastly, images of instruments are incorporated into images of the patients anatomy allowing the surgeon to see the exact location of the instrument in three-dimensions and in real time.

Applications Cranial Neurosurgery tumor biopsy, tumor resection, cerebrospinal fluid management Spinal screw placement throughout the spine Orthopedic Joints/Trauma total knee replacement, total hip replacement, trauma Ear, Nose & Throat functional endoscopic sinus surgery, lateral and anterior skull base surgery Advantages By providing advanced three-dimensional imaging the Stealth Station allows surgeons to pinpoint exact locations and targets without damaging nearby tissue by offering views from normally impossible angles and by including the instrumentation in the images. Due to the fact that surgeries are minimally invasive, pain, scarring, and recovery time are all reduced. The wide variety of surgeries that can make use of this product is also an advantage. Proper positioning can still be found even when the patients anatomy is atypical. Specifically, when using the Stealth Station in spinal surgery, the patient is subjected to a reduced amount of radiation exposure.

Disadvantages Just like the da Vinci System, the major drawbacks to using the Medtronic StealthStation are its large initial investment cost and the inherent learning curve present when surgeons must use a new system they arent used to.

Orthopilot
Operation

The Orthopilot system is used to provide doctors with a way to accurately execute large joint replacement/corrective surgeries. The procedures vary depending on the type of surgery, however the general methodology of the surgery is as follows: The surgeon fixes sensors to the part of the patient being operated on, and then moves the patient in specific natural motions so that the camera receives the data and uses it to form a model on the screen. The representations on the monitor allow the surgeon to perform the surgery with greater accuracy, as the Orthopilot system will be able judge when the joint is properly aligned.

Applications:
Orthopilot has a number of well documented applications in the realm of large joint replacement and repair. The most common include: Total Knee Arthoplasty Unicondylar Knee Arthoplasty Total Hip Arthoplasty Cartilage Defect Management Anterior Cruciate Ligament (ACL) Reconstruction High Tibial Osteotomy (HTO)

Advantages

Prior to Orthopilot (and computer assist devices similar to it), it was not always certain that an implant would be placed in the optimal position. With the navigation system the implant can be placed within 3 degrees of perfect position at almost every surgery. The navigation also allows minimally invasive surgery to be performed easily because of the display, thereby increasing recovery time and decreasing post operative pain. Also, once a surgeon becomes familiar with the navigation system, surgery time will decrease, which is an important clinical and economic factor.

Disadvantages

As with most computer assist devices, the major disadvantages are due to the fact that the machines are very expensive, the surgeon must undergo new training to learn how to use the device, and initially the surgeries will take much longer as the surgeon is becoming familiar with the new procedure.

NeuroMate

Neuromate

Neuromate was the first robotic system designed to perform stereotactic brain surgery. The system is currently used to aid surgeons in the execution of stereotactic neurosurgical procedures. It was designed by Integrated Surgical Systems Inc. and was designed to performs surgeries using the VoXim, IVS Software Engineering software system. The image guided, computer controlled device manipulates a 6 jointed robotic arm, allowing for 5 degrees of freedom. The NeuroMate system gained FDA approval in the summer of 1999

Operation NeuroMate can be used with the patients head either placed in a frame or without a frame during surgery; the difference between the two is the accuracy of the imaging displayed, with the frameless method currently less accurate but improving. The robotic and software system interact, providing a 3D view of anatomical structures of the brain using CT or MRI scans. Once a plan is formed the surgeon will control the arm, using the imaging displayed on a PC as to guide the operation.

Applications A wide range of neurosurgical procedures including: Removal of brain tumors Movement disorder surgery (for disorders such as parkinsons) Implantation of devices to stimulate the brain (in order to alleviate the symptoms of epilepsy)
Advantages NeuroMates PC based planning system was created so that it easily interfaces with other popular planning systems offered by other companies. The machine augments surgical skill and greatly reduces fatigue, making long operations less difficult. The accuracy of the robot also decreases operation time, especially operations involving multiple biopsies. Disadvantages NeuroMate is useful in neurosurgery only, not a number of different applications like Da Vinci (and other similar products). This device is very expensive and with very few machines being purchased, it is not economically viable for the developer/producer to continue marketing the product. In a similar vein, neurosurgery is less common and less profitable than heart and many other surgeries, therefore it is less attractive for hospitals to spend such a large amount of money on this device.