• John Koivukangas

Working for years with engineers, my final academic medtech project: a surgical robot that could operate in our intraoperative MRI suite, Department of Neurosurgery, Oulu University Hospital, Finland.



In August 2009 a biopsy needle guide was attached to the end piece and the robot was then programmed to repeat, in the magnetic field, a series of non-collision steps to position the guide correctly. The needle was then passed by hand to a vitamin capsule inside a melon, as verified by our navigator.


We planned a clinical version within three years. It was not to be. I left my clinical position as chief neurosurgeon in 2010 to help my wife Pirjo recover from spinal cord injury.

However, the Montpellier company from France, Medtech, did offer our department their ROSA Locator robot only two years later giving credence to our optimistic plans.


My academic medicine career 1980-2014 centered on surgical visualization of brain for minimally invasive neurosurgery, including the technology for both imaging and for surgical procedures to improve our results, while we all waited for the cures of molecular biology, hopeful that someday they will replace some of the strides my generation made.


Reference:

Heikkilä T, Yrjänä S, Kilpeläinen P, Koivukangas J, Sallinen M (2012) An assistive surgical MRI compatible robot: First prototype with field tests (Chapter 19). In: Explicative Cases of Controversial Issues in Neurosurgery. F. Signorelli (ed.) INTECH open access, published May 23, 2012 under CC BY 3.0 license. ISBN 978-953-51-0623-4. DOI: 10.5772/29557

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  • John Koivukangas


Ultrasound, navigation and MRI were next combined in a surgical MRI suite at Oulu University Hospital in my quest for surgical image of brain to ensure safer surgery for the patient.


A Finnish low-field 0.23T open configuration MRI scanner uniquely could be turned off, with a ramp-up time of only six minutes. It had automatic registration of images to the patient’s anatomy. It was one of only eight concepts in the world in the 1990's (picture: scanner, optical navigator, display). We operated on Wednesdays. On other days, radiological procedures and routine imaging studies allowed for continual full use.


On Tuesday afternoons I would accompany my patient to the suite for a full navigation session: MR imaging and surgical planning: drawing site of the tumor, scalp incision and craniotomy onto the scalp. The patient saw an augmented reality display of the surgical plan, considered to be reassuring.


At first, we used our arm-based navigator (Elekta), then an optical navigator was provided by Philips based on our visualization solution. Philips also licensed our proprietary Onesys Navigator software (picture) for text and 3D images. As a formal hospital roll-out, it was interfaced to the EMR (ESKO) of Oulu University Hospital, Oulu, Finland.


The picture below shows the overall graphical user interface (GUI) on the left, a representative 3D image in the center, and pertinent 2D images on the right. The session is stored in the hospital server for rapid retrieval and review. It should be noted also, that while today it is typical to refer to the graphics on the computer as the "G" in GUI, this is a mistaken notion. A single screen with the world's best "G"UI is inferior to a multi-screen workstation.


Reference:


Tuominen J, Yrjänä SK, Katisko JP, Heikkilä J, Koivukangas J (2003) Intraoperative imaging in a comprehensive neuronavigation environment for minimally invasive brain tumour surgery. Acta Neurochir Suppl 85: 115-20.


Workstation 1999, clinical workflow: EMR on the left, PACS opened from EMR in the middle, specific isolated images bookmarked and selected on the right. The why, the where and the what.

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  • John Koivukangas

Päivitetty: 2. maalis 2020


Software, 1996, visualizing MRI together with 3D interactive model from PACS

22 years ago, a local technical college had acquired a printer system based on laser solidification of epoxy fluid to produce a 3D model layer by layer. The MRI data was from a patient of mine at Oulu University Hospital. The patient had been operated for third ventricluar cyst in an open procedure years before.


The pioneering navigational software of Onesys Oy was used to segment the scalp and ventricular system and the printer made a life-sized model. The new procedure was practiced by drilling a navigated hole into the model for precise placement of the endoscope introducer. This software solution helped pave the way for developing an imaging solution for clinicians and surgeons, not only radiologists.


Successful removal of the cyst was done with a Codman endoscope guided into position using the Onesys Navigator software, which featured the TCS (tool-coordinated system) now used in all image-guided systems of the various vendors. In the image, the TCS shows the yellow axis of the endoscope approaching the cyst.


The TCS images show where the endocope would be, and later was, going. TCS was revolutionary at a time when stereotactic orthogonal images were being used in other pioneering navigators. The seminal scientific paper on the TCS, originally called the "principle of the common axis" for surgical instruments including the endoscope and microscope was published in 1993, as recounted in earlier posts.


3D printed model from PACS (1:1 scale of head)


Reference:

Koivukangas J, Y Louhisalmi, J Alakuijala, J Oikarinen (1993) Ultrasound-controlled neuronavigator-guided brain surgery. J Neurosurg 79: 36-42.

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