Workflow and intervention times of MR-guided focused ultrasound – Predicting the impact of new techniques

Advanced software for MRgFUS treatment planning

BACKGROUND AND OBJECTIVES

Herein, a user-friendly software platform for 3-dimensional Focused Ultrasound treatment planning based on Magnetic Resonance Imaging (MRI) images is presented.

METHODS

The software directly retrieves and loads MRI images. Various design tools can be used on the MRI images to define the treatment area and the sonication parameters. Based on the treatment plan, the software controls the robotic motion and motion pattern of Magnetic Resonance guided Focused Ultrasound (MRgFUS) robotic systems to execute the treatment procedure. Real-time treatment monitoring is achieved through MRI images and thermometry. The software's functionality and performance were evaluated in both laboratory and MRI environments. Different treatment plans were designed on MRI images and sonications were executed on agar-based phantoms and polymer films.

RESULTS

Magnetic Resonance (MR) thermometry maps were acquired in the agar-based phantoms. An exceptional agreement was observed between the software-planned treatment area and the lesions produced on the polymer films.

CONCLUSIONS

The developed software was successfully integrated with the MRI and robotic system controls for performing accurate treatment planning and real-time monitoring during sonications. The software provides an extremely user-friendly interface, while in the future it could be enhanced by providing dynamic modulation of the ultrasonic parameters during the treatment process.

Process model analysis of parenchyma sparing laparoscopic liver surgery to recognize surgical steps and predict impact of new technologies

BACKGROUND

Surgical process model (SPM) analysis is a great means to predict the surgical steps in a procedure as well as to predict the potential impact of new technologies. Especially in complicated and high-volume treatments, such as parenchyma sparing laparoscopic liver resection (LLR), profound process knowledge is essential for enabling improving surgical quality and efficiency.

METHODS

Videos of thirteen parenchyma sparing LLR were analyzed to extract the duration and sequence of surgical steps according to the process model. The videos were categorized into three groups, based on the tumor locations. Next, a detailed discrete events simulation model (DESM) of LLR was built, based on the process model and the process data obtained from the endoscopic videos. Furthermore, the impact of using a navigation platform on the total duration of the LLR was studied with the simulation model by assessing three different scenarios: (i) no navigation platform, (ii) conservative positive effect, and (iii) optimistic positive effect.

RESULTS

The possible variations of sequences of surgical steps in performing parenchyma sparing depending on the tumor locations were established. The statistically most probable chain of surgical steps was predicted, which could be used to improve parenchyma sparing surgeries. In all three categories (i-iii) the treatment phase covered the major part (~ 40%) of the total procedure duration (bottleneck). The simulation results predict that a navigation platform could decrease the total surgery duration by up to 30%.

CONCLUSION

This study showed a DESM based on the analysis of steps during surgical procedures can be used to predict the impact of new technology. SPMs can be used to detect, e.g., the most probable workflow paths which enables predicting next surgical steps, improving surgical training systems, and analyzing surgical performance. Moreover, it provides insight into the points for improvement and bottlenecks in the surgical process.

Free-breathing 3D Stack-of-Stars Gradient Echo Sequence in MR-guided Percutaneous Liver Interventions: Evaluation of Workflow and Diagnostic Quality

PURPOSE

To evaluate workflow efficiency and diagnostic quality of a free-breathing 3D stack-of-stars gradient echo (Radial GRE) sequence compared to a breath-hold 3D Cartesian gradient echo (Cartesian GRE) sequence for needle position control in MR-guided liver interventions.

MATERIALS AND METHODS

12 MR-guided liver interventions were performed on a 1.5 T Siemens Aera and analyzed retrospectively. 15 series of the Radial GRE sequence were compared to 14 series of the Cartesian GRE sequence regarding the time interval between two consecutive live-scans for needle tracking (Tracking-2-Tracking-Time). The quality of both sequences was compared by the SNR within comparable slices in liver and tumor ROIs. The CNR was calculated by subtraction of the SNR values. Subjective image quality scores of three radiologists were assessed and inter-rater reliability was tested by Fleiss' kappa. Values are given as mean ± SD. P-values < 0.05 were considered as significant.

RESULTS

The median Tracking-2-Tracking-Time was significantly shorter for the Radial GRE sequence, 185 ± 42 s vs. 212 ± 142 s (p = 0.04) and the median SNR of the liver and tumor ROIs were significantly higher in the Radial GRE sequence, 249 ± 92 vs. 109 ± 67 (p = 0.03) and 165 ± 74 vs. 77 ± 43 (p = 0.02). CNR between tumor and liver ROIs showed a tendency to be higher for the Radial GRE sequence without significance, 68 ± 48 vs. 49 ± 32 (p = 0.28). Mean subjective image quality was 3.33 ± 1.08 vs. 2.62 ± 0.95 comparing Radial and Cartesian GRE with a Fleiss' kappa of 0.39 representing fair inter-rater reliability.

CONCLUSION

A free-breathing 3D stack-of-stars gradient echo sequence can simplify the workflow and reduce intervention time, while providing superior image quality. Under local anesthesia, it increases patient comfort and reduces potential risks for needle dislocations in MR-guided liver interventions by avoiding respiratory arrests for needle position control.

Generic surgical process model for minimally invasive liver treatment methods

Surgical process modelling is an innovative approach that aims to simplify the challenges involved in improving surgeries through quantitative analysis of a well-established model of surgical activities. In this paper, surgical process model strategies are applied for the analysis of different Minimally Invasive Liver Treatments (MILTs), including ablation and surgical resection of the liver lesions. Moreover, a generic surgical process model for these differences in MILTs is introduced. The generic surgical process model was established at three different granularity levels. The generic process model, encompassing thirteen phases, was verified against videos of MILT procedures and interviews with surgeons. The established model covers all the surgical and interventional activities and the connections between them and provides a foundation for extensive quantitative analysis and simulations of MILT procedures for improving computer-assisted surgery systems, surgeon training and evaluation, surgeon guidance and planning systems and evaluation of new technologies.

Full coverage path planning algorithm for MRgFUS therapy

Background

High‐quality methods for Magnetic Resonance guided Focussed Ultrasound (MRgFUS) therapy planning are needed for safe and efficient clinical practices. Herein, an algorithm for full coverage path planning based on preoperative MR images is presented.

Methods

The software functionalities of an MRgFUS robotic system were enhanced by implementing the developed algorithm. The algorithm's performance in accurate path planning following a Zig‐Zag pathway was assessed on MR images. The planned sonication paths were performed on acrylic films using the robotic system carrying a 2.75 MHz single element transducer.

Results

Ablation patterns were successfully planned on MR images and produced on acrylic films by overlapping lesions with excellent match between the planned and experimental lesion shapes.

Conclusions

The advanced software was proven efficient in planning and executing full ablation of any segmented target. The reliability of the algorithm could be enhanced through the development of a fully automated segmentation procedure.

Surgical process modelling strategies: which method to choose for determining workflow?

The vital role of surgeries in healthcare requires a constant attention to improvement. Surgical process modelling is an innovative and rather recently introduced approach for tackling the issues in today's complex surgeries. This modelling field is very challenging and still under development, therefore, it is not always clear which modelling strategy would best fit the needs in which situations. The aim of this study was to provide a guide for matching the choice of modelling strategies for determining surgical workflows. In this work, the concepts associated with surgical process modelling are described, aiming to clarify them and to promote their use in future studies. The relationship of these concepts and the possible combinations of the suitable approaches for modelling strategies are elaborated and the criteria for opting for the proper modelling strategy are discussed.