Robot-assisted neurosurgery

Transcription

1 Robot-assisted neurosurgery Delivering precision to stereotactic neurosurgical procedures

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3 Table of contents Robot-assisted neurosurgery 4 Precision, versatility and productivity 5 Precise and repeatable surgical localisation 6 Allowing you to focus on patient care 7 Frameless operations 8 Physiological and image-guided procedures 8 Compatible with a range of imaging technologies 9 Procedure: implantation of depth electrodes for epilepsy monitoring 10 Procedure: deep brain stimulation 11 Procedure: biopsy 12 Responsive service & support wherever you are 13 References 14 3

4 Robot-assisted neurosurgery Precision in everything The neuro mate surgical robot provides a platform solution for a broad range of stereotactic neurosurgical procedures. neuro mate has been used in thousands of electrode implantation procedures for deep brain stimulation (DBS), stereo electroencephalography (SEEG) and biopsy. neuro mate provides consistent, rapid, precise targeting and reduces clinical complication rates in stereotactic procedures 3/5. neuro mate can be used with a stereotactic frame, or in frameless mode for reduced patient trauma. It is also compatible with procedures under general and local anaesthesia 1/2. neuro mate is in constant use in most centres where it is in operation and has pride of place as the cornerstone of functional and stereotactic procedures. neuro mate has CE approval. neuro mate is manufactured in a ISO 13485:2003 compliant environment and it is registered as a Class IIb (Europe) medical device. Renishaw has made a long term commitment to delivering precision engineered products that support innovative neurosurgery. Robots offer a wide array of benefits in the surgical arena. They increase the accuracy and dexterity of the surgeon, reduce the tremor of the human hand, and can amplify or reduce the movements and/or forces applied by the surgeon. Benabid & Nowinski (2003) 7 4

5 Precision, versatility and productivity A new platform for functional neurosurgery Renishaw is applying cutting-edge precision engineering technology to the challenges of functional neurosurgery. We are helping leading clinicians to enhance the safety and costeffectiveness of their procedures, improving patient outcomes through consistently accurate delivery of implantable devices 3/4/5. The neuro mate surgical robot is a central element of this strategy. It provides a flexible yet highly repeatable platform for precision functional neurosurgery. It can integrate neatly with your established procedures, providing precise spatial positioning of a tool holder or tool guide in order to guide standard surgical instruments. neuro mate also offers you the possibility to develop innovative and more productive ways of working. Advanced image-guided methods allow you to accurately and reproducibly perform a pre-established surgical plan, but also modify trajectories and tool positions in a matter of seconds as dictated by the course of the surgery. This gives you the opportunity to save time without compromise. neuro mate at the renowned training facility the Bristol Medical Simulation Centre, UK. neuro mate is a well-established robot in stereotactic functional neurosurgery. It provides a fast and easy way for trajectory modifications. Benabid & Nowinski (2003) 7 5

6 Precise and repeatable surgical localisation Improving patient outcomes and safety In functional neurosurgery, when targeting structures such as specific nuclei of the basal ganglia, thalamus or midbrain, precision is vital. To achieve a consistent, safe and efficacious therapeutic outcome, you have to be sure that any errors in positioning of implantable devices and neurosurgical instruments are minimised. As with any manual process, establishing the point of entry to address cerebral targets using a frame arc assembly is prone to variation resulting from calculation errors, deformation 10 or plain human error when setting the dials on the frame. The integration of a tailored computerized environment, CT and MRI imaging and the stereotactic robot developed by the neurosurgical and scientific teams in Grenoble has simplified many procedures for the benefit of the operated patients. Devaux in Talairach (2007) 12 In other walks of life, manual processes are being replaced by rapid, programmed, automated techniques. Similarly, a neuro mate robot can move, orientate and hold an instrument or tool guide in a fully automated manner. Positioning is more consistent and repeatable than using conventional manual methods, whilst the chance of human error is virtually eliminated. And with reduced surgery times, infection risk is also minimised 4/11. 6

7 Allowing you to focus on patient care Optimising OR time Using a neuro mate means there is more opportunity to concentrate on the clinical aspects of procedures. neuro mate provides a stable platform to support the safe use of a number of tools. This may either reduce the dependence upon the use of two surgeons or ensure that both are fully focused on the procedure itself. With its VoXim software and integrated surgical planning system, neuro mate is a compelling solution for accuracy, consistency and efficiency benefitting both you and your patients. 7

8 Frameless operations Physiological and image-guided procedures Free yourself from your stereotactic frame Whilst stereotactic frames provide excellent localisation and multiple fiducials that act as references for instrument positioning, they place a significant burden on the patient that cannot be tolerated for long periods. This necessarily compresses the period between imaging and operating, reducing the time that is available for surgical planning. The neuro mate system operating in frameless mode is at least as accurate as a stereotactic frame alone 1/2. This enables the neuro mate robot to be used in frameless mode for functional neurosurgery 2. Furthermore, it allows for separation of the imaging and surgical procedures, enabling more focus to be placed on optimising the surgical plan. Physiological targeting Micro electrode recording (MER) has been used for many years to localise the surgical site. It relies on detecting characteristic information about neuronal activity, enabling perioperative pinpointing of target areas such as the subthalamic nucleus (STN), the globus pallidus internus (GPi) and the ventral intermediate nucleus (Vim). The neuro mate surgical robot works very effectively with MER, assisting with the precise placement of recording electrodes. Work with your existing frame This is not to say that you cannot continue to use your existing frame with a robot. The neuro mate robot supports all commonly used frames including Leksell (Elekta), CRW (Radionics), ZD (Fischer), and Talairach (Alcis). The neuro mate laser tool The frame-based robotic system has the same level of application accuracy as the best standard localisation system. However, standard frame-based approaches are cumbersome to use and limited in terms of instruments. Li et al. (2002) 1 A major advantage in our experience has been the ability to separate the imaging from the surgical procedure. Highresolution imaging is undertaken under general anaesthesia 24 hours prior to surgery and ample time is available for detailed image analysis and trajectory planning. Varma & Eldridge (2006) 2 The image-guided procedure The neuro mate may also be used for an imageguided approach. Vital regions - such as sulci and blood vessels - may still be visualised and avoided. This, combined with error-free target calculation and positioning, may result in safer surgical procedures. 8

9 Compatible with a range of imaging technologies Pre- and peri-operative imaging The neuro mate surgical robot is able to operate with your current preand peri-operative CT or MRI imaging methods. Its VoXim * planning software can accept tomography data from any source that conforms to the DICOM standard. After planning of the stereotactic approach, the software calculates both the surgical trajectory(s) and the neuro mate control parameters. Intra-operative imaging neuro mate also integrates with intra-operative imaging. For instance, the robot can be adapted to suit Medtronic s O-arm ** multi-dimensional surgical imaging system, allowing you to verify target localisation before the patient leaves the OR. Similarly, an adapted head fixation component can support the use of C-arm devices for intra-operative imaging. The robot planning software can overlay images acquired peri- or intraoperatively onto the pre-operative image data, highlighting electrode deformations and targeting errors, from which corrections can be planned immediately. The neuro mate robot is capable of the same accuracy in targeting as a stereotactic frame, but I cannot stress enough the advantages for patient comfort and safety. The reduced time for surgery has effectively reduced the risk of infection to close to zero. Dr Olivier Delalande, Paediatric Neurosurgeon, Fondation Rothschild, Paris, France * VoXim is a registered trademark of IVS Technology GmbH. ** O-arm is a registered trademark of Medtronic Inc. *** VoXim is the complete solution for three-dimensional diagnosis and therapy planning which can be used in various areas of medicine. The basis for working with VoXim are volumetric image data of CT or MRI. VoXim allows high speed processing of each kind of slice image data. The included VoXim *** planning software solution has been customised for use with the neuro mate robot. 9

10 Procedure: implantation of depth electrodes for epilepsy monitoring Pre-surgical assessment of epilepsy in a fraction of the time Millions of patients worldwide, many of them children, suffer from epilepsy, a third of which are refractory to drug treatment 14. In many such cases, invasive brain surgery is indicated to identify regions of the brain in which the epilepsy originates. The conventional method involves implanting a subdural electrocorticography grids or strips, but is limited to accessible cortex areas and can exhibit high complication rates 15. By contrast, stereo-electroencephalography (SEEG) monitoring is a helpful and well tolerated technique for the definition of the epileptogenic zone in complex cases of childhood drug-resistant epilepsy 5/13. In SEEG procedures, multiple electrodes must be accurately placed, sometimes implanted in both hemispheres. Extra electrodes allow better mapping of the boundaries and volume of the epileptogenic zone, for subsequent excision surgery. Conventional techniques present a practical barrier to extensive SEEG electrode placement, as moving a stereotactic frame from one target position to another is a time-consuming process. Robotic placement, by contrast, can reduce the time in theatre from up to 10 hours to an average of just 3 hours 4. A robot assisted operation offers a less stressful patient experience, reducing patient discomfort and anxiety, as well as improving safety through a reduced risk of infection 5. 10

11 Procedure: deep brain stimulation Transformative therapies Deep brain stimulation (DBS) can provide remarkable therapeutic benefits for otherwise treatment-resistant movement and affective disorders such as chronic pain, Parkinson s disease, essential tremor, dystonia, obsessive-compulsive disorder, and major depression. It is a technique that relies on precise placement of electrodes, targeting structures deep within the brain. Reduction in the risk of human error combined with a very stable, rigid platform makes neuro mate ideal for DBS lead delivery. It is here that a surgical robot once again proves its worth, enabling rapid movement between targets. Recent developments in DBS to treat Parkinsonism have included stimulating regions surrounding the STN such as the caudal part of the zona incerta nucleus 9. These novel targets drive the need for precision in implantation, which an image-guided robotassisted surgical method is well placed to support. neuro mate headholder and attachments 11

12 Procedure: biopsy Rapid & safe tumour diagnosis Progress in medical imaging and treatment modalities for brain tumours are driving a re-evaluation of the role of stereotactic biopsies. Their appeal derives from their reliability and innocuousness, enabling a confident diagnostic, without clinical aggravation or delay in treatment. From this, a suitable, often multi-modal therapeutic approach can be developed. The frameless registration system frees up surgical space and expands possible trajectories whatever the head orientation. This considerable increase in working space provides a huge advantage, allowing to access a lesion with high efficiency and safety. With its accuracy, the robot allows approaches that we did not allow ourselves with a traditional frame. 12 Professor Serge Blond, Lille University Hospital, France Robotic image-guided surgery simplifies the stereotactic biopsy procedure with no loss of diagnostic reliability, and zero morbidity and mortality. Lefranc et al. (2009) 6 12

13 Responsive service and support wherever you are Global presence Renishaw s network of subsidiary companies and distributors provides support and advice to our customers around the world. As a surgeon, you can be assured that, wherever you are located, Renishaw will be there to provide the service and support you need. Rapid service that keeps you operating Renishaw recognises how much hospitals rely upon our products to keep their neurosurgery departments running smoothly. That s why we offer comprehensive service and support contracts that will ensure that interruptions to service are kept to the absolute minimum. 13

14 References 1. Li QH, Zamorano LJ, Pandya AK, et al. The application accuracy of the neuro mate robot--a quantitative comparison with frameless and frame-based surgical localization systems. Computer aided surgery : official journal of the International Society for Computer Aided Surgery. 2002;7(2): Varma TR, Eldridge PR. Use of the neuro mate stereotactic robot in a frameless mode for functional neurosurgery. The international journal of medical robotics + computer assisted surgery : MRCAS. 2006;2(2): Procaccini E, Dorfmüller G, Fohlen M, Bulteau C, Delalande O. Surgical management of hypothalamic hamartomas with epilepsy: the stereoendoscopic approach. Neurosurgery. 2006;59(4 Suppl 2):ONS Dorfmüller G, Bulteau C, Fohlen M, Jalin C, Delalande O. Frameless stereotactic robot-guided placement of depth electrodes for stereoelectroencephalography in presurgical assessment of children with refractory partial epilepsy. In: Abstracts of the 7th European Congress on Epileptology. Helsinki; Cossu M, Cardinale F, Castana L, et al. Stereoelectroencephalography in the presurgical evaluation of focal epilepsy: a retrospective analysis of 215 procedures. Neurosurgery. 2005;57(4): Lefranc M, Touzet G, Reyns N, et al. [Current role of stereotactic biopsies for pineal region tumours. A retrospective series of 87 patients]. In: Marseille Neurosurgery 2009 Joint Annual Meeting (EANS-SNFC). Marseille; Benabid AL, Nowinski WL. Intraoperative robotics for the practice of neurosurgery: a surgeon s perspective. In: Apuzzo ML. The Operating Room for the 21st Century. Amer Assn of Neurological Surgeons; 2003: Enchev Y, Oi S. Historical trends of neuroendoscopic surgical techniques in the treatment of hydrocephalus. Neurosurgical review. 2008;31(3): Plaha P, Ben-Shlomo Y, Patel NK, Gill SS. Stimulation of the caudal zona incerta is superior to stimulation of the subthalamic nucleus in improving contralateral parkinsonism. Brain : a journal of neurology. 2006;129(Pt 7): Maciunas RJ, Galloway Jr. RL, Latimer JW. The application accuracy of stereotactic frames. Neurosurgery. 1994;35(4): Cardinale F, Castana L, Cossu M, Lo Russo G. Surgical aspects in SEEG: towards a safe, simpler, faster and multimodal methodology. In: 15th Quadrennial Meeting of the World Society of Stereotactic and Functional Neurosurgery, May 24-27, Toronto, Ontario, Canada; Devaux BC. Postface. In: Talairach J Souvenirs des études stéréotaxiques du cerveau humain. John Libbey; Bulteau C, Dorfmüller G, Fohlen M, et al. [Epilepsy surgery during infancy and early childhood in France]. Neuro-Chirurgie. 2008;54(3): Kwan P, Brodie MJ. Early identification of refractory epilepsy. The New England journal of medicine. 2000;342(5): Hamer HM, Morris HH, Mascha EJ, et al. Complications of invasive video-eeg monitoring with subdural grid electrodes. Neurology. 2002;58(1):

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16 Renishaw (Ireland) Ltd. Swords Business Park Swords, Co. Dublin Ireland The neuro mate is not currently licensed for sale in Canada or cleared for sale in the United States. Renishaw 2011 all rights reserved. RENISHAW and the probe emblem used in the Renishaw logo are trademarks of Renishaw plc in the UK and other countries. Apply innovation is a trademark of Renishaw plc. neuro mate is a registered trademark of Renishaw mayfield SA. H