Image guidance for trans-oral robotic surgery

项目摘要 头颈部癌症（口腔、咽和喉）是全球第五大常见癌症。 经口腔手术方法，如经口腔机器人手术（TORS）和经口腔激光显微手术 (TLM)有效，减少并发症和长期治疗发病率。的缺点之一 经口入路是术中评估肿瘤范围和定位关键血管的难点 结构，导致阳性边缘和血管并发症的风险。图像引导和手术 导航在鼻窦、颅底和神经外科中发挥着重要作用， 这些程序的安全性和有效性。将这项技术应用于经口 手术以改善肿瘤深度的评估和避免血管结构。图像引导 目前不适用于经口腔机器人手术。主要原因是术中组织明显 引入牵开器时发生的变形，需要提供手术入路。这 术中变形限制了将术前成像准确配准到术中的能力 状态随着达特茅斯独特的外科中心提供术中CT和MRI成像， 创新，术中成像可行。然而，目前暴露所需的仪器， 在经口机器人手术期间的气道管理在CT成像上产生显著的伪影。我们有 开发了一种新型的3D打印聚合物喉镜，使我们能够安全地获得无伪影图像， 患者在喉镜为基础的经口手术程序，现在正提出开发一个类似的 用于机器人手术的CT兼容牵开器系统，并探索手术器械的开发 TORS的导航框架。我们努力的首要目标是提高药物的安全性和有效性， 经口腔机器人手术，使外科医生能够通过使用 手术导航为了实现这一目标，我们建议探索图像引导的经口腔机器人手术 在两个不同的阶段：1）开发和验证CT兼容的牵开器和器械跟踪， 便于术中成像和手术导航，2）比较传统TORS和图像- 引导TORS（igTORS）切除嵌入舌根、喉和 尸体头部的扁桃体。重要的是，这一igTORS框架将通过使用临床 通常用于神经外科导航的标准导航系统（即Medtronic的StealthStation）;这 将帮助我们更快地将这个框架转化为床边， 导航系统到本计划结束时，我们预计已经制定了一个完整的框架， 用于经口腔机器人手术的集成手术引导系统。将建议进行后续研究， 评估该框架在接受TORS的临床患者人群中的有效性。

PROJECT SUMMARY Cancers of the head and neck (oral cavity, pharynx, and larynx) are the 5th most common cancers worldwide. Trans-oral surgical approaches such as trans-oral robotic surgery (TORS) and trans-oral laser microsurgery (TLM) are effective, reducing complications and long-term treatment morbidity. One of the drawbacks of the trans-oral approach is the difficulty in intraoperatively assessing tumor extent and locating critical vascular structures, resulting in positive margins and risks of vascular complications. Image guidance and surgical navigation play a significant role in sinus, skull base, and neurosurgery, demonstrating improvement in the safety and efficacy of these procedures. There may be advantages to applying this technology to trans-oral surgery for improved assessment of tumor depth and avoidance of vascular structures. Image guidance is currently not feasible for trans-oral robotic surgery. The main reason is the significant intraoperative tissue deformation that occurs with the introduction of retractors needed to provide surgical access. This intraoperative deformation limits the ability to accurately register preoperative imaging to the intra-operative state. With the availability of intra-operative CT and MRI imaging at Dartmouth’s unique Center for Surgical Innovation, intra-operative imaging is feasible. However, current instrumentation required for exposure and airway management during trans-oral robotic surgery creates significant artifact on CT imaging. We have developed a novel 3D printed polymer laryngoscope that enables us to safely acquire artifact free images of patients during laryngoscopy-based trans-oral surgery procedures and are now proposing to develop a similar CT-compatible retractor system for use in robotic procedures and to explore the development of a surgical navigation framework for TORS. The overarching goal of our efforts is to improve the safety and efficacy of trans-oral robotic surgery and enable surgeons to perform surgery on more complex cases through the use of surgical navigation. To achieve this goal, we propose to explore image guidance for trans-oral robotic surgery in two distinct phases: 1) development and validation of a CT-compatible retractor and instrument tracking to facilitate intraoperative imaging and surgical navigation and 2) comparison of conventional TORS and image- guided TORS (igTORS) in the resection of faux tumor models embedded in the base of tongue, larynx, and tonsils of cadaver heads. Importantly, this igTORS framework will be implemented through use of clinically standard navigation systems typically used for neurosurgical navigation (i.e. Medtronic’s StealthStation); this will help us to translate this framework more quickly to the bedside than had we developed a custom navigation system. By the end of this program we expect to have developed the framework for a fully integrated surgical guidance system for use in trans-oral robotic surgery. Follow on studies will be proposed to evaluate the efficacy of this framework in a clinical population of patients undergoing TORS.