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The aim of computer-aided surgery (CAS) is to advance the utilization of computers in the development of new technologies for medical services. The Asian Conference on Computer Aided Surgery (ACCAS) series provides a forum for academic researchers, clinical scientists, surgeons, and industrial partners to exchange new ideas, techniques, and the latest developments in the field. The ACCAS brings together researchers from all fields related to medical activity visualization, simulation and modeling, virtual reality for CAS, image-guided diagnosis and therapies, CAS for minimally invasive intervention, medical robotics and instrumentation, surgical navigation, clinical application of CAS, telemedicine and telesurgery, and CAS education. The ACCAS is also interested in promoting collaboration among people from different disciplines and different countries in Asia and the world. This volume helps to achieve that goal and is a valuable resource for researchers and clinicians in the field.



Medical Robotics and Instruments

Nonmetallic Guide Sheath with Negative Pressure Shapelocking Mechanism for Minimally Invasive Image-Guided Surgery

To address the access and stability problems in endoscopic surgery, we developed a device called rigid–flexible outer sheath. This sheath can be switched between flexible and rigid modes by a novel pneumatic shapelocking mechanism, and it has a double curvature structure that enables it to flex in four directions at the distal end and three directions on the rigid–flexible shaft. The prototype is 300 mm long with a 20 mm outer diameter, and equipped with four working channels. All parts of this device are made of plastic and are MRI-compatible. Insertion performance in a phantom experiment was evaluated in an open MRI environment. The experimental results showed that the outer sheath could follow a curved path, and that the sheath was compatible with an MRI environment. This means the outer sheath should be useful in surgery with MRI guidance.
Siyang Zuo, Ken Masamune, Kenta Kuwana, Takeyoshi Dohi

Study of Design Method for Surgical Robot Using Surgeon’s Operation Manner

Recent design methods for surgical robots suffer from an inherent problem. In these methods, the surgeon’s operation manner is not considered when designing the robotic mechanism. As such, it is possible that a non-user-friendly robot is developed for surgeons to operate. To solve this problem, we developed a system that takes into consideration the surgeon’s operation manner during the design phase of the robot. Using this system, we can operate a simulated robot with any mechanisms and can search a mechanism that is user-friendly in terms of the surgeon’s operation manner. In the experiments, we investigated the need for considering the surgeon’s operation manner when designing a surgical robot. The results clearly show there is indeed such a need.
Hiroto Seno, Kazuya Kawamura, Yo Kobayashi, Masakatsu G. Fujie

Prototype Design of Robotic Surgical Instrument for Minimally Invasive Robot Surgery

This paper presents the prototype design of the robotic surgical instrument for minimally invasive surgery robot. For high reliability and stiffness characteristics of the instrument, it has been designed on the basis of 3-DOF (degrees of freedom) parallel robot mechanism with three identical PSR (Prismatic-Spherical-Revolute)- serial chains. Further, for the forceps grasp and axial rotational motions, it has one additional center leg. With this mechanical structure, 4-DOF motions of forceps, i.e., forceps grasp motion, 2-DOF wrist orientation, and 1-DOF axial rotation, are possible. Further, the capability of pure axial rotation of the proposed instrument forceps may enable more dexterous surgery compared to the other surgical instruments. Detailed description of the proposed me chanism is given and performance of the prototype compared to the other robotic instruments are discussed in this paper.
Man Bok Hong, Yung-Ho Jo

Polarizing Beam Splitter Endoscope for Simultaneously Observing Front and Lateral View

Fetal surgery sometimes requires multiple field-of-views (FOVs). The authors have developed an FOV extended endoscope for simultaneously observing front and lateral view with single lens system. A polarizing beam splitter (PBS) mounted at its distal end guides the rays from the two FOVs to relay lenses in orthogonal linear polarizations, and the other PBS mounted at its base separates them at eye lens systems. However, the images of the two views are superimposed because lenses rotate the direction of linear polarization. To solve the problem, the authors adopt a rectifier to cancel the rotation. Additional approaches consist of polarizing plates, image processing, and light source control. Polarizing plates improve the contrast of image by 13.8%. Light source control unit switches chip LEDs on and off. The cameras synchronized to LEDs get images alternately. Taken endoscopic movie with light source control was 30fps. By using these methods, clearer images are acquired.
Tomoya Tsuruyama, Noriaki Yamanaka, Kenta Kuwana, Ken Masamune, Keri Kim, Takeyoshi Dohi

CAS for Minimally Invasive Intervention

Clipping Device with a Clear Liquid-Flushing Endoscope Equipping Wide View Coaxial Nozzle for Edge-to-Edge Repair Surgery without Heart-Lung Machine

We developed clipping device that could carry out edge-to-edge repair through endoscopic observation of the intracardiac valves, without using a heart-lung machine. One is a clear liquid-flushing endoscope which equipped coaxial round jet nozzle to observe φ8-mm area, called “wide view coaxial nozzle”. The other one is a clipping mechanism to carry out edge-to-edge repair without using a heart-lung machine. The clipping device was developed with the clear liquid-flushing endoscope which equipped wide view coaxial nozzle and evaluated the performance of this clipping device with an in vivo experiment.
Tetsuya Horiuchi, Ken Masamune, Hiroyuki Tsukihara, Noboru Motomura, Kenta Kuwana, Takeyoshi Dohi

Cooling Effect of the Ligamentum Flavum for Preventing Dural Puncture during the Epidural Anesthesia

In order to develop a new epidural needle achieving less deformation of the ligamentum flavum during the needle insertion, preliminary investigation on cooling effect of the ligamentum flavum was done. Porcine spines from a slaughterhouse were heated in 42 degrees Celsius or cooled in 4 degrees Celsius or frozen. Needle insertion tests revealed that cooling the ligamentum flavum showed no significant effect in both the maximum reaction force and the deformation. Conventional epidural needle could not insert the frozen specimens. Stained specimens revealed that the maximum insertion force and the deformation were positively correlated with thickness of the ligamentum flavum.
Kiyoshi Naemura

An Algorithm for Control of Flexing Instruments for Single-Incision Laparoscopic Surgery

Single-incision laparoscopic surgery (SILS) brings many benefits for patients but surgeons’ burden increases due to the following problems; the narrowness of the surgeon’s hand operating range, the visual obstruction of the surgical site, and so on. In order to reduce their burden, we have developed a master-slave robot system for SILS which enables surgeons to perform SILS with laparoscopic techniques. This paper shows a calculation algorithm for control of flexing instruments on the slave side. Through simulation and physical experiments, we confirmed that our algorithm worked enough to manipulate flexing instruments and surgeons performed SILS as if they were performing conventional laparoscopic surgery.
Yuki Horise, Atsushi Nishikawa, Yu Kitanaka, Mitsugu Sekimoto, Norikatsu Miyoshi, Shuji Takiguchi, Yuichiro Doki, Masaki Mori, Fumio Miyazaki

A Laser Steering Endoscope with High Laser Transmission Efficiency

This paper reports a miniaturized endoscope that transmits a high-power infrared laser beam to arbitrary points in the endoscopic view for the treatment of twin-to-twin transfusion syndrome. The miniaturized endoscope has an external diameter of 3.5 mm expect for illumination and also improved on the laser transmission efficiency by using a GRIN rod lens as a relay lens. The experiment showed the laser transmission efficiency on the unit of the object and relay lens system was 72%. The thermal increase of the endoscope tip during the laser irradiation was 0.5°C. The maximum laser power was almost 30 W at the source power of 50 W. The laser power has the possibility to coagulate vessels. The steerable ranges were a total of 28.7 degrees in horizontal direction and a total of 25.9 degrees in vertical direction. This large range of selecting target provides easier use.
Noriaki Yamanaka, Ken Masamune, Kenta Kuwana, Hiromasa Yamashita, Toshio Chiba, Takeyoshi Dohi

Image Guided Diagnosis and Therapies

Video Information Management System for Information Guided Neurosurgery

As the boundary between glioblastoma and normal tissue is unclear, precise resection is required to reduce the risk of post-operative adverse event such as aphasia and to elongate residual life of the patient by resecting tumor region completely. Surgeons use various information such as preoperative and intraoperative image, surgical navigation, pathological images, and so on, to decide resection line. In conventional operating room, information is dispersed. In this study, video information integration system was implemented using dedicated hardware video mixer. In clinical evaluation, pre-set window layout was selected just by pushing a button, and neither delay nor noise was observed. In the future study, we will implement automatic layout changing system depending on the surgical scenario.
Takashi Suzuki, Kitaro Yoshimitsu, Manabu Tamura, Yoshihiro Muragaki, Hiroshi Iseki

Development of a Laparoscopic Surgical Training System with Simulation Open Framework Architecture (SOFA)

With a number of advantages over traditional laparotomy, laparoscopic surgery is a successful minimally invasive surgical procedure. However, laparoscopy demands high surgical skill. For efficient and safe training, virtual surgery simulation systems have been developed recently. In this paper, we describe the development of a laparoscopic surgery training system using Simulation Open Framework Architecture (SOFA). The simulation software was integrated with a two-hand haptic device specially developed for laparoscopic surgical training. As an example, we focused on the simulation of gallbladder removal surgery using laparoscopic instruments. Gallbladder removal was successfully simulated by the proposed methods. We expect this training system to be similarly successful in simulating a number of other surgical procedures.
Youngjun Kim, Kyunghwan Kim, Frédérick Roy, Sehyung Park

Intuitive Touch Panel Navigation System through Kyoto Digital Sosui Network

We have developed multi-touch panel robotic arm control system for thoracoscopic surgery. Our multi-touch panel navigation system consists of green laser guide maker, robotic arms with four spindles, multi-touch panel monitor, and PCs for control regulation. The multi-touch panel monitor recognized the finger-touch; thereby the tip of the robot arm is controlled just on the green maker. For estimation in remote control use, the PC for the robot control was placed in Kyoto Prefectural University of Medicine, which was connected through the Kyoto Digital Sosui Network, a gigabit Ethernet with layer-2 security.  Another computer for the remote control of the PC for the robot control was placed in Yamashiro Public Hospital, 35 kilometers south of Kyoto city, through the same gigabit Ethernet. Using virtual network computing (VNC), which is a graphical desktop sharing system to control another computer, we demonstrated a remote control of the robot and collected the packets to examine the traffic bandwidth. The robot was successfully controlled in remote conditions.  The throughput of the Ethernet was 16.4 ±3.6 Mbps in the remote control of the robot using VNC.  The round-trip time was 19.9 ± 0.39 msec, while 8000 bytes data was sent by using ping command.  We demonstrated an intuitive touch panel navigation system, which a surgical robot stopped an arterial bleeding in an animal model.  The robot system was successfully controlled through a gigabit Ethernet between two distant hospitals.
Junichi Shimada, Kazuhiro Ito, Daishiro Kato, Masanori Shimomura, Hiroaki Tsunezuka, Satoru Okada, Kaori Ichise, Shunta Ishihara

EEG-Based Acute Pain Control System

Once the sensory receptor is stimulated by the injury pain is initiated, i.e. the electrical signal from the site of stimulus is sent to the brain. This study proposes the use of an electroencephalogram (EEG) as an index for self-controlling of the acute pain via the EEG biofeedback system. Relationship between the EEG signal and the levels of pain is investigated. Once the acute pain is occurred, experimental results illustrate that alpha (8-13 Hz) frequencies decrease as well as the beta (20-25 Hz) frequencies increase in the posterior areas. This index can be further used for the acute pain control system in our ongoing study. The success of this technique would lead to the reduction of using the medicine for real-time controlling of the acute pain.
Nattakul Saithong, Waraporn Poolpoem, Pradkij Panavaranan, Jannipa Saetang, Yodchanan Wongsawat

Medical Image Computing

High-Quality Intra-operative Ultrasound Reconstruction Based on Catheter Path

This paper presents a new method for improving image quality of intra-operative ultrasound for catheter intervention. A preliminary volume was constructed by extracting all colored pixels of 2D Doppler images. After center line was computed, cross sections of vessel were sampled and segmented by a modified region growing combining intensity distribution, curvature and area threshold. An ellipse was estimated based on the segmented contour. Finally, the estimated ellipses were interpolated onto the new center line which was registered to catheter path. The method was evaluated by a vessel phantom with bifurcations. The results show that the modified region growing can estimate an accurate contour and a high quality reconstruction can be obtained by interpolating estimated cross sections.
Kuan Luan, Takashi Ohya, Hongen Liao, Ichiro Sakuma

Nonlinear Reaction Force Analysis for Characterization of Breast Tissues

This paper addresses a diagnostic palpation system based on the measurement of nonlinear elasticity. An indentation probe is used to press against breast tissue. Then, the measured reaction force is used to estimate the parameters of nonlinear elasticity, which enables the identification of tissue type, such as fat, muscle, mammary gland or tumor. Here, we present the basic concept of our study and preliminary experimental and simulation results from pilot studies. More specifically, we measured the nonlinear response of reaction force using the breast of a goat. In addition, we also simulated the reaction force using nonlinear biomechanical simulation with several tissue types. Large differences in reaction force occur only in the nonlinear range in both experimental and simulation situations. Our results confirmed the feasibility of our concept.
Mariko Tsukune, Yo Kobayashi, Takeharu Hoshi, Yasuyuki Shiraishi, Tomoyuki Miyashita, Tomoyuki Yambe, Masakatu G. Fujie

MRI Based Sulcal Pattern Analysis for Diagnosis and Clinical Application in Neurosurgery

MRI is used not only for anatomical location and characterization but also for 3D views of sulci and gyri. T1WI-MRI captured with 3D-volume acquired 3D-views of sulci and gyri on fifty healthy volunteers and two patients. The software that we developed analyzed and labeled sulcal patterns of cerebral cortex automatically comparing to a standard brain model. We focused the post-central sulcus (PoC) and 2 neighboring sulci with an inter-sulcal analysis (Relations) including an inter-sulci junction (PoC and cingulate sulcus posterior [Cing]). The value of PoC-Cing Relations of focal cortical dysplasia (FCD) is higher than that of normal, while the value of glioma is much less among that of normal. The PoC of FCD and a few normal brains have junction with Cing. This informative value and a presence of inter-sulci junction suggest that cortical folding dynamics might influence the folding patterns of cerebral cortex. This sulcal labeling can analyze normal and abnormal patient’s brains for clinical use.
Manabu Tamura, Hiroki Nishibayashi, Mitsuhiro Ogura, Yuji Uematsu, Toru Itakura, Jean François Mangin, Jean Régis, Soko Ikuta, Kitaro Yoshimitsu, Takashi Suzuki, Chiharu Niki, Yoshihiro Muragaki, Hiroshi Iseki

Adaptive Rendering Method for Low Resolution Auto-stereoscopic 3-D Medical Images

Three-dimensional (3-D) displays have been receiving attention since they are more realistic and intuitive than two dimensional (2-D) displays. In this study, a rendering method to extract important features and enhance them for creating Integral Videography (IV) for medical use was studied and implemented. The resolution of IV mainly depends on the number of lenses which constitute the lens array. Consequently, the resolution observed from one viewpoint is not high enough for practical use and it sometimes prevents observers from understanding quickly. This is because the low resolution cannot depict high frequency image and it even becomes noise. We introduced non-photorealistic rendering (NPR) approach to the IV image. The NPR method will enable observers to understand the structure more intuitively and precisely because the method enhances important features. The idea to apply NPR methods to optimizing the rendering method of IV is conceptually unique. In this study, we proposed the feature extracting algorithm with dynamic threshold using the image depth for IV image.
Takehito Teraguchi, Kenta Kuwana, Ken Masamune, Takeyoshi Dohi, Susumu Nakajima, Hongen Liao


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