Track 2: Tecnologías para la transformación del sistema sanitario 2.4. Revolución en el quirófano

1. The Digital Operating Room-
Revolution or Evolution
MIHealth 2012, Barcelona
May 25th, 2012
Heinz U Lemke, PhD
Technical University of Berlin, Germany
Innovation Center Computer Assisted Surgery
University of Leipzig, Germany
Research Professor of Radiology,
University of Southern California, Los Angeles, USA
International Foundation for
Computer Assisted Radiology and Surgery - IFCARS
www.ifcars.org

2. Content
1. Motivation
2. DOR, TIMMS and related activities
3. Patient- and Process Modelling
4. Standards in Surgery
5. Conclusion

3. Innovation Center Computer Assisted Surgery
University of Leipzig, Germany
ICCAS Project timing: 2005 – 2016
Partner institutions: 8
Grant volume: 22 Mio €
Example of work items:
• Patient Modelling
• Surgical Workflow Modelling
• Surgical PACS/TIMMS
• Surgical DICOM
• (Surgical IHE)
• ... (OR.NET)
International Foundation for
Computer Assisted Radiology and Surgery - IFCARS
Example of work items:
• Patient Specific Modelling and MGM
• TIMMS and the Digital Operating Room (DOR)
• Surgical DICOM (WG 24) and IHE
• Education (MICARS and JICARS)
• CARS Congresses
• ... (ITFoM and OR.NET projects)

4. Innovation Center Computer Assisted Surgery
University of Leipzig, Germany
Implementation of a modular DOR systems architecture at ICCAS

5. Computer Assisted Digital OR Suite for Endoscopic MISS
Problems: Image guided vs. n-D model guided therapy
Video Endoscopy Image Manager - C-Arm Images
Monitor Report
MD’s
Staff
RN, Tech
EEG Monitoring
MRI Image -
PACS
C-Arm
Left side of OR Fluoroscopy
Laser
generator
EMG
Image view Monitoring
boxes Digital endoscopic OR suite facilitates MISS Teleconferencing
- telesurgery
H-K. Huang, IPI, University of Southern California and John Chiu, California Spine Institute

6. Examples of DOR devices Source: T. Lüth, MiMed

7. Examples of vendor specific DOR integration
Source: T. Lüth, MiMed

8. Digital Operating Room (DOR) Maturity Levels
Evolutionary Growth Path, (2005-2025++)
Functionalities/
System Features
• Surgical cockpit systems
• Model Based Medical
Evidence (MBME)
• Knowledge and decision • RT access to P2P
management, surgical process repos.
• Hospital/enterprise wide • Intelligent RT data mining
interoperability, • Full voice/gesture control
• DOR process redesign with • Clinical quantitative and • Medical TIMMS architect.
EMR and signal integration statistical assessment, • RT CAD integration
• Pre-op image integration
• WF management (engine)
incl. device/room control
• IHE integration profiles
for surgery and intervent.
• Intelligent (situation
aware) robotic devices …
• Basic DICOM in Surgery • Full DICOM in Surgery • Patient specific models • Surgical (flight) recorder
• HD video and digital • IO image acquisition • Basic IHE integration • Surgical solution systems •…
image acquisition • Navigated Control profiles for surgery and services •…
• Boom-mounted devices • Modelling and simulation • Smart walls incl. nD visual. •… •…
• Automatic reporting • Intelligent camera • Basic model guided interv. •… •…
• Integrated device control • Device interface harmon. • SIP/functional harmon. •… •…
•… •… •… •… •…
Time Periods
2005+: Maturity level 1 2010+: Maturity level 2 2015+: Maturity level 3 2020+: Maturity level 4 2025++: Maturity level 5
DOR vendor specific DOR peri-operative DOR intra-operative DOR vendor independent DOR intelligent infrastructure
integration processes optimisation process optimisation integration and processes
© Heinz U. Lemke, Febr. 2011

9. 2015+: Maturity level 3
• DOR process redesign with
EMR and signal integration
• WF management (engine)
incl. device/room control
• Full DICOM in Surgery
• Basic IHE integration
profiles for surgery
• Smart walls incl. nD visual.
• Basic model guided interv.
• SIP/functional harmon.
•…
2015+: Maturity level 3
DOR intra-operative
process optimisation

10. Content
1. Motivation
2. DOR, TIMMS and related activities
3. Patient- and Process Modelling
4. Standards in Surgery
5. Conclusion

11. Discovering knowledge in data, situations and processes
Pathologies Staff and Tools
Patients
Models of patients and medical activities (i.e.diagnostic and interventional workflows)

12. Personalised Medicine Integrated (model based)
in the DOR Patient Care
EBM, MBME, Mechatronics
Processes, (Navigation,
Modalities Omics EMR Workflow,IHE ablation, …)
(X-ray,CT, US,
MRI++,SPECT,
PET,OI)
Modelling,
Integration,
Education
Biosensors Prediction
Planning and
(physiology, and Diagnosis
metabolism, (Data fusion,
Intervention
(Simulation, decision
serum, tissue, …) Simulation, CAD, ...)
support, validation, …)
Data bases
(Atlas,
P2P repositories, Future ICT-based Infrastructure
data grids, ...)
EBM – Evidence-based medicine
MBME – Model-based medical evidence
IHE – Integrating the healthcare enterprise

13. Personalised Medicine Integrated (model based)
in the DOR Patient Care
EBM, MBME, Mechatronics
Processes, (Navigation,
Modalities Omics EMR Workflow,IHE ablation, …)
(X-ray,CT, US,
MRI++,SPECT,
PET,OI)
Biosensors
(physiology,
metabolism,
serum, tissue, …)
Models of patients and medical activities (i.e.diagnostic and
interventional workflows)
Data bases
(Atlas,
P2P repositories, Future ICT-based Infrastructure
data grids, ...)
EBM – Evidence-based medicine
MBME – Model-based medical evidence
IHE – Integrating the healthcare enterprise

14. Personalised Medicine Integrated (model based)
in the DOR Patient Care
EBM, MBME, Mechatronics
Processes, (Navigation,
Modalities Omics EMR Workflow,IHE ablation, …)
(X-ray,CT, US,
MRI++,SPECT,
PET,OI)
Functional components/engines
Biosensors Imaging Kernel for Diagnosis
and Modelling Simulation WF and K+D Visualisation and Validation
(physiology, Biosensors Management Rep. Manager Intervention
metabolism,
serum, tissue, …)
Data bases
(Atlas,
P2P repositories, Future ICT-based Infrastructure
data grids, ...)

15. Concept of an ICT architecture and functionalities
for Model Guided Therapy (MGT)
Repo- Data Exch.
Engine
sitory
Control
Images WF and Devices/
Modelling Computing Rep. Validation
and K+D Mechatr.
tools tools tools tools
signals tools tools
Imaging Kernel for Diagnosis
Visualisation
and Modelling Simulation WF and K+D and Validation
Rep. Manager
Biosensors Management Intervention
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure for data, image, model and tool communication for patient model-guided medicine
Data and Patient Process Models and
information specific models medical records
Models

16. Computer Assisted Digital OR Suite for Endoscopic MISS
Problems: Image guided vs. n-D model guided therapy
Video Endoscopy Image Manager - C-Arm Images
Monitor Report
MD’s
Staff
RN, Tech
EEG Monitoring
MRI Image -
PACS
C-Arm
Left side of OR Fluoroscopy
Laser
generator
EMG
Image view Monitoring
boxes Digital endoscopic OR suite facilitates MISS Teleconferencing
- telesurgery
Courtesy of Dr. John Chiu

17. MISS ePR Control System
Dataflow of Minimally Invasive Spine Surgery ePR
IO Imaging Kernel for Visualisation
and WF and K+D Rep. Manager
Biosensors Management
Visualization &
Fault- Display Module
Fault-tolerant tolerant
Pre-OP Input Gateway ePR Module 3
1 2 Pre-OP image/data
Pre-OP Pre-OP Input
Gateway 1) ePR Server Display
Image/Data Historical 320Monitoring
2)
6 4
Module
Intra-OP Input
Intra-OP Gateway 3) Archive/
5 Intra-OP image/data
database 7
Intra-OP 9
Real-time Post-OP Input Display
Image/Data
Gateway
5 Post-OP Authoring
Post-OP 10 & Display Module
Post-OP
8
Data 11
Courtesy of : H-K. Huang, University of Southern California and
John Chiu, California Spine Institute

18. Surgical ePR Control System
utilized for endoscopic procedures to insure safe and accurate MISS
Intraoperative monitor - live data/”real time” image/data - vital signs, 02
sat , EMG, laser, endoscopic and fluro images
Courtesy of : H-K. Huang, University of Southern California and
John Chiu, California Spine Institute

19. Data Exch.
Multi-media ePR system for MISS Repo- Engine
sitory Control
within TIMMS architecture
Therapy Imaging and Model Management System (TIMMS)
Images WF and Devices/
Modelling Computing Rep. Validation
and K+D Mechatr.
tools tools tools tools
signals tools tools
IO Imaging Kernel for Diagnosis
and Modelling Simulation WF and K+D Visualisation and Validation
Biosensors Management Rep. Manager Intervention
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and Models WF`s, EBM, Models and
(Simulated ”cases” intervention
information Objects)
records

20. Navigated Control Unit NCU
Shaver and intranasal drill: ACC sphenoid-clivus, 39 years, male
Step #2: prevention of the skull base by NC
Source: G. Strauss

21. Navigated Control Unit NCU
Shaver and intranasal drill: ACC sphenoid-clivus, 39 years, male
Step #2: prevention of the periorbit by NC
Source: G. Strauss

22. Data Exch.
Multi-media ePR system for MISS Repo- Engine
sitory Control
within TIMMS architecture
Therapy Imaging and Model Management System (TIMMS)
Images WF and Devices/
Modelling Computing Rep. Validation
and K+D Mechatr.
tools tools tools tools
signals tools tools
IO Imaging Kernel for Diagnosis
and Modelling Simulation WF and K+D Visualisation and Validation
Biosensors Management Rep. Manager Intervention
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and Models WF`s, EBM, Models and
(Simulated ”cases” intervention
information Objects)
records

23. Content
1. Motivation
2. DOR, TIMMS and related activities
3. Patient- and Process Modelling
4. Standards in Surgery
5. Conclusion

24. “n+1“ Generic and Complimentary Viewpoints
from different Domains of Discourse
Holistic Viewpoint
Anatomic Surgical
Information “Integration“
viewpoint viewpoint
Physiologic Patients
Metabolomic
viewpoint viewpoint
Mechanistic/kinetic Genetic
Diseases viewpoint
viewpoint Other viewpoints:
• Informatics
• Pedigree
• Homeostasis
Pathologic
viewpoint
… •
•
•
Epigenetics
Frailty-Syndrom
Orthomolecular
Radiological
viewpoint
etc.

25. Larynx Tumor
25

26. MTheory: Example of laryngeal carcinoma
Information entities are a sample only
and not technically or clinically validated

27. MTheory tree: Example of laryngeal carcinoma
Information entities and structure are a sample only
and not technically or clinically validated

28. MTheory graph with attributes: Example of laryngeal carcinoma
Information entities, structure and attributes are a sample only
and not technically or clinically validated

29. Concept of an ICT architecture and functionalities
for Model Guided Medicine (MGM)
Repo- Data Exch.
Engine
sitory
Control
Modelling tools WF, K+D tools
Images e.g. Curation, e.g. Inferencing, Devices/
Computing Rep. Validation
and EBM and MBME, Prediction, Mechatr.
Clinical guidel. tools Model updating, tools tools
signals P2P best pract.. etc. tools
Imaging Kernel for Diagnosis
Visualisation
and Modelling Simulation WF and K+D and Validation
Rep. Manager
Biosensors Management Intervention
Medical Information and Model Management System (MIMMS)
ICT infrastructure based on software engineering and data, information and communication standards/frameworks
(e.g. MDA, OSA, DICOM, HL7, IHE etc.)
Models and medical records
Data and Information
e.g. EMR, Patient Process e.g. Outcome reports,
OMICs specific models
Models
Source: Heinz U. Lemke

30. Top level workflow for minimally invasive reconstruction
of the mitral valve
S. Jacobs, D. R. Merk, D. Holzhey, V. Falk: Modellbasierte Therapie in der Herzchirurgie

31. P2P “Best Practice“ PSM/PM representations
(knowledge portal)
Reference expert knowledge
Peer Expert I
Peer Expert II
Generic models and
Repository of workflow
patient-spec. models
reference models (WFs, SIPs)
etc.
for medical techniques, WF graph
Simulation and
operating instructions, Education
Peer Expert III
etc.
P2P - Peer-to-peer
PSM - Patient-specific modelling
PM - Process modelling
Peer Expert IV Source: Heinz U. Lemke

32. Content
1. Motivation
2. DOR, TIMMS and related activities
3. Patient- and Process Modelling
4. Standards in Surgery
5. Conclusion

33. IT Standards for the DOR
Surgical DICOM services and IOD`s derived from
TIMMS functionalities and interface requirements
Therapy Imaging and Model Management System (TIMMS) WG 24 “DICOM in Surgery“
New integration profiles and the need for a new IHE Domain “Surgery”

34. WG 24 “DICOM in Surgery“
Project Groups to assist the surgeon
• PG1 WF/MI Neurosurgery
• PG2 WF/MI ENT and CMF Surgery
• PG3 WF/MI Orthopaedic Surgery
• PG4 WF/MI Cardiovascular Surgery
• PG5 WF/MI Thoraco-abdominal Surgery
• PG6 WF/MI Interventional Radiology
• PG7 WF/MI Anaesthesia
• PG8 S-PACS Functions
• PG9 WFMS Tools
• PG10 Image Processing and Display
• PG11 Ultrasound in Surgery

35. WG 24 “DICOM in Surgery“
Overview of current DICOM supplements
• Supplement 132: Surface Segmentation
• Supplement 131: Implant Templates
• Supplement 134: Implantation Plan SR Document

36. WG 24 “DICOM in Surgery“
Surface Segmentation
Supplement 132 specifies a way to store and
communicate meshes as DICOM instances, allowing
the storage of the meshes together with the images
on a PACS server.

37. First proposal for IHE in Surgery
New integration profiles and the need for a new IHE Domain “Surgery”

38. Implantation Planning
 Digital implantation planning is of increasing importance
 Issue: No commonly accepted file format for implant
templates
Digital 2D Planning
Digital 3D Planning
Source: Oliver Burgert

39. Content
1. Motivation
2. DOR, TIMMS and related activities
3. Standards in Surgery
4. Conclusion

40. Digital Operating Room (DOR) Maturity Levels
Evolutionary Growth Path, (2005-2025++)
Functionalities/ Revolution
System Features after 2025 ?
• Surgical cockpit systems
• Model Based Medical
Evidence (MBME)
• Knowledge and decision • RT access to P2P
management, surgical process repos.
• Hospital/enterprise wide • Intelligent RT data mining
interoperability, • Full voice/gesture control
• DOR process redesign with • Clinical quantitative and • Medical TIMMS architect.
EMR and signal integration statistical assessment, • RT CAD integration
• Pre-op image integration
• WF management (engine)
incl. device/room control
• IHE integration profiles
for surgery and intervent.
• Intelligent (situation
aware) robotic devices …
• Basic DICOM in Surgery • Full DICOM in Surgery • Patient specific models • Surgical (flight) recorder
• HD video and digital • IO image acquisition • Basic IHE integration • Surgical solution systems •…
image acquisition • Navigated Control profiles for surgery and services •…
• Boom-mounted devices • Modelling and simulation • Smart walls incl. nD visual. •… •…
• Automatic reporting • Intelligent camera • Basic model guided interv. •… •…
• Integrated device control • Device interface harmon. • SIP/functional harmon. •… •…
•… •… •… •… •…
Time Periods
2005+: Maturity level 1 2010+: Maturity level 2 2015+: Maturity level 3 2020+: Maturity level 4 2025++: Maturity level 5
DOR vendor specific DOR peri-operative DOR intra-operative DOR vendor independent DOR intelligent infrastructure
integration processes optimisation process optimisation integration and processes
© Heinz U. Lemke, Febr. 2011

41. Informatics platform/infrastructures as a
Repo- Data Exch.
reference architecture for the OR.NET project Engine
sitory Control
Therapy Imaging and Model Management System (TIMMS)
Images WF and Devices/
Modelling Computing Rep. Validation
and K+D Mechatr.
tools tools tools tools
signals tools tools
IO Imaging Kernel for
and Modelling Simulation WF and K+D Visualisation Intervention Validation
Biosensors Management Rep. Manager
Therapy Imaging and Model Management System (TIMMS)
ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy
Data and Models of WF`s, EBM, Models and
patients ”cases” intervention
information
records

42. Summary points
• We are at the beginning of a long path in the evolution
from the conventional OR towards an intelligent and fully
integrated (vendor independent) digital operating room
(DOR).
• Interdisciplinary cooperation of researchers, clinicians
and industry to accommodate multiple view points based on
a common understanding of the workflows within a
therapeutic domain of discourse is indispensible for the
advancement of the DOR.
• Standard development based on agreed upon DOR
architectures and interfaces is in progress but need to be
accelerated.
• Because of the complexity of surgical workflows and
patient-specific models further research and development
on workflow and knowledge and decision management
systems is essential.

43. Questions
• How can we bring researchers, clinicians and leading
vendors in the field of the DOR onto the same table to
define standards?
• How can we assess optimization of perioperative and
intraoperative processes with respect to patient
outcome?
• Which role will model-guided surgery (patient-specific
models and workflow models) occupy in the evolution of
the DOR during the next 10-20 years?

44. INVITATION to CARS 2012
16th Annual Conference of the
International Society for
30th International
Computer Aided Surgery
EuroPACS Meeting
www.cars-int.org
14th International Workshop on 4th EPMA/IFCARS Workshop on
Computer-Aided Diagnosis CMI Personalised Medicine and ICT
18th Computed 13th IFCARS/SPIE/EuroPACS
Maxillofacial Workshop on Surgical PACS and
Imaging Congress the Digital Operating Room

45. Thank you for your attention