A Physical Brain Model for Neuroendoscopic Training ... · the neurosurgeon's disposal, including...
Transcript of A Physical Brain Model for Neuroendoscopic Training ... · the neurosurgeon's disposal, including...
The Centre of Image Guided Innovation and
Therapeutic Intervention (CIGITI)
The Hospital for Sick Children
University of Toronto, Canada
A Physical Brain Model for Neuroendoscopic Training, Evaluation,
and Robot Design
James M. Drake FRCSC
11th SANS & 2nd APNS Annual Meeting Joint Conference Riyadh April 2017
Surgical Simulation for Training• Surgical simulation increasing (mandatory) role in training: fail
safe environment, repetitive training/evaluation/certification
• Number of unanswered important issues: fidelity (realism), translation to real world
• ETV ideal task – technically challenging, high risk, difficult to verbally teach, hand over
• Endoscopic colloid cyst resection, ETV-CPC, Endoscopic craniosynostosis surgery similar technical challenges
• Number of simulators, virtual, physical, cadaver – which is best ?
J Neurosurg. 2013 Feb;118(2):250-7. Needs assessment for simulation training in neuroendoscopy: a Canadian national survey. Haji FA1, Dubrowski A, Drake J, de Ribaupierre S. RESULTS: Thirty-two (55.2%) of 58 surgeons completed the survey. All believed that virtual reality simulation training for ETV would be a valuable addition to clinical training. Selection of ventriculostomy site, navigation within the ventricles, and performance of the ventriculostomyranked as the most important steps to simulate. Technically inadequate ventriculostomy and inappropriate fenestration site selection were ranked as the most frequent/significant errors. A standard ETV module was thought to be most beneficial for resident training.
New anatomical simulator for pediatric neuroendoscopicpractice. Coelho G, Zymberg S, Lyra M, Zanon N, Warf B. Childs Nerv Syst. 2015 Feb;31(2):213-9
Quality assessment of a new surgical simulator for neuroendoscopic training. FilhoFV, Coelho G, Cavalheiro S, Lyra M, ZymbergST. Neurosurg Focus. 2011 Apr;30(4):E17.
Anatomical pediatric model for craniosynostosissurgical training. Coelho G, Warf B, Lyra M, ZanonN. Childs Nerv Syst. 2014 Dec;30(12):2009-14
J Neurosurg. 2014 Aug;121(2):228-46. doi: 10.3171/2014.5.JNS131766. Epub 2014 Jun 20.
The use of simulation in neurosurgical education and training. A systematic review.Kirkman MA1, Ahmed M, Albert AF, Wilson MH, Nandi D, Sevdalis N.
RESULTS:Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon's disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18.CONCLUSIONS:The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.
Model Based Pediatric Neurosendoscopy Courses
Image Guided Colloid Cyst ResectionFlexible scope ETV CPC
Metopic Endoscopic Craniosynostosis Virtual Reality ETV
Construction of the Simulator
Mold with ventricular cast Choroid Plexus, venous detail Brain with encasing skull
Replaceable III vent floor III vent floor installed Brain stem with basilar system
Stronglydisagree
(1)
Disagree
(2)
Neutral
(3)
Agree
(4)
Stronglyagree
(5)
1. The camera view is comparable to what you wouldsee in a real surgical scene.
1 (4 %) 14 (61 %) 8 (35 %)
2. Performing the ventriculostomy on the floor of the 3rd ventricle of the model feels like it does in reality
1 (4 %) 16 (64 %) 8 (32 %)
3. The simulator matches actual tissue propertiesclosely.
1 (4 %) 19 (76 %) 5 (20 %)
4. The bleeding looks realistic. 12 (48 %) 13 (52 %)
5. This model helps to develop camera skills needed forETV.
7 (29 %) 17 (71 %)
6. This model helps to develop hand-eye coordinationneeded for ETV.
8 (32 %) 17 (68 %)
7. The ventriculostomy task is a valuable training exercise.
5 (20 %) 20 (80 %)
8. Use of this model will increase resident competencywhen used to train residents prior to their first ETV.
5 (20 %) 20 (80 %)
9. I would be interested in using this model to train residents.
6 (24 %) 19 (76 %)
42 itemsDevelopment and content validation of performance assessments for endoscopic third ventriculostomy. Breimer GE, Haji FA, Hoving EW, Drake JM. Childs Nerv Syst. 2015 Aug;31(8):1247-59.
Global Rating Score – 9 items
Testing reliability and validity of the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT) Gerben E. Breimer,, Faizal A. Haji, Giuseppe Cinalli MD, Eelco W. Hoving, James M. Drake, Neurosurgery in Press
Virtual Reality Simulator
Q u e s t i o n n a i r e
Recruitment and group assignment (n = 26)
Groups 1+ 2: Physical
Simulator ETV Trial (n = 13)
Groups 3 +4: VR Simulator ETV Trial (n = 13)
Groups 1+ 2: VR Simulator
ETV Trial (n = 13)
Groups 3 +4: Physical Simulator ETV Trial (n = 13)
Q u e s t i o n n a i r e
Domain Physical simulator
mean rating (SD)
VR simulator mean
rating (SD)
p-value
Anatomy
Surface 3.9 (0.7) 3.8 (0.9) 0.50
Lateral ventricle 4.1 (0.6) 4.5 (0.7) 0.04
Third ventricular floor 4.0 (0.9) 4.4 (0.6) 0.03
Overall 4.0 (0.6) 4.2 (0.6) 0.11
Domain Physical simulator
mean rating (SD)
VR simulator mean
rating (SD)
p-value
Instrument Handling
Endoscope 4.7 (0.6) 4.0 (0.9) <0.01
Tools 4.6 (0.6) 3.9 (0.6) <0.01
Tactile feedback 4.4 (0.7) 3.4 (1.2) <0.01
Tissue manipulation 4.3 (0.7) 3.6 (1.1) 0.02
Overall 4.5 (0.5) 3.7 (0.8) <0.01
Content of procedure
Steps 4.4 (0.6) 4.2 (0.9) 0.07
Skills 4.4 (0.6) 4.0 (0.9) 0.04
Challenge 3.8 (1.0) 3.4 (1.1) 0.11
Overall 4.2 (0.6) 3.9 (0.8) 0.03
Domain Physical simulator
mean rating (SD)
VR simulator mean
rating (SD)
p-value
Overall fidelity (realism)
Suspended disbelief 3.9 (0.6) 3.8 (0.7) 0.23
Real-life comparability 4.1 (0.6) 3.9 (0.7) 0.75
Real-life situations,
factors, and variables
in scenario
4.0 (0.7) 3.8 (0.9) 0.26
Overall 4.0 (0.5) 3.8 (0.6) 0.31
Domain SickKids simulator NeuroTouch
Cost (USD) $6,000* $80,000
Durability Must replace 3rd ventricle floor
w/ each case and silicone brain
w/multiple uses
Can be used repeatedly
without any additional
cost/materials
Variability of
clinical
cases
New cases require new brain
mold/floor insert; bleeding
scenarios available; can be
used with neuronavigation
Only one case currently
available, additional cases
require re-segmentation of
underlying scenario
*Estimate does not include cost of neuroendoscopic equipment
Design and Evaluation of a Concentric Tube Robot for Minimally-Invasive Endoscopic Pediatric NeurosurgeryV. Bodani, H. Azimian, T. Looi, J.M. Drake
Development of a Patient-Specific Brain Simulator for Endoscopic
Colloid Cyst ResectionVivek Bodani, Gerben Breimer, Faizal Haji, Thomas Looi, James Drake
Center for Image Guided Innovation and Therapeutic Intervention, The Hospital for Sick Children
41st Annual William S. Keith Professorship in NeurosurgeryJune 6, 2016
Colloid Cysts of the Third Ventricle
• 0.5 – 2% of all intracranial tumors1
• Acute non-communicating hydrocephalus, sudden death, headache, memory disturbance
• Microsurgical approach –transcortical, transcallosal– “Gold standard”
• Endoscopic approach– Reduced morbidity– Limited access to and visualization of
the site of cyst attachment to the roof of third ventricle
– Increased rate of subtotal resection, cyst recurrence, reoperation2
Chowdhry et al. 20133
Patel et al. 20124
Simulation-Based Medical Education
• Obtaining the required operative experience can be difficult5:– Work hour restrictions– Increased complexity of procedures– Rapidly advancing technology– Increased demand for patient safety,
cost-efficiency
• Simulators provide a risk-free environment without time or resource constraints6–9
• Research Objectives:– Design and construct a patient-specific
silicone-based brain simulator for endoscopic colloid cyst resection
– Evaluate the simulator’s realism (face validity) and procedural/educational content (content validity)
BrightMatter Brain Simulator10
NeuroTouch5
Design Requirements
• Highly realistic
– Appearance• Patient-specific anatomy
• Bleeding
• Realistic sulcal/gyral patterns
– Tissue properties and tactile feedback
– Use of actual endoscopic instruments
– Neuronavigation: CT, MRI
• Inexpensive
• Reusable
• Easy storage/maintenance
• Simple to fabricate
Preoperative Imaging Segmentation
3D Modeling
3D Printing and Silicone Molding
Fused Deposition Modeling
Replicator 2(Makerbot Industries, New York City, NY, USA)
Lulzbot Taz5(Aleph Objects, Inc., Loveland, CO, USA)
ColorJet Printing
ProJet 4500(3DSystems, Rock Hill, SC, USA)
Neuroendoscopy Simulator
Simulator Imaging
MRI T1 CoronalCT Axial MRI T1 Axial
Instrumentation
• Neuroendoscopy System (MINOP InVent, Aesculap, Inc., Center Valley, PA, USA)– 0o and 30o angled endoscope– Bimanual instrumentation – scissors,
forceps– Suction/Irrigation – 6-French NG Catheter
• Neuronavigation (StealthStation EM, Medtronic, Inc., Minneapolis, MN, USA)– Preoperative CT and MRI fusion– Fiducial- and surface-based registration– Field generator and skull-mounted
reference frame
Aesculap MINOP InVent
Procedure Setup
Endoscopic Colloid Cyst Resection
AS
Fo
TS
Th CP
CC
SP
CH
Participant Demographics (n = 15)Demographic Information n
Level of Training
Junior Resident (PGY 1-3) 7
Senior Resident (PGY4-6) 4
Fellow 4
Staff 0
Handedness
Right 14
Left 1
Previous Simulator Use
Yes 1
No 14
Surgical Experience (median [range])1 2 [0 – 13]
1Observer, assistant, or primary surgeon in an endoscopic or open colloid cyst resection
Feedback Survey Results
5-point Likert scale: 5 – strongly agree, 4 – agree, 3 – neutral, 2 – disagree, 1 –strongly disagree
Feedback Survey Results
5-point Likert scale: 5 – strongly agree, 4 – agree, 3 – neutral, 2 – disagree, 1 –strongly disagree
Recommendations
• Optimize orientation of the head to ensure ergonomic hand positions
• Increase brain compliance to ease cyst extirpation from the ventricles
• Increase case complexity for experienced trainees– Normal-sized ventricles
– Choroid plexus adherent to cyst wall (cautery)
– Increased cyst fluid viscosity (tissue shaver)
– Dense attachment of cyst to roof of third ventricle (fornix, internal cerebral veins)
– Intraseptal cyst location
– Bleeding scenarios
Conclusions
• Successfully built patient-specific silicone-based colloid cyst simulator
• Performed initial validation of simulator’s realism, procedural content, and value as training tool
• Future work– Further improve simulator realism
– Incorporate cautery, ultrasound, tissue shaver
– Increase case complexity
– Conduct additional validation studies (construct validity)
Overview of Fabrication Process of Metopic Model
DICOM CT/MRI -> Mimics Software -> Magics Software -> 3D Printing
Fig. 1. 3D Surface Model of Metopic Skull Segmented from DICOM Using Mimics (MaterialiseNV) (A.), Assembly of Reusable Model-Base and Cartridge Using Magics (Materialise NV)
(B.), Final Metopic Model Assembled (C.)
Course Station Setup
Stages of Sagittal Procedure
Summary of Questionnaire Results for Metopic Model (n =11)
Item Num.Questionnaire Item
Strongly
Disagree (1)
Disagree
(2)
Neutral
(3)Agree (4)
Strongly
Agree (5)
An
ato
my
1.Surface anatomy was realistic and appropriately detailed for planning and
performing the skin incisions.0 (0%) 0 (0%) 1 (9%) 6 (55%) 4 (36%)
2.Scalp and sub-periosteal tissue plane were realistic and had appropriate detail
for exposure of the anterior fontanelle and metopic suture.0 (0%) 0 (0%) 2 (18%) 6 (55%) 3 (27%)
3.The skull and anterior fontanelle, fused metopic suture and epidural space were
realistic and had appropriate detail required to perform the surgery.0 (0%) 0 (0%) 2 (18%) 4 (36%) 5 (45%)
Inst
rum
ent
Han
dlin
g
4. Endoscope handling was realistic 0 (0%) 0 (0%) 0 (0%) 4 (36%) 7 (64%)
5. Instrument handling was realistic 0 (0%) 1 (9%) 0 (0%) 2 (18%) 8 (73%)
6. The haptic (tactile) feedback from the simulator was realistic 0 (0%) 0 (0%) 1 (9%) 4 (36%) 6 (55%)
7.The response of the tissue to manipulation by the endoscope and instruments
was realistic0 (0%) 0 (0%) 1 (9%) 8 (73%) 2 (18%)
Co
nte
nt
of
Pro
ced
ure
8.Steps required to complete the task were representative of the steps for the real
procedure0 (0%) 0 (0%) 3 (27%) 5 (45%) 3 (27%)
9.Skills required to complete the task were representative of the skills required for
the real procedure0 (0%) 0 (0%) 3 (27%) 4 (36%) 4 (36%)
10. This task was technically challenging 0 (0%) 0 (0%) 3 (27%) 6 (55%) 2 (18%)
Task
Fid
elit
y
11. The simulator suspended disbelief 0 (0%) 0 (0%) 2 (22%) 4 (44%) 3 (33%)
12. The simulator environment is realistic of the real-life situation 0 (0%) 0 (0%) 1 (9%) 7 (64%) 3 (27%)
13. Real-life factors, situations & variables were built into the simulation scenario 0 (0%) 0 (0%) 2 (18%) 7 (64%) 2 (18%)
Table 2: Summary of Questionnaire Results for Sagittal Model (n=15)*
Item
NumberQuestionnaire Item
Strongly
Disagree (1)Disagree (2) Neutral (3) Agree (4)
Strongly
Agree (5)A
nat
om
y
1.Surface Anatomy was realistic and appropriately detailed for planning and
performing the skin incisions.0 (0%) 0 (0%) 1 (7%) 8 (53%) 6 (40%)
2.Scalp and subperiosteal tissue plane were realistic and had the appropriate
detail required for exposure of the anterior fontanelle and sagittal suture.0 (0%) 0 (0%) 1 (7%) 11 (73%) 3 (20%)
3.The skull and anterior fontanelle, fused sagittal suture and epidural space
were realistic and had appropriate detail required to perform the surgery.0 (0%) 1 (7%) 1 (7%) 8 (53%) 5 (33%)
Inst
rum
ent
Han
dlin
g
4. Endoscope handling was realistic 0 (0%) 0 (0%) 0 (0%) 6 (40%) 9 (60%)
5. Instrument handling was realistic 0 (0%) 0 (0%) 1 (7%) 6 (40%) 8 (53%)
6. The haptic (tactile) feedback from the simulator was realistic 0 (0%) 0 (0%) 3 (20%) 4 (27%) 8 (53%)
7.The response of the tissue to manipulation by the endoscope and
instruments was realistic0 (0%) 0 (0%) 1 (7%) 7 (47%) 7 (47%)
Co
nte
nt
of
Pro
ced
ure
8.Steps required to complete the task were representative of the steps
required to complete the real procedure0 (0%) 0 (0%) 0 (0%) 8 (53%) 7 (47%)
9.The skills required to complete the task were representative of the skills
required to complete the real procedure0 (0%) 0 (0%) 3 (20%) 5 (33%) 7 (47%)
10. This task was technically challenging* 1 (7%) 0 (0%) 4 (29%) 4 (29%) 5 (36%)
Task
Fid
elit
y 11. The simulator suspended disbelief* 0 (0%) 0 (0%) 4 (29%) 7 (50%) 3 (21%)
12. The simulator environment is realistic of the real-life situation 0 (0%) 0 (0%) 3 (20%) 8 (53%) 4 (27%)
13.Real-life factors, situations and variables were built into the simulation
scenario0 (0%) 2 (13%) 2 (13%) 8 (53%) 3 (20%)
* For Item 10 and Item 11, n = 14
Conclusions
• There are many applications for advanced technology in intracranial endoscopy both for simulation training, and tool development, including 3D printing, and robotics in their broadest sense.
• Advances in this area will be particularly relevant to other areas of neurosurgery as well as other surgical specialties
• Demonstrating efficacy, in terms of improved clinical outcomes, will be critical, both for simulation training, and novel tools, to justify their investment and costs.
• There will likely be an increasing role for surgical simulation in examination and certification