Surgical Navigation - insights into wayfinding and navigation processes in the human body

Cognitive ergonomics for minimally invasive therapies – some insights into wayfinding and navigation processes in

the human body

Position

Thomas Stüdeli14 December 2009

Farewell lecture Thomas StüdeliFaculty of Industrial Design Engineering

Delft University of Technology

Position

Destination

References and Obstacles

New course

Thomas Stüdeli Ergonomics, Human Factors, Safety Engineering

Delft University of Technology, Faculty of Industri al Design Engineering

Medisign group – Research and Product development in healthcare, e.g. “Surgical cockpit” www.io.tudelft.nl/medisign

Human Information Communication Design Intelligent products, ambient intelligence, perception, information processing and information design

“Augmented Reality in Surgery ” (FP6, 2004-2008), AR/VR-Systems for


2004-2008), AR/VR-Systems for surgery and intervention radiologywww.ariser.info

[Lamata 2007] [Mühl 2007]

ARIS*ER www.ariser.info• “Augmented Reality for Surgery”, FP6 programme, 200 5-2008 • Six academic and two industrial partners, app. 40 i nvolved

researchers


Augmented Reality in Surgery (ARIS*ER) - Laparoscopy


Augmented laparoscopic images (liver resection)

Lack of haptic feedback and limited orientation performance in laparoscopic images

Augmented Reality in Surgery (ARIS*ER) – Robotic surgery

Augmented robotic arms (robotic surgery)

Collisions of robotic arms outside the field of view of the surgeons


Augmented Reality in Surgery (ARIS*ER) –Intervention radiology


How to visualize relevant anatomical information for (safe and efficient) abdominal needle placements?

Augmented needle trajectory line – 2D image & 3D map

Minimally invasive cardiac surgery

Keywords: Team work, Complex operation, Cardio pulmonary bypass, Time-critical, Patients safety

Human factors: Safety , Efficiency , Quality


Catheter positioning system

Annuloplasty ring solution

[Graduation Project Felipe Morales 2009]

[ARIS*ER cardiac project2006-2008]

What could be an “intelligent” User Interface? (Exp. Needle placement)


[Laban, Korteland, Boudri & Stüdeli 2008]

Agenda• Motivation (ergonomic viewpoint)

– Minimally invasive Surgery– Design of navigation support

• Navigation and wayfinding processes (safe and prudent)


(safe and prudent)– Orientation, Navigation Wayfinding

• Latest research– Role of information modalities (visual,

haptic, mental model)• Outlook

Operation theater – a special work environment


• Individual AND team work• High time pressure AND high demands• Action tasks AND monitoring / control

tasks• Highly complex AND highly regulated

“Entering an Operation Theater, it’s like going 100 years back in Ergonomics” Richard Goossens (10.8.2009 Beijing)

Motivation• Importance: Computer systems, visualization techniques,

and robotic technology aim to enable and/or supportsurgical actions. Navigation is obviously one essential action.

• Definition: “Surgical navigation” has not generally been well defined and therefore has been used inconsistently. It’s essential for communication in between multidisciplinary teams to be aware of those different foci


multidisciplinary teams to be aware of those different foci and usages of key words.

• Aims:– Know-how transfer: The aim is to translate know-how from

cognitive models of navigation and wayfinding into the field of surgical navigation.

– Support: The ultimate aim is to contribute to the design of more intuitive and more effective information and navigation systemfor the medical domain.





processes (safe and prudent)– Orientation, Navigation Wayfinding



Classical (maritime) navigation Navigation is… “process of planning,

documentation and control of a movement of a ship or vehicle from one location to another”

[Bowditch 1802]

i. Positioning ,

Navigation processNavigation


ii. Determination of next target position, landmarks and possible hazards between position and target position

i. Positioning , determination of actual position

iii. Movement,and control of actions

Wayfinding

Navigation process …• Classical navigation is an iterative process

that is intuitively understood. • The process demands:

– spatial capacities (thinking in space)– strategic decision making – safety and risks analyzes– management of parallel tasks


– management of parallel tasks• Navigation is strongly influenced by

– vehicle and or involved tools– navigation environment– navigation task

• Medical procedures and surgical or interventional tasks can be interpreted as navigation processes.

Safe navigation ?Factors: time, environment, tasks (demanded accuracy, pruden ce etc.)


Thomas StüdeliBasle 22 June 2009

Navigation vs. Wayfinding• Navigation process demands:

– Spatial orientation– Strategic decisions– Safety and Risk – Management of parallel tasks

• Supported e.g. by topographical maps

• “all the perceptual, cognitive, and decision-making processes necessary to find one’s way.”[Arthur and Passini 1992]

• Supported e.g. by schematic maps or car navigation systems


topographical maps

Orientation

• Absence of orientation is called disorientation, it’s seen as a symptom of confusion [Bellenkes et al 1992].

• Orientation is an active process: ”person's self-awareness with regard to position, time and place.”


place.” • For every navigation step orientation is

synonymous for “Where am I?” (Shewhart cycle (PDCA) Plan)

• Orientation is a “mental registration” –registration of the mental spatial model to the real environment (reality)

Wayfinding[Allen 1999, Professional Geographer]

• Tasks – Commute : travel along familiar routes in familiar

environments.– Explore : travel into unfamiliar environments.– Quest : exploratory travel in an unfamiliar environment to


– Quest : exploratory travel in an unfamiliar environment to an unfamiliar destination.

• Strategies– Depend on possible and preferred spatial updating

methods– Field of save travel [Gibson & Crooks 1932, Dominguez 1997]

– …

Human body as navigation environment

• Surgeons commute, explore and quest [Allen 1999,

Professional Geographer] the human body during MIS. The navigation process depends on tissue characteristics and the body region.

• Human body as a navigation environment can be characterized by:– Size of the working area (scale)


– Size of the working area (scale)– Tissue properties (e.g. rigidity)– Risks in the working area

• Wayfinding strategies differ e.g. between – Small working areas, e.g. brain surgery small part of

a complex organ– Single organ (liver, heart, kidney)– Multiple organ (complicated and big abdominal or

heart surgeries).

Take home message…Surgical navigation supports

• Be aware of the surgeons’ navigational process:– Parallel tasks – Iterative process (feedback important).

• A support should aim to truly unburden the surgeon from a specific (entire) task


surgeon from a specific (entire) task (e.g. car navigation system: wayfinding strategy).

• Provide feed forward information not a feed now information. Take in account the “field of safe travel” and support learning of movement patterns (e.g. “in 200m to the right” and not “you are here”).

Human body as an navigation environment

• The human body is an atypical navigation environment with the special characteristics of being – relatively small in size– not easily accessible– non-rigid, and changeable.

• The human body is too different from the classical


• The human body is too different from the classical navigation environments in order that existing design guidelines for navigation aids can be directly translated.

• Surgeons use the known cognitive concepts to navigate and therefore those cognitive models on human orientation, navigation and wayfinding help to describe and understand surgical navigation.

Surgical navigation strategies• Safety constraints:

– “Area of safe travel” (field of view, visibility) – Demanded accuracy (distance to vital

structures)• Accessibility and characteristics of

working area:– Small part of a complex organ (e.g. brain

surgery)– Single organ (e.g. liver, heart, kidney)


– Single organ (e.g. liver, heart, kidney)– Body region with multiple organs (e.g. major

abdominal or heart surgeries)• Different tissue characteristics in different

regions and organs (rigidity, changeability)• Complexity of surgical task

– Shape and form of “surgical plain”– …

• In the room– Different teams

• In a team– Changing teams– Changing positions

• In surgical work place and working field

Adaption of the user to the technology…or … (re -)orientation in OR


• In surgical work place and working field– Direct and indirect

views– Surgical tools& complex technology,

e.g. robotic tools or navigation system

[examples: IORT corectal cancer, ARIS*ER UI-Worksho p, Catharine Hospital Eindhoven]

Safe NavigationPosition Where am I? Hazards?

DestinationWhat do I want to see?Where do I want to go?What paths are possible?

References and Obstacles What will I see?

Checkor Study

Plan

Do

New course I move, and I control my movements! Act


What paths are possible?What will I see?What elements do I want to avoid?

• Two connected cycles (bold : navigation, italic: wayfinding)• Strategic and safety related problems (wayfinding aspects) • Location and orientation aspects (navigational aspects)

adapted from [Stüdeli 2008 ARIS*ER] & [Stüdeli 2009 GfA]Based on [Shewhart 1939, Q-Kontroll-Zyklus, Plan-Do-Check-Act][Bowditch1802, The American Practical Navigator]







haptic, mental model) • Outlook

Questions

• What is the role of the different information modalities?– visual, haptic, mental model– intra-operatively


– intra-operatively

(What can be transferred from pre-operative planning into intra-operative planning?)

• What is the relation between spatial and safety aspects?

Methods• Structured interviews

– Interview (therapy, general type of difficulties, successful navigation strategies)

– Sketch of “working area” (paper & pencil). • Intra-operative observations

– Observation (n=3) surgeries or interventions (notes, sketches)

– Encouraged to speak aloud everything that he/she


– Encouraged to speak aloud everything that he/she was thinking and doing

– Scene camera (record of workflow and verbalizing)• Analysis of interview data and sketches

– spatial-orientational variables: node, path, district, landmark, edge (Lynch 1960, p.145),

– safety-strategical variables: hazards, degree of accuracy, special attention

– information sources: direct view, indirect view, haptic, mental model

Lynch’s elements vs. anatomical landmarks

Landmarks[Lynch 1960]

Functions Examples of anatomical landmarks and landmarks used by surgeons in human bodies

Node Focal point of travel Vessel bifurcations

Path Channel for navigation Vessels, needle trajectory


Path Channel for navigation movement

Vessels, needle trajectory (indicated through a navigational aid)

District Reference point Familiar region, e.g. tissue structures on a CT

Landmark Reference point into which one does not enter

Vital structures

Edge Indicates district limits Capsules, ligaments, vessels

Catheter vs needle Intervention

• Catheter is flexible • Path follows anatomy /

vascular system (inside aorta, around organs)

• “Anatomical intervention”

• Needle is rigid • Path follows needle

trajectory (across organs)• “Unanatomical

intervention”


[pictures: Graduation report Thijs Van Oorschot 2009]

Spatial information need for surgical action

Anatomical (Catheter)(n=2)

Mental model

Visual (d) direct

view

Haptic

Node *** *** **

Path *** ** ***

District *** ** **

Landmark ***** **

• High importance of mental model during ‘action’ (flow of work)

• Subjects acquire ‘as much as possible’


** **Edge **

Unanatomical (Needle)(n=2)

Node *** ** *

Path *** ** -

District *** * (d **) **

Landmark *** ** (d **) **

Edge ** * (d **)

much as possible’ spatial information in all modalities

• No differences in use of edges and landmarks on medical images

*** Highly relevant (> 80%, 5 out of 6, found in interview, sketch, and verbalization)** Relevant (> 50%, 3-4 out of 6)* Minor importance (> 15%, minimal 1 out of 6)

spatial-orientational vs

safety-strategical

Navigation Wayfinding

Position

Destination

References and Obstacles

Checkor

Study

Plan

Do

New course

Act


Navigation– Constant updating– ‘As much as possible’– ‘Optimization’ of

benefits (speed, quality)

Wayfinding– ‘Stop-and-go’– Decision points– Highly iterative– ‘Minimization of

risks’

Two worlds…?Position Where am I?

DestinationWhat do I want to see?

References and Obstacles What will I see?

Checkor Study

Plan

Do

New course I move, and I control my movements! Act

Position

strategic and safety related problems (wayfinding aspects)


[adapted from Stüdeli 2009]

PositionAm I safe? Hazards?

DestinationWhere do I want to go?What paths are possible?

References and Obstacles What elements do I want to avoid?

Checkor Study

Plan

Do

New course I control my movements! Act

Control of location and orientation (navigational aspects)

Conclusions

• Mental model is highly relevant - even in simple applications – Transferred from pre-operative planning into

intra-operative planning is important

• Huge information need during MIS,


• Huge information need during MIS, surgeons want “As much as possible”!

• Safety information is highly spatial, but not necessary anatomical information– E.g. Angles, volumes, areas, length, distance to

target






• Recent research– Role of information modalities (visual,


Outlook & Questions

Research Methods?• How to (better) quantify verbalization data?• What does eye tracking offer?

Practical relevance for more complex applications?


applications?• Two surgeons, 4 eyes, two mental models?• Collaborative mental models…?

Practical implication for Ergonomist and Designers?

• Selection, priorization, and presentation of information

Operation time

Surgical team

Technology

Safety / Information / Workload

Idea finding: Moderated Workshops with Engineers and MD

Design

Surgery

Systems Architecture& Graphics

Robotics & Control


[Stüdeli, Freudenthal, de Ridder 2007 WWCS]

Thomas StüdeliiNNOVATION fORUM, Tuttlingen 23 June 2009

Ergonomics

Surgery

& Graphics

Computer graphics

Robotics & Control

Information processing and fusion

MRI-TechnologySurgery

Anaesthesiology

Ergonomics

Robotics & Control

Final Animal tests for the ARIS*ER cardiac system


Systems Architecture& Graphics

Thank you for your attention,

good bye and see you again!

ARIS*ER is funded by the European Union as part of the 6th framework programme for research under the Marie Curie Actions for Human Resources and Mobility, contract MRTN-CT-2004-512400.


Thomas Stü[email protected]

LinkedIn http://nl.linkedin.com/in/stuedelithomas

XING http://www.xing.com/profile/Thomas_Stuedeli

Surgical Navigation - insights into wayfinding and navigation processes in the human body

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