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Surgery Angiography and Computer Tomography Angiography and Computer Tomography in one OR – First of its Kind in the World Courtesy of Robert Weersink, MD, University Health Network, Toronto, Canada By Jay Parkes The integration of two Siemens devices, Artis zeego and SOMATOM Definition Flash, within a single OR provides new opportunities for clinicians to evaluate the best imaging modality for the operating room based on image quality, navigation and accuracy, and fusion of different imaging modalities with real-time virtual endoscopy. The recently opened GTx-OR (Guided Therapeutics Operating Room) at the University Health Network in Toronto is the first OR site in the world to combine a Siemens SOMATOM Definition Flash scanner and a Siemens Artis zeego robotic angiography system within the same operating theater. The SOMATOM Definition Flash scanner provides the ‘gold standard’ for CT imaging, while the Artis zeego provides excellent 3D rotational angiography for flexible integration within the operating environment. An Artis OR table that can articulate between the two modalities is included in the roster of GTx-OR equipment. The plan is to use the speed of the CT system to capture a high resolution CT dataset and co-register these images with cone-beam CT images acquired using the Artis zeego during the surgical procedure. That way the surgeons can update the 3D image during the procedure and have full access to the patient at the same time. The updated 3D image lets the surgeon localize the remaining tissue to be removed, and provides an accurate 3D map for tracking and navigation of surgical tools or with Video-Assisted Thoracic Surgery (VATS). Currently, there is not a lot of published data available regarding this use of 3D intraoperative imaging  “The dual-energy CT gives you exquisite image definition and incredible resolution,” said Robert Weersink, MD, a medical physicist at UHN who is also a leader of the GTx- OR project. Since it is difficult for a surgical team to access a patient inside the O-ring of the CT scanner, however, the patient can be moved to the Artis zeego, which also provides high-quality 3D images – for helping surgeons as they conduct open and minimally invasive procedures. The C-arm of the highly robotic Artis zeego can be swung away from the patient while surgeons work, and then moved back into the exact same position, enabling the doctors to re-image and resume their work. Better Margins for Tumor Excision According to Jonathan Irish, MD, Chief of Surgical Oncology at UHN and leader of the GTx-OR project, cancer funding has provided most of the financial support. As a result, the first to be treated have been cancer patients, such as those with tumors in the head and neck region, for example. Here, tumors are often close to important anatomical structures, such as arteries and nerves, so localization of the anatomy is a very important initial step in surgery to avoid serious damage to the patient. In the past, surgeons using pre-operative imaging have been able to precisely visualize the anatomy in this region. However, as soon as surgery begins, the anatomy changes due to manipulation by the surgeon. This challenge is compounded by the fact that important structures in this region are typically very small and surgeons wish to operate in a minimally invasive manner as often as possible. For these reasons, accurate image guidance can be tremendously helpful. In the GTx-OR, this will be accomplished by coregistering the CT scanner, and syngo DynaCT images acquired during the procedure using the Artis zeego. Dr. Irish expects this high-level imaging hardware and software to give surgeons in the GTx-OR an even better view of what they are cutting so they can excise more of the tumors they are targeting, while leaving healthy tissue intact. Ultra-Minimally Invasive Surgical Resection of Small Pulmonary Nodules An increasing number of small pulmonary nodules are being detected on CT scans due to CT screenings in high risk patients. CT-guided, fine-needle aspiration or transbronchial biopsy is performed for the diagnosis of such nodules; however, this procedure is limited “We’re at the interface of industry and academia, surgery and physics. We can take ideas that start in the lab … test them, and bring them for the benefit of patients.” Jonathan Irish, MD Chief of Surgical Oncology at UHN and leader of the GTx-OR project 56  AXIOM Innovations | December 2013 | www.siemens.com/angiography


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