Note: Descriptions are shown in the official language in which they were submitted.
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GRAPHICAL USER INTERFACE L'GR
CGMPUTER.-ASSIS~L'ED SURGERY
ICI.~FICFiE APFErTI3I
Not Applicable.
~ECf~iNICAI~ FIEhL)
The present invention relates in general to
computer--assisted surgery, and, in particular to a
graphical user ~_nterface, method and system for
facilitating an orthopedic surgical proc:eaare with guidance
from an expert system.
BACKGRC3UND ~F ~.'FIE INL'E~1~I~ON
Orthopedics is a branch of mediwine concerned with
diseases, injuries, and conditions of the musculoskeletal
system. A large number of= orthopedic surgeries are
performed each dad,. To be optimally successful and
efficient an orthopedic surgery require, in addition to a
professional surgical team, perfect instruments, imaging
support for planning and performing the surgery, and
prec_~se control of_- each step of the surgery. ~'hese
requirements are especially important when performing an
orthopedic surgery using implants (for example screws, such
as pedicle screws used in spinal surgery) because a
misplaced implant may cause sericus harm too th.e patient,
and further may fail to achieve its desired function.
Currently, in some types of orthopedic surgery
including spinal opera-Mans, a screw hole position is
assessed by radiographic imaging and curette palpation. It
is recommended that holes be palpated w~~_th a curette, or by
setting an electrorayographic or fibroscopic probe, before
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screw installation. Furthermore, confirmation of screw
placement requires intraoperative radiographing. In some
types of orthopedic surgery more than one screw is placed
into a patient. The variety of types of orthopedic surgery
requires different surgical instruments and implants in a
plurality of sizes and types. A11 of t'n.is makes the fob of
a surgical team mere complicated. Some techniques for
surgical operat.iors employ a computerized surgical
assistance system that uses orthogonal X-ray imaging of the
part of the patient of interest in order to simolify the
tasks of the su-yg~_cal team. As is known in the art,
installation of pedicle screws, hip replacements, knee
replacements, and various other. orthopedic, orthodontic and
neurological procedures can be assisted using computer
technology.
An example of a computerized surgical assistance
system is described it U.S. Patent No. 6,450~978 entitled
INTERACTIVE COMPUTER--ASSIS'fED SURCJ-rrC~AL~ SYSTEM AND
METHOD THEREOF, which issued to Brosseau et al. on
September 17, 2002" Brosseau et a1_. describe a computer-
assisted surgical system and method i.r_ which a computer
includes t~-Free-dimensional models of anatomical str-uctures
and a user interface including a position sensing system to
register_ in real-time the relative ioositions of the
anatomical structures of interest and of a surgical tool.
Interactions between the tool and the anatomical structure
are displayed on a monitor using the three-dimensional
models. Multi-view display, transparency display and use of
cutting planes allow the surgeon to visualize the
interaction between the tool and the anatomical structures
any time during the surgical procedure. The system can also
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predict the constraint on anatomical structures before
surgery.
Many other computer-assisted surgery systems are known
and widely used, especially systems that are particularly
useful or explicitly adapted for use in orthopedic sur_gery~
An example is United States Patent Number 5,305~203,
entitled COMPUTER-AIDED SURGERY 1-APPARATUS, which
issued April 19, 1994 to Raab. Raab teaches a
computer-aided surgical device for aiding a surgeon in
positioning a su_rgica~ ir,str_ument (power or manual) when
performing surgery on unexposed and exposed portions of a
patient. A rudimentary graphical user interface provides
geometric diagrams to assist a surceon in guiding a
surgical instrument.
While all such systems provide a user interface, they
depend on the expertise of the su:_geon to guide the
surgical process ~ As is we~_1 known,, modern surgery is
performed by skilled teams that cooperate to accomplish the
task as accurately and efficiently as possible. However,
current computer-a:asisted surgery syst:em~s lack an expert
system core that is adapted to capitalize on the expertise
of team members.
Therefore there exists a need for a computer-assisted
surgery system with a graphical user interface that can be
used by a surgical team to facilitate a surgical procedure
using the expert system. The GUI preferably provides an
interface that is simple to u.se~ and integrated with the
expert system core.
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RY O~' ~I3E ~ NTION
It is thereforr~ an object of the :i.nvention to provide
a computer-assisted surgery system with a graphical user
interface (GUI) adapted to guide a surgical tear~~ through a
surgical procedure. The GUI provides a=,n interface that is
simple to use, and integrated ~rith the expert system core.
F3FtIE~' DE~CR~PT~O~d OP ~~3E InRAyNC3~
Further features and odvantage~ of the present
invention will become apparent from the following detailed
description, taken in combination with the appended
drawings, in which:
FIG. 1 schematically illustrates a system for
performing computer-assisted surgery (C:AS) that inclwdes a
graphical user interface (GUI) in a::ccardance with the
invention;
FIG. 2 is a flow chart illustrating principal steps of
a method for guiding the surga_cal team. in. performing a CAS
procedure via a GUI;
FIG. 3 schematically i1_lustrates an organization of
content of a main menu cf the GUT used for computer
assisted surgery;
FIG. 4 is a schematic view of a maim menu display page
in a GUI used for computer assisted surgery, in accordance
with an embodiment of the inventioi2;
FIG. 5 is a schematic view of a display page in the
GUI for guiding a surgical team during -the calibration of
an instrument;
FIG. 6 is a schematic view of a second instance of the
main menu display page shown in FIG. 4;
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FIG. 7 is a schematic view of a disp lay page in the
GUI for guiding the surgical team through acquisition of
images of the patient;
FIG. 8 is a schematic view of a display page in the
GUI for guiding a surgical team during the validation of an
acquired image;
FIG. 9 is a schematic view of a c,.isplay page of the
GUI for guiding a surgical team during the preparation of
an implant site; and
FTG. 10 is a schematic view of a display page of the
GUI for guiding the surgical team through installation of
an implant.
It should be noted th~a.t throughout the appended
drawings, like features a-re identified by like reference
numerals.
I7ETAI~E~3 DESCRI~'~I~N C3F'° ~."~IE ~I~ETS ENiSODIN~N''1'
The invention provides a simplified user interface for
guiding a surgical team through a computez:-assisted surgery
(CAS) procedure driven by an expert system,
FIG. 1 shows an exemplary embodiment of a system 100
for performing a CAS, in accordance with an embodiment of
the invention. The system 100 includes a computer 102 in
an operating room 108. The cozriputer 102 has a
processor 104 for executing a CAS applicat ion and a display
monitor 106. The display monitor 106 presents information
to a surgical team 110 in a graphical user interface
(GUI) 112. In particular, the display monitor 106 is a
video display adapted to display images in real-time. The
GUI 112 includes a plurality of display pages associated
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with respective steps required to perform the surgical
procedure. Some of the visual display pages display
virtual images of selected surgical instruments 118 used
during the surgical procedure everlai_d on fluoroscopic
images of a part of a patient 220 tha-c. is subject to the
surgical procedure. A manual input dev~_ce is preferably
connected to the computer 102 to pe-:rmit the surgical
team 110 to input commands to 'she CAS program for advancing
through the series of display pages of GUS 112, as each of
the respective steps of the surgical procedure is
successively completed. The manual in~out device may be a
keypad 114 that is easi~.y sterilized and resistant to fluid
contamination. As is known to the persons skilled in the
art, the manual input devi cF', like the keypad, c:an be
placed in a sterilized plast~i.c bag. A similarly adapted
foot-operated input device 122 may also be connected to the
computer 102. 'hhe foot-operated device 122 preferably
includes two pedals, one associated with an affirmation
action, and the other with a negation action. Likewise two
keys of the keypad 114 are associated with respective
affirmation and negation actions. Th.e surgical team 110
may choose to operate eitl~.er the keypad 114 or the
foot-operated input de~lice 122, as required. The
computer 102 may further be connected to a mouse or like
user input device.
The computer 102 is connected t.o a tracking system
that includes a biwocular video camera 116 for locating and
tracking position, orientation and movement of the surgical
instruments) 118 which are secured to instrument
locator(s), as cail_-i be explained below in more detail.
An imaging system, such as a fluoroscope 117 (a well
known X-ray imaging system), acquires oriented fluoroscopic
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images of a part o.y a patient 120 that is subject to the
surgical procedure. As will be understood b:y those slcilled
in the art, other i_nac~ing systv~ms can also be used such as
any one of CT-Scan, NiRI, PET~ ultrasound and Echography.
The images acquired by the fluoroscope 11'7 are provided to
the computer 102, in accordance with nh~:~ invention. As
many oriented fluoroscopic images as aye required for the
surgical procedure are acquired. The fluoroscopic images
are processed by the CAS to provide views of the part of
the patient 120 that are aligned with and scaled to the
tracking system. Respective fluoroscopic images are then
displayed in corresponding image content fields of display
pages, and provide a visual guide for the surgical team 110
in the preparation and installation of are implant, as will
also be explained below in more detaiJ_. The computer 102
may also be connected to a date network which may be a data
network such as the Internet 124 or a local area r;.etwork
(hAN) for accessing a remote data source 126 that stores
expert systems or application s externally of the operating
room 108. Alternatively, thE~ expert system applications
are stored in a memory of the computer 10'2.
The invention also provides a method for guiding the
Surgl.Ca1 team 110 in performing a CAS procedure using the
GUI 112. A general overview of the _rnethod is described
with reference to a flow chart 150 shown in FIG. 2. The
method provides the surgical_ team 1i0 with information
related to respective steps required to perform the
surgical procedure using the ~'~L7I 112. Virtual
representations of selected surgical instruments (herein
"virtual instruments") within a field of view of the
traclcing system are overlaid on the images of the part of
the patient 120 that is subject to the surgical procedure.
In addition, a series of display pages presented by the
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GUI 112 guide the surgical team 110 through the CAS
procedure, as each of the r_e:>pective steps is completed.
One embodiment of the GUI 112 provides visual and audio
information related to instrument calibration, patient
imaging, implant site preparation, and implant
installation.
The method starts (step 152) by placing the CAS
equipment 102 in the operating room :108. Patient data,
surgery type, and other information is then entered into
the computer 202 (step 15~). The surgical instruments 128
are then calibrated (step 156)> During the calibration
stepP the surgical team 110 is prom~cted to identify a
surgical instrument to be calibrated and to connect a
three-dimensional instrument locator 1"_9 tc the identified
instrument 118. In one embodiment, the instrument
locator 119 is a light-reflect~_ve reference tool. i~hen the
identified instrument 1.18 is secured t.o the instrument
locator 119~ the instrument is moved into a field of view
of the binocular video camera 11.6 of the tracking system,
so that images of the instrument locator :L19 can be used to
automatically calibrate the instrument.
The surgical team 110 is (step 158) prompted to effect
the acquisition of one or more differently oriented
fluoroscopic images of the part of the patient subject to
the surgical procedure. The resulting fluoroscopic images
are then verified (step 160). If an image is not
satisfac.tory~ (i.e. there is unacceptable contrastP the
orientation is incorrect etc.) the expert system returns
to step 158 to permit a substitute image to be acquired.
Otherwise, the expert system advances to step 162, and the
image is calibrated. If more images a re .required for the
surgical procedure (as determined in step 164), the expert
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system returns to step 158, Otherwise the expert system
advances to step 166. Menu options may be provided to
permit the surgical team 110 to transform images, for
example by selecting options to rotate, change contrast or
brightness, flip or restore the fluoroscopic image.
In step 166, the fluoroscopic images are validated by
the surgical team 11C with the guidance of the expert
system. The GUI 1i2 prompts the surgical team to place one
of the calibrated instruments on a part of t=he patient that
is subject to the surgical procedure, and to compare the
actual location of the surgical instrument 118 with the
virtual instrument superimposed on the r:_mage of the pa_r~ of
the patient. If the alignment between the calibrated
instrument and image of the virtual. instrument is not
acceptable, the image is deleted and tr~e procedure returns
to step 158 where another fluoroscopic Image is acquired.
Once the fluoroscopic images required for the
procedure have been calibrated and validated, the surgical
learn 110 is then guided through the pz:eparation of implant
sites (step 168). The GU:~ 112 prompts the surgical
team 110 to position a calibrated dril:L guide or an awl tip
connected to a calibrated instrument handle (for example)
on the part of t:~e patient where an implant is to be
inserted. The sv~te preparation is facilitated by the
images which display the fluoroscopic image or images of
the part of the patient, and by the virtual instruments.
Preferably an axis of the virtual instrument is displayed
to indicate an orientate on of the dri:Ll guide or awl tip,
The alignment of the position and orientation of the
virtual instrument and the fluoroscopic images of the
patient permit the surgical team to monitor site
preparation, which Generally involves drilling a hole to
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prepare a bone tc; receive the implant. Planning the
implant site to se'_ect a position and axis of orientation
may be performed as taught in the r~bo~;re-referenced co-
pending, co-assigned patent applicaticn. Furthermore,
during the preparation of the implant site, the GUT 112 may
display a depth gauge used t:o indicate t:o the surgical
team 110 a distance of travel of a dri~.)_ bit. The surgical
team naturally monitors the depth of the hole throughout
the preparation of the implant. site 170, in. part using the
.LO GUI 112 that dynamical:~y updates the Visual display to
indicate to the surgical team 110 the distance of travel of
the instrument as the 121StruZllent is used to prepare the
implant site.
The GUI 112 then prompts the surgical team 110 to
insert the implant (step 172). Th.e GUI 112 displays
selections to permit the surgical team 110 to advance to an
implant installation step, and there displays, in
corresponding image content fields, the fluoroscopic images
of the part of the patient that: were displayed during
implant site preparation. The virtual instrument, and an
image of the selected implant positioned and oriented with
respect to the other elements in view (herein a "virtual
implant") are overlas.d on the di:;played fluoroscopic
images. The virt~.za1 path of the implant is computed by the
CAS application by tracki ng a path of the instrument used
to insert the implant into the prepared implant site.
After the implant is installed, a "snap shot" (screen image
saved in a file on the computer hard drive) is generally
acquired (step 1i4). Snap shots may also be acquired at
other times during the procedure us:i_ng a predefined
commandb. keypad 114 key, mouse selection, etc.
Fluoroscopic images may also be taken to document the
position of the ~.mpiant (s) . If it i;_~ determined that
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another implant is to be inserted at a site visible .in the
fluoroscopic images (step 176), the expe.r_t system returns
to step 1&8. If required, the surgica_ tears may return to
step 158 to acqui-r_e fluoroscopic images (not shown on the
flow diagram). The GUI 1i2 will prompt the surgical team
to clear the image banks if the clamp has been displaced.
Otherwise, it is determined (step 178; whether surgery is
required at another site that .requires repositioning of the
vertebral clamp or other position reference tool. If so
7.0 the image bank is cleared ( step 180 ) , ar_~d another location
is prepared for surgery (step 182). The procedure then
returns to step 158 to acqui-r_e images of the next site.
Otherwise, the surgical team can quit the CAS application.
FIG. 3 illustrates content and selections available
7_5 from a main menu 204 of the GLJI 122, i~~~ accordance with an
embodiment of the present invention. As shown in FIG. 3,
the main menu 204 includes a plurality of selections that
are organized thematically. The selections provide the
surgical team 110 ~~aith access to the functionality of the
20 CAS system 100, which is augmented with display pages.
Some of the display pages (other tharu the main menu 204
display page) are also illustrated in FIG. 3.
In the embodiment illustrated in FIG. 3, the GUI 112
provides a main menu 204. It will be noted that the main
25 menu 204 is a display screen with a Uniform view that
dynamically displays content and selections depending on
selections made by the surgical team, and a state of the
expert system. As such, selections are adaptively
displayed by the main menu 204
30 The main menu 204 is accessed after patient
:information, surgery type, and other ins=o~:~mation is entered
in one or more preliminary pages 202. A patient to be
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operated on is identified, the Type of operation !in the
illustrated embodirlent, a spinal surgical procedure) is
specified and an identification of each member of the
surgical team is recorded, alo~:zg with any ot=her documentary
information required. The type of_ operation is used by the
CAS to select an instance of an expert system to drive the
GUI 112. Consequently, the type of operation determines a
configuratior_ of the remainder of the GUI 112, whir_h may
differ from the exemplary structure described with
reference to FIG. 3.
The main menu 204 permits the swrgical team 110 to
access three general categories of furActionality, namely:
an instrument calibration L:election 206 for accessing
functionality related to a calibrati_orz of selected
instruments to be used during the su_rgv.cal procedures a
patient imaging se:~ection 208 for accessing functionality
related to a~:,quiring, processing and validating
fluoroscopic images of a part of the vatient; an implant
preparation and installation selecticr~. 210 for accessing
functionality related to implant site planning, implant
site preparation and implant insta_~lation. A setup
selection 212 is also proviced to permit the surgical
team 110 to quit the CAS applicats.on, and reset the
tracking system. Other selections may also be displayed by
the main menu 204 to provio.e access i_o other desired
functions of the CAS application suc.~.z as, for example,
context-sensitive help. The sLtup category may be used for
selecting an arrancrement of the patie:.n'~, tracking system,
fluoroscope, etc. tn~ithin each category of functionality,
the GUI 112 may i nclude as ma:Y~y d.ispla.y pages as requi red
to enable effica.ent and intuitive access to the
functionality of the CAS application.
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Each of the categories of functionality offered by the
selections 206-222 is associated with a corresponding menu
bar icon that is used to effect the se sections 206--2:12, as
will be described further below with respect to two
instances of the main menu 204 illustraced in FIGsa 4,6.
Chile the expert system guides the surgical team
through the steps of t'r~e surgical prot:.ec~ure, at any time
while the application is run~iing there may be one menu
selection suggested by the expert system, one or more
allowable but not elicited selection., and one or more
displ aged but not-selectable option (s ) . T'he not-selectable
options are displayed as not availabi.e by a grayed-out
appearance. Fo_r example, at a fv-r_st :Lnst ante of the main
menu 204, the in,.plant pre~oaration and installation
1.5 selection 210 is rot selectable and is grayed-out, as
required instrurt~ents have no-~ been ~:~,al.ibrated, and the
required fluoroscopic images have not yet been acquired,
calibrated, and verified. Further indications (such as
~'Smlleys", a WlZo.ru., aSSlstant, etC. ) may be associated
with the respects.ve selections 206-210 to indicate ~rhich
steps have been successfully completed and/or are to be
completed. The first step expected by j~.he expert system is
the selection and calibration cf one or' more instruments to
be used in the invention.
Activating the instrument cals_bration selection 206 in
the main menu 204 updates a means of selections presented
to the surgical team. In 'the =illustrated embodiment, f:hese
selections includes widgets (selectable icons, buttons,
menu options, etca) for selecting at least one of a list of
instruments that may be of use in the surgical procedure
for launching respective calibr.at.ion display pages used to
guide the surgical. team through the calibration of the
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associated instrument. Specif_i.cally, a. U--handle (universal
tool handle) selection 216 and a drill guide selection 218,
which are useful fo_r orthopedic spinal surgery, are
presented. If the U-handle selection 216 is activated, a
calibrate U-handle display page 220, an ern'oodiment of which
is schematically illustrated in FIG. 5, is displayed.
Similarly, if the drill guide selection 218 is activated, a
calibrate drill guide display page 222 i.s displayed. As
will be understood by those skilled :in the art, more or
1_0 different instruments rr.ay be required for other surgeries
such as hip or knee replacements, for e:xampl.e .
Pr_eferablyr in accordance with t=he invention,
activation of the U-handle selection 216 or the drill guide
selection 218 is effected by an action widget. The action
widget is preferably an affirmation ac~ion button that is
consistently displayed in a11__ displa~° pages in a same
position. The affirmation action button ry.'~s further
associated with a respective pedal o= the foot-operated
device 122, and a key on the keypad 1:L4. The affirmation
action button is associated with tl~.e acceptance of a
currently presented option by the expert system via the
GUI 112.
The calibrate U-handle and calibrate drill guide
display pages 220,222 preferab=iy include illustrations and
instructions for demonstrating how to secure the instrument
locator 119 to the instrument, and directions for placing
the =nstrument within a field of view of the tracking
system, as will be descried further J~elow with reference
to FIG. 5. Once an instrument has been: calibrated, the
expert system again displays inst~:~urnent cal~_bration
selection 206 and suggests a next instrument. that is deemed
necessary for the sv.~rgical procedure< Once all instruments
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required for the surgical procedure have been calibrated,
the expert system raay present the main menu 204, with the
patient imaging selection 208 high:Lighted to prompt
selection. The surgical team may alternatively choose the
instrument calibration selection 206, and calibrate an
optional instrument, if desired.
The patient ,~maging selection 208 cf the main menu 204
is used to access functionality of the C~?S related t o the
capturing and processing of images of a. surgical site. The
patient imaging selection 208 provides an acquire images
setup selection 22~:, a validate images selection 226, a
transform images selection 228 and a clear image bank
selection 230.
Activation of the acquire images setup selection 224
launches an acquire fluc;roscope image c!isplay page 232 that
guides the surgica,. team in controlling an imaging system
(such as the fluoroscoyoe', of the CAS system to acquire
fluoroscopic images. ~n7hen the imaging system is ready; the
surgical team is prompted to acquire a fluoroscopic image
using the affs_-rmation action button. The acquired
fluoroscopic image is ,displayed immediately to the surgical
team in the image content field of the acquire fluoroscope
image display page 232 so tr~.at it c:an be verified, to
ensure that adequate resolution of the specific area of
interest is achieved. An example of the acquire
fluoroscope image display page 232, in accordance with the
illustrated embodiment, is shown in F7:G. 7.. The acquired
images are automatically calibrated by activation of an
affirmation action button in accordance with an embodiment
of the invention. P. calibrate fl_uorc>scc>pe image display
page 234 showing progress of she calib-Nation procedure is
lisplayed. The calibwated fluoroscopic images of the
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surgical site is scaled to match the calibrated
instruments, and are aligned w?_th the tracking system.
After each f,-uor oscopic image is calibrated~ the
patient imaging :5electicn of the main menu 204 is
displayed. After_ a firsc set. of calibrated f1_uoroscopic
images (in this example the fluorosc:oy,'_c images are a
paired anterior-posterior (AP) image and ~:. lateral (LAT)
image) is calibratedy the expert system suggests the
validate images selection 226~ although the surgical team
may elect to acquire further images.
If the validate images selection 226 is selected and
the affirmation action button is act:Lvated~ a va:Lidate
image display page 236 is launched. The validate image
display page 236 displays instructions trzat enable the
surgical team to Tralidate a fluoroscopic: image by comparing
positions of a calibrated instrument on the part of the
person subject to the procedureY with. a position of the
corresponding virtual instrument on the fluoroscopic image.
In accordance with i~he illustrated embodimentP FIG. 8 shows
an exemplary validate image display page 236. The surgical
team~ following step-by-step i:~structions can validate the
calibrated image to verify th~:t the fluov~_OSCOpIC image is
correctly aligned and scaled ~rith the v_ri~ual instrument
and the coordinates of the tracking system. After the
surgical team has compared a calibrated image with the real
points on the surgery .site, the surgical team can accept
the calibrated image us~~ng the affirmation action button,
or discard it using a negation action button, that is
consistently present in all of the display pages. If the
image is acce~otedn the image is stored in an image bank of
a memory of the com}~wter 102. Converse.l.yF ;i_f the image is
rejected, the image is deleted.
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Once the fluoroscopic image is t=ither accepted or
rejected, the expert system presents the main menu 204. T_f
there are more images that require validation, the main
menu 204 is presented with the patient imaging
selection 208 selectable, ~.nd the validate images
selecti.cn 226 suggested. If the required number of
fluoroscopic images a-re not av~~ilable (:i.a. Borne have been
deleted), the acquire images setup selecticn of the main
menu 204 with the patient ~_maging selection 208 being
suggested is displayed. Otherwise, the implant preparation
and installation selection 210 is selects able while the
implant site preparation selection 252 is suggested.
After a minimum required dumber of fluoroscopic images
have been validated, the surgical team can select the
implant preparation and instal:Lation seiecai on on the main
menu 204. However, it is not until all calibrated images
are validated, that. the expert system displays the main
menu 204 suggesting the implant preparation and
installation selectu_on 210. ~TOnetheless, the surgical team
can return to the patient imaging selection 208, and. choose
a transform images selection 228 which permits tre surgical
team to modify images by selecting opt=ion;a to rotate an
image 240, change a contrast 242 or a brightness 244 of the
image, or restore a transformed image 24~. Upon completion
of the transformation, t le surgical team ~'_s presented with
the same transformation options, and the :~urgical team can
select another flucroscapic image, and apply ore or more
other such transformations. C~lhen the surgical team has
completed the desired transformations, the main menu is
selected. The main menu 204 with the implant preparation
and installation selection 210 active i.s ~>resented and the
implant site preparaticn 252 is suggested. (assuming a
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sufficient number of fluoroscopic images have been
calibrated and validated).
Whenever an image is calibrated, the surgical team may
select from the main menu 204 under the patient imaging
selection 208, a clear image bank selection 230 that
displays a remove images display page 248. The remove
images display page 248 enables the surgical team to delete
selected images acquired for the surgical procedure. The
CUI i12 preferably displays the images in the image bank to
facilitate selection of fluoroscopic images to delete. A
remove all images selection on the remove images display
page 248 is generally used to restart i:cnage acquisition.
When the required number of calibrated and validated
fluoroscopic images are present, and the instruments to be
used are calibrated, the surgical team is guided to select
the implant site preparation selection 252, which is
suggested by the main menu 2f4s The affirmation of the
implant site preparation selection 252 iaunch.es a prepare
implant site display page 254 u.hat guides the surgical team
through the preparation of_ the implant cite" At this time,
the implant installation selection 256 is not available,
and is grayed-out.
Selection of the implant site preparation
selection 252 displays the prepare irnp-iar~t site display
page 254. The surgical instrument chosen to prepare the
implant site is aut:omat:ically detected using the instrument
locator 119. After the instrument enters the field of view
of the tracking systerr~r a status of an icon representing
the calibrated instrument is charged: When the surgical
instrument enters a field of view of the acquired image,
the corresponding virtual instrument is superimposed on the
image in both image content fields, as shown in one
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embodiment illustrated in FIi~. 9 > Y~lhen the site is
prepared, the surgical team selects the main menu 204 and
is returned to the implant preparatiot2 and installation
selection, in which the suggested action is implant
installation 256.
In one embodiment of the invention, a depth gauge may
be used t o guide the drilling of an implant site. After an
implant site is prepared to receive an implant, the
surgical team may prepare another implant site or install
the implant. When ready, the surgical team is presented
with an install implant display page 258, after affirming
the implant irastallation selection 256. The install
implant display page 258, an exemplary embcdiment of which
is illustrated in FIG. 10, guides the surgical team through
a process of inserting the i:azplant. A select screw (or
implant) size (or size and type) widget is provided to
permit the surgical team to select one of a catalog of
implants that is to be inserted at the implant site. The
virtual instrument and a selected virtual implant are
superimposed in real-time ovear the fluoroscopic images of
the part of the patient 120, permitting a visual
representation of the actual path of 'the installed implant
and the instrument.
After the implant is installed, surgical records may
be completed by acquiring images of the implant using the
fluoroscope, for example, o.r_ a snap shot of the image
presented on the display moni'~or 1_06.
When the surgical team s lects the setup selection 212
from the main menu 204, a reset tracking system
selection 260, and a quit application selection 262 are
presented. If the tracking system fails for one reason or
another, the surgical team selects the reset tracking
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system selection 26G, which provides a set of options and
display pages for troubleshooting and remediation of the
tracking system. T~7hen the surgical team has completed its
procedure the quit application. selectior_ 262 is used to
exit the program.
D~~p~.ay Pale F~a.t
Having described an organizational structure of the
GUI 112 shown in FIG. 3, an embodiment of selected display
pages of one implementation of the GU:I 112 is further
described below, anal is schematically illustrated in
r IGs . 4-10, in order to illut~trate ho~a the expert system
driven GUI 112 provides an Pfficient: interface for the
surgical team 210. The sequence of di.spl.ay pages followed
during a surgical. procedure may vary, depending on the
selections by the surgical team.
Each of the display pages in accordance with the
illustrated embodiment is visually divided into a top part,
a middle area, ar_ci a bottom part . The bottom part of the
GUI 112 includes an action bar 300 that displays an
affirmation action button 302 and a negation action
button 304 (although any widget of equivalent effect could
be used). A uniform view of the options presented to the
surgical team by the expert system is maintained to
simplify the interface with t:rie surgical -team. Rather than
presenting a number of options to the surgical team 110,
the action bar 300 provides for the affirmation, or
negation of a current option presented to the surgical
team, and a main menu button 306 for accessing the main
menu display page 204 (two instances of which are shown in
FIGS. 4,6). As the foot-operated input device 122 provides
activation of the affirmation and negation action
buttons 302~304, hands-free access to the functionality of
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the CAS application is facilitated. As will be recognized
by those skilled in the art, hands-free operation is
important in many surgical procedures.
The action buttons (i.e. buttons on the action
bar 300) are represented in a state that provides visual
information about the accessibility oz the button. The
effect of triggering the action button, and a state of
accessibility of the action button, is generally dependant
on selections made in the top part and middle area of the
display page that presents the action button. As described
above, if an action button is not accessible, it is
grayed-out; if the action button has been activated, it is
illustrated as a depressed buttons if the action button is
a suggested action by the expert system, the action button
is intermittently illuminated (i.e. 'flashing"'); otherwise,
a normal view of the action button is 'presented, indicating
that the action button can be selected even though it is
not suggested. If the action button is deactivated, a
mouse cursor cannot be used to select the action button,
and a corresponding key on the keypad 114 is ineffectual.
An audio tone may be associated with an attempt to select a
grayed-out button.
With reference to particu_Lar display pages
(illustrated in FIGS. 4-10), these states are exhibited.
When the main menu 204 is displayed, the main menu
button 206 is not accessible, and is accordingly grayed-out
(FIGs. 4,6). Further, in the validate image display
page 236 shown in FIG. 8 the main m.en.u button 206 is
grayed-out to ensure that a currently selected fluoroscopic
image is either validated or rejected, to prevent the
fluoroscopic image from remaining in an ambiguous state.
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The main menu button 206 is otherwise a~Gailable at each of
the display pages illustrated.
On both illustrated instances of the main menu 204,
the expert system suggests the selections highlighted (in
the top parts and middle areas of the display pages) and
accordingly the affirmation action buttons 302 on these two
pages are flashing The negation action buttons 304 are
also grayed-out as there is no negative action associated
with the selection identified by the 'pop parts and middle
areas of the display pages.
In the calibrate U-handle display page 220 shown in
FIG. 5, both the affirmation and negation action
buttons 302, 304 are grayed-out as the actions taken by the
surgical team are on the instruments themselves. As the
last step in the instrument. calibration procedure, the
U-handle is placed within a field of view of the tracking
system, which automaticali~_v' calibrates the surgical
instrument. During this last step, a completion bar. is
overlaid on the calibrate U-handle display page 220 and the
negation action button 304 is disp7_ayed i.n the normal
(ready fcr activation) state, and is annotated with text
indicating that the calibration process will be canceled if
the negation ar_tion button 304 is selected. Similarly the
affirmation and negation action buttons 302,304 are grayed-
out in FIG. 10, because the function of the illustrated
install implant display page 258, is uo permit a visual of
the insertion, and to permit the selection of the implant
size and type; none of_ which requires the action buttons.
In FIGs. 7 and 8 both the affirmation and negation
action buttons 302,304 are displayed in the ready state.
Further in FIG. 9 the negation action button 304 is in the
ready state, whereas the affirmation action button 302 is
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not available. At this juncture, activation of the
negation action button 304 deletes a selected fluoroscopic
image.
It will further be noted ~rith referer_ce to FIGS . 4-10,
that the affirmation action button 304 and negation action
button 302 are ar~notat ed with text that indicates a
response to a corresponding presented option whenever the
action button is not in a deactivated state. Acco_rdzngly,
in FIGS. 4,5 the affirmative action button 302 annotated
with "accept" is associated with initiating a selected
procedure step (specifically the calibration of the
universal handle, and the acguisition of a fluoroscopic
image, respectively). In FIG. 7 the aff.irma.tion action
button 302 is annotated with the text ''Calibrate°', while
the negation action button 304 is annotated with "Delete" a
fluoroscopic image. The "Delete" annotation on the
negation action button 304 is also present on the prepare
implant site display page 254 and effects the same action.
The affirmative action button 302 presented on the validate
image display page 236 shown in FIG. 8 is annotated with
the text °'Accept", indicating sa.tisf_actory agreement
between the virtual instrument with respect to the
fluoroscopic image, and the actual instrument with respect
to the part of the persora. The negation. action button 304
on the validate image display page 236 is annotated with
"Reject°' and is a:Lso used to delete a selected fluoroscopic
image on the basis that it is not in acceptable alignment
with a calibrated instrument.
h3ain hierau Di~~ai~~ ~agc~ F°arat
FIGS. 4,6 schematically illustrate two instances of an
exemplary main menu display page 204 displayed by GUI 112
on the display monitor 106. The instance shown in FIG. 4
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is consistent with an initia~> presentation of the main
menu 204, displayed once the preliminary information about
the suy~gery has been entered. In the instance shown in
FIG. 4, the main rnen~,z 204 is presented once the expert
system asserts 'that instrument calibration is complete.
In accordance ~~rith the illustrated embodiment, the top
part of the main menu 204 displays a menu bar 310. The
menu bar 310 includes four rr~enu bar icons 316-322 each
representing a respective one of the categories of
functionality shown in FIG. 3; name~i_y~ the instrument
calibration selection 206 represented by an instrument
calibration icon 3:~.6 that resembles the three dimensional
instrument locator 1191 the patient imaging selection 208
represented by a patient imaging icon 328 resembling the
fluoroscope 117; the implant preparation. and installation
selection 210 represented bar an implant icon 320 that
resembles a vertebra contains.ng an implant: and the setup
selection 212 represented by a setup icon 322 that, in
other embodiments is associated with the preliminary
display pages 202. It will be noted that the three icons
relevant to performing the surgical procedure
(icons 316-320) are grouped together, whereas the setup
icon 322 is visually separated. The menu bar 320 further
includes a right and a left button 324a,324b (which could
be replaced by any equivale.rzt widget) that is associated
with a respective key on the keypad x.14 and indicates the
keys that can be used to change the selected menu bar icon
(or other vertically offset selection set in procedural
display pages). The right and left buttons 324a,324b are
preferably also selectable by the mouse, if such an input
device is available.
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A righlighted border around a selected menu bar icon
(as shown in FIG. 4, the instrument calibration icon 316)
indicates which of the categories of functionality is
currently active. Grayed-out menu bar icons (like other
widgets) indicate that the menu bar icon (such as implant
icon 320, as schematically shown on both FIGS. 4,6; are not
available for selection; in a manner similar to the action
buttons. In accordance with the illustrated embodiment of
the invention, when the main menu 209: is displayedp each
time the right or -~eft button 324a,324b is selected a menu
bar icon that is right-adjacent or left-adjacent to a
currently selected menu bar icon becomes the selected merau
bar icon, wherein right and 7_eft adjacer;.cy are determined
by the visual order with the further specification that the
setup icon 322 is left-adjacent to the instrument
calibration icon 316, a_r~d reciprocal)y, the instrument
calibration icon 316 is r~lght-adjacent to the setup
icon 322. In accordance with some embodiments of the
invention, the grayed-out icons are by-passed. For
example, when an icon right-adjacent to the selected icon
is not available, and therefore grayed-out, activation of
the right button 324a does not bring about the selection of
the grayed-out icon; but rather selects the menu bar icon
that is right-adjacent tc the grayed-oat button, if that
button is available. Alternatively,. grayed-out menu bar
iccns can be selected, however no options are available for
selection in a middle area of the main menu 204, and both
affirmation and negation acta_on buttons 302,304 are grayed
out and not avai~.ableg when a grayed-out menu bar icon is
selected.
The middle area of the main menu 204 displays one or
more selections associated with a currently selected menu
bar icon. As the instrument calibration icon 316 is
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selected in the main menu 204 shown in FIG. 4, the middle
area selections presented form a list of surgical
instruments that may be used in the surgical operation
identified during initial setup. As an organizational
feature of the information displayed in the middle area,
the selections are divided into tasks 334 and options 336.
The task selections (i..e. selections presented within a
task field, such as the calibrate U-handle selection 216)
are deemed mandatory by the expert system, unlike optional
selections (i.e. selections presented within an option
field, such as the drill guide selection 218) are optional.
It will be noted that the calibrate U--handle selection 216
is highlighted by a text -background color inversion,
although any other highlighting scheme could be used, to
indicate which of the selections e~ualifies the option
presented to the surgical team. Accordingly, the action
currently suggested by the expert system is the acceptance
of the U-handle selection 216; which is presented when the
instrument calibration icon 316 is active. The surgical
team further has an option of choosing another selection
from the task or option fields 334,336 using up or down
buttons 342a,342b. Changing the highlighted selection in
the middle area using the up and down buttons 342a,342b in
relation to grayed-out selections is analogous to the
operation of the right and left buttons 324a,324b. The up,
down, right, and left buttons 34;?a,342b,324a,324b are
embedded in lists, menus, etc. and are used for changing
selections, menu options, etc. on different display pages
of the GUI 112, permitting the effic,'_ent use of the keys on
the keypad 114. As will be apparent to those skilled in
the ar_t, any number of layouts that provide the above-
described functicnality in a user friendly and accessible
manner can also be used in embodiments of the invention.
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The middle area of the main menu 204 shown in FIG. 6
displays selections associated with the patient imaging
icon 318 that is currently selected. Specifically the task
field includes the acquire images setup selection 224, and
the validated images selection 226, the former of which is
highlighted. zhe option field includes the transform
images selection 228, and the clear image bank
selection 230. As only the ac~~uire images selection 224 is
in the ready state (and all others are grayed-out), the
effect of the up and down buttons 342a,342b is null.
Pr~ced~x~ra~. Dis~L~.P~~ F~~~
Display pages 220, 232, 236, 254 and 258 shown in
FIGS. 5,7,8,9, and 10, respectively, are termed
"procedural°' display pages as they rea.ate to steps in the
computer assisted surgical procedure. An crientation
bar 350 is featured on the top part of the procedural
display pages for providing information :relating to the
current step in the CA.S 100. Specifically the orientation
bar 350 includes a place for the menu bar icon that
indicates the category of functionality accessed (shown in
a top left-hand corner), and a brief text field 352 for
identifying a current step in tha surgica l procedure,
notifying the surgical team of ava,~.lable commands, etc.
Naturally the instrument calibration icon 316 is presented
on the calibrate U-handle display page 220; the patient
imaging icon 318 is presented on the acquire fluoroscope
image display page 232 and the validate image display
page 236; and th.e implant ~_con 320 is presented on the
orientation bar 350 of the prepare implant site display
page 254, and the install implant display page 258.
The orientation bar 350 further d:Lsplays a plurality
of instrument icons 354. Specific instrument icons 354 are
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identified as follo~~rs: tJ-handle instrument icon 354a (shown
on procedural display pages 220,236,254, 258)8 C-arm
instrument icon 354b (shown on acquire fluoroscope image
display page 232)a clamp instrument icon 354c (shown in
procedural display pages 232,236,254y 258)a and drill
instrument icon 354d (shown on the prepare implant site
display page 254). T:ne instrument icons 354 presented on a
procedural display page indicate which of the calibrated
instruments (or instruments in the process of being
calibrated) are expected to be used in. the current step of
the surgical procec:ure. These indicated instruments may be
presented in either a normal view, indicating that the
instrument associated with the instrument icon 354 is
within the field of view of the tracking system, or in a
grayed-out view to indicate that the associated ir_strument
is not within the field of view of the tracking system.
For example, the drill instrument icon 354d on the prepare
implant site display page 254 shown in. F.a.G. 9 is grayed-out
to indicate that the drill guide is not within the field of
view of the tracking system.
The middle area of t:he procedural display pages
displays one or more content fields related to a step in
the surgical procedure that is underway. For example,
calibrate U-handle display page 220 presemts an illustrated
guide 356 for securing the instrument locator 119 onto the
universal handle, and placing the instrument locator 119
within the field of view of the tracking system.
The middle areas of each procedural display page that
is displayed after a fluoroscopic image is acquired,
preferably includes two image content fields: an anterior-
posterior (A-P) image content field 358x, and a lateral
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(LAT) content field 358b, for displaying respective
fluoroscopic images 359a,359b.
The fluoroscopic images 359a,359b are preferably X-ray
images but alternative imaging (e.g. ultrasound) can be
used for imaging the part of the patient. In accordance
with the embodiment shown, a vertebra7_ clamp is in a view
of the fluoroscopic images 359a,359b and is rigidly secured
to the spine of the patient. The clamp is used to
automatically calibrate the fluoroscopic images 359a,359b
during the calibration step.
In accordance with the illustrated embodiment, a
number of AP and hAT fluoroscopic images may be acquired.
Associated with each of the image content fields 358a,358b
for which selection of the fluoroscopic image is possible
25 (i.e. procedural display pages 232,236,254) is an image
selection field 360, which, in the illustrated embodiment
includes a numeral that identifies the fluoroscopic image,
and the up and down buttons ;s42a,342b. The up button 342a
is associated with a fluoroscopic image that has an
incrementally higher identifier numeral, and conversely,
the down button 342b is associated with an image raving an
incrementally lower identifier numeral. In alternative
embodiments, other image identifiers, and widgets for
selecting images by their identifiers, can be used to
provide intuitive user interaction. If only one image is
acquired for display in one image content field, as is the
case of the A-P image content field 358a in the acquire
fluoroscope image display page 232 shown in FIG. 7, the up
and down buttons 342a,342b are grayed.-out.
The image content fields 358a,358b of the validate
image display page 236, the prepare implant site display
page 254, and the install implant display page 258 are
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shown with overlaid virtual instruments 370. More
specifically the awi tip of the U-handle is displayed over
the fluoroscopic image 359b of the validate image display
page 236, and over the fluoroscopic images 359a,359b in the
prepare implant site display page 254. The virtual
instrument associated with the U-handle, having an
appropriate tip is shaven ~,aith a virtua7_ z.mplant 372 (which
is a pedicle screw) on the install impl ant display
page 258. In the illustrated embodiment of the prepare
implant site display page 254, an axis 374 extends a
predetermined distance from the center of the virtual
instrument used to prepare the implant site, the axis being
concentric with a major axis of the instrument. This
axis 374 is useful for ensuring that the bored hole is well
chosen. In some embodiments, the virtual implants remain
displayed on the fluaroscopic images 359a,359b even after
installation.
'!he patient imaging ican 318 is a.lsa displayed in each
image content field. If the patient imaging icon 318 of an
image content field is grayed-out(e.g. the LAT image
content field 358b in FIG. 7), no image is available for
viewing in the image content field, and a background 362
and image selection field 36() are grayed-out as well. Lf
the patient imaging icon 318 contains an ellipsis, the
image is in a pracess of being acquiv~ed (for example, see
the A-P image com.ent field 358a show~~ in FIG. 7) . If the
image is not yet validated, it is marked with an X, as
shown in the LAT image content field 358b of FIG. 8,
whereas the successfu:ily validated image content field is
marked with a o~~.eck, as shown in the P.-P image content
field 358b of the same figure.
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The image conter_1t fields 358a,358b may further include
backgrounds 3~2 that can be emphasized. or deemphasized to
indicate which of the two image content fields is currently
selected. In procedural display pages that permit the
selection of fluoroscopic images, th.e surgical team is
enabled to change the selectio-~ of the image content field
using one of the r~_ght and left buttons 324a, 324b. If the
A-P image content field is currently selected (as in
FIG. 7) the right button 324a is included s.n the A-P image
content field, for alternating selection to the LAT image
content field. Symmetrically, a LAT image content field
that is currently selected (as in FIGS. 8,9j includes the
left button 324b, for selection the A-P image content
field. As the LAT image content field 358b shown in FIG. 7
is associated witYi an empty image bank, the right
button 324a is grayed-aut. Naturally the image selection
field 360 of only the selected image content field is
emphasized and includes the up and down buttons 342a, 342b.
It will be noted that the installation of the implant after
the site has been prepared generally requires the same view
of the implant site to be rendered because that image is
most precisely calibrated with the drilled hole.
Accordingly no option for changing displayed images is
presented to the surgical team (i.e. no image selection
field 360;, during the implant installation procedure step,
and backgrounds '?62 of both image content fields are
highlighted.
Other fields as required are defined for respective
purposes related to respective procedure steps. For
example, an implant size field 364 that includes widgets
for charging a selected impl~:nt size ;or alternatively size
and type) is shown in FIG. 10. As is preferable, the
implant size field 364 includes right and left
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buttons 324a,324b. In alternate errlbodi.ments of the
invention, the middle area of the instal7_ implant display
page 258 includes a virtual path overla:~.d on each of the
fluoroscopic images 359a,359b that are concentric with the
implant sites, the path being computed with respect to the
axis of the implant:, and an implant s=_ze . As the implant
(e.g., a pedicle screw) is installed, tree virtual path of
the implant is displayed in a contrasting color over the
prepared implant site 510, for example" Concurrently, a
20 depth of the pedicl.e hole may be shown on a depth gauge as
'the insertion progresses. This permits the surgeon to
monitor an axis of orientation and a depth of insertion of
the implant.
Another examp7_e of a field used fo r a specific step in
the surgical procedure is associated with the validate
image display page 236. An illustrated description
field 366 overlays the unselected image content field 358a
in order to identify anatomical reference points used to
verify the alignment of the calibrated instrument with the
calibrated fluoroscopic. image (displa.yed in image content
field 358b}. More specifically, the illustrated
description field 358a displays arrows indicating points
suggested by the expert system to be used to validate the
fluoroscopic image. The surgical team places a calibrated
instrument 118 on corresponding anatomical features of the
patient. As the surgical team places the calibrated
instrument (the U-handle with the awl tip, for example)r
the CAS computes a position of the awl tip with respect to
the image to be validated (fluoroscopic image 359b) and the
GUI 112 displays a virtual image of v.he instrument on the
fluoroscopic image 359b. The actual location of the
calibrated instrument is then compared with the virtual
representation ov the instrument on the fluoroscopic
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imacxe 359b. If the actual location of the calibrated
instrument 118 at t:~e plurality of poieas on the part of
the patient is indistinguishable from the position of the
virtual representation of the instrument. on -the image to be
validated, the image is validated and can be used for
surgical purposes. The surgical team 220 accepts the
validated image by pressing the affirmation action
button 302. Alternatively, an audio tone may be sounded to
indicate that the validated image has been saved.
The invention therefore provides an expert system
driven graphical user interface that facilitates surgical
procedures by guiding a surgical team through a surgical
procedure, while providing critical information respecting
the calibrations of the system, preparation of the implant
site~ and placement of implants.
The embodiments) of the invention described above
is(are) intended to be exemplary onlyr The scope of the
invention is therefore intended to be :L.imited solely by the
scope of the appen~ed claims.
