Computer Aided Surgery

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A Full 3D-Navigation System in a Suitcase

W. Freysinger, M. J. Truppe, A. R. Gunkel & W. F. Thumfart

To cite this article: W. Freysinger, M. J. Truppe, A. R. Gunkel & W. F. Thumfart (2001)

A Full 3D-Navigation System in a Suitcase, Computer Aided Surgery, 6:2, 85-93, DOI:
10.3109/10929080109145995

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 Computer Aided Surgery 6:85-93 (2001)

Clinical PaDer
A Full 3D-Navigation System in a Suitcase
W. Freysinger, PH.D., M.J. Truppe, M.D., A.R. Gunkel, M.D., and W.F. Thumfart, M.D.
4 0 Vimalization Laboratory, E h T Clinic, University of Innsbrmck (WF., A.R. G., WF.T.), and
ARTMA CmbH, Vienna @4.3.T.), A m ' a

ABSTRACT Objective: T o reduce the impact of contemporary 3D-navigation systems on the

environment of typical otorhinolaryngologic operating rooms, we demonstrate that a transfer of
navigation software to modem high-power notebook computers is feasible and results in a practi-
cable way to provide positional information to a surgeon intraoperatively.
Materials and Methods: The ARTMA Virtual Patient System has been implemented on a
Macintosh PowerBook G3 and, in connection with the Polhemus FASTRAK digitizer, provides
intraoperative positional information during endoscopic endonasal surgery.
Results: Satisfactory intraoperative navigation has been realized in two- and three-dimen-
sional medical image data sets (i.e., X-ray, ultrasound images, CT, and MR) and live video.
Conclusions: This proof-of-concept study demonstrates that acceptable ergonomics and
excellent performance of the system can be achieved with contemporary high-end notebook com-
puters. Comp Ad Surg 645-93 (2001). 02001 Wiley-Liss, ~ n c .

Kty wordr: augmented reality, ARTMA, frameless stereotaxy, VBH mouthpiece, image-guided
surgery, telepresence

OBJECTIVE
Currently, navigation systems are realized as cabi-
nets of various sizes or trolleys that either reside in
the operating room (OR) or are wheeled into the
OR when required. Introduction of such naviga-
tional equipment into the OR consumes valuable
space due to the physical dimensions of the de-
vices. For otorhinolaryngologic surgery, the stan-
dard setup is such that the surgeon, an assistant, and
the nurse are clustered around the patient's head,'
while the light source, video tower, instrumentation
table, suction-irrigation unit, and anaesthesiologic
equipment are placed in close proximity to the
patient (see Fig. 1). With the introduction of com-
puter-aided surgery techniques to neurosurgery2-5
and Ear, Nose and Throat (ENT) surgery,6 and
especially to video-endoscopic surgery of the para-
nasal sinuses,7.*the navigation unit and its operator
joined the surgical team.
In all surgical disciplines, contemporary in-
traoperative navigation is accomplished by means
of passive or active optical position sensing de-
vices like the Optotrak (Northern Digital, Inc.,
Waterloo, Ontario, Canada, http://www.ndigital.
com), FlashPoint (IGT, Inc., Boulder, CO, http://
www.imageguided.com) or similar devices. De-
pending on the technological solution chosen,
optical digitizers may be quite voluminous. If a
stationary setup of the navigation system in the
OR is chosen with the infrared cameras mounted
on the ceiling above the operating table,9 flexi-

~~ ~

Received August 18, 2000; accepted January 23, 2001.

Address correspondencelreprint requests to: Dr. Wolfgang Freysinger, 4D Visualization Laboratory, ENT Clinic, University
of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. E-mail: wolfgang.freysinger@uibk.ac.at.
This article is based on a presentation given during CARS '99, Paris, France, June 23-26, 1999.
02001 Wiley-Liss, Inc.
86 Freysinger et al.: A Full 3D-Navigation System in a Suitcase
Fig. 1. Our current standard setup for navigated endo-
scopic sinus procedures with application of the Zeiss STN
system (Carl Zeiss, Oberkochen, Germany). The navigation
unit (right) is placed close to the video tower (center), while
the bar of the optical digitizer is placed so as to view the
infrared-emitting diodes of the measuring probe and of the
dynamic reference frame (sterile draped, faintly visible at
the top of the patient's head), even when the suction-
irrigation endoscope is inserted into the paranasal sinuses of
the patient. Note the close proximity of the 3D-navigation
unit and its operator to the sterile nurses' tables to provide
optimum visibility of the axial, coronal, sagittal, and mul-
tiplanar reformatted CT images for the surgeon.
bility of the intraoperative setup is lost and in-
traoperative patient positioning is restricted to
one position. Thus, the range of possible surger-
ies becomes limited.
Until now, systems with magnetic three-di-
mensional (3D) position sensing devices have been
rare: examples include the Cygnus System"
(COMPASS International, Inc., Rochester, MN,
http://www.compass.com) for neurosurgery in con-
nection with a stereotactic frame and the InstaTrack
System of VtI (Woburn, MA), which is dedicated
to functional endoscopic sinus surgery.11-13 Re-
cently, the Nicolet system has become available for
ENT procedures.14 This list is not intended to be
complete and should be used as a starting point
only.
Selecting a magnetic digitizer provides a
technological solution that consumes the least
space intraoperatively. However, the price for this
is the need to carefully choose instrumentation and
metallic/magnetizable elements15J6 in the surgical
environment (see below).
To overcome these shortcomings and build a
proof-of-concept system that seamlessly integrates
into existing OR equipment, we decided to use the
ARTMA MedScanII software (ARTMA Inc., Vi-
enna, Austria, http://www.artma.com) in connec-
tion with a magnetic digitizer (FASTRAK, Pol-
hemus, Inc., Colchester, VT, http://www.polhemus.
com) running on a high-end notebook computer.
MATERIALS AND METHODS
Hardware
The platform for the MedScan I1 software is a
Macintosh PowerBook computer, G3 series
(Macintosh Inc., Cupertino, CA, http://www.apple.
com) with an 8 GB hard disk, 292 MHz tact rate,
192 MB RAM,4 MB video RAM, 10 base T
Ethernet, 2 PC card slots, S-VHS out, VGA out,
serial and SCSI interfaces. The software runs under
the operating system 0 s 9. The computer can be
connected to the FASTRAK digitizer through the
serial port, and to the live endoscopic video (com-
posite or Y/C) with a Capsure PC Videocard (PAR
Technologies, Scottsdale, AZ, http://www.irez.
com). The Zoomed Video Card can handle S-VHS
and composite video signals in all norms (NTSC,
PAL, SECAM).
The magnetic digitizer can handle up to four
probes simultaneously with an update rate of 30 Hz
per receiver and spatial and angular resolutions of
0.38 mm and 0.025" over a working range of 760
mm, respectively, and static spatial and angular
accuracies of 0.8 m and 0.15", respectively. The
probes of the FASTRAK digitizer can be gas ster-
ilized with ethylene oxide. So far, we have reached
approximately 60 sterilization cycles without any
impairment of function. The origin of the magnetic
field, the emitter cube (with side length of approx-
imately 6 cm), is placed close to the patient's head
on the operating table (see below).
Other Equipment for Navigation
To provide safe navigation with the magnetic digi-
tizer we had to replace the metallic headrest with a
wooden one.17 Recently, a dedicated operating ta-
ble with a nonmagnetic head part made of radiolu-
cent plastic has been developed by the authors in
close cooperation with the manufacturer, Brumaba
(Hartkirchen, Germany). The emitter cube is placed
on the headrest of the dedicated OR table close to
the patient's head and secured with surgical tape.
This simply serves to to prevent it from falling to
the ground, and to keep it in the volume recom-
mended for surgery (a sphere with radius of ap-
proximately 75 cm).'*J9
For our video-endoscopic procedures, we use
standard equipment: 4-mm rigid 0" and 25" endo-
scopes in a suction-irrigation handpiece (Richard
Wolf, Knittlingen, Germany), a three-chip camera,
video modules, and illumination from Storz (Karl
Storz, Tuttlingen, Germany).
 Frysinger et al.: A Full 3D-Navigation System in a Suitcase 87
The assembly of the suction-irrigation endo-
scope, i.e., the endoscope, shaft, three-chip camera,
and suction-irrigation handpiece, is mechanically
stable; it is tracked in space by a sensor that is
mounted on the handpiece by means of a dedicated
structure.20 The sensors can be mounted on the
endoscope assembly within the mechanical toler-
ances of the components, and thus preoperative
registration and operation planning become possi-
ble (see later). Basically, the magnetic sensor is
inserted in one shell, with the cable stowed on the
back, and the shell is fitted onto the handpiece (see
Fig. 2). Once the locking mechanism is engaged, it
is mounted firmly on the video-endoscope (Fig. 3).
The construction is lightweight, rugged, and can be
steam sterilized.
Patient tracking is realized by means of the
VBH mouthpiece” carrying a magnetic sensor.
The VBH mouthpiece is, in brief, an individual
imprint of the patient’s upper dentition securely
attached to the upper jaw by underpressure. If the
device is worn during CT imaging with the two
registration rods in place, it can be used as a tool for
establishing a preoperative patient-to-image regis-
tration. Also, the radiopaque markers attached to
the registration rods serve as stable and well-de-
fined points for intraoperatively registering the pa-
tient to hisher preoperative 3D The
repositioning accuracy of the mouthpiece has been
found to be in the submillimetric range,23 and the
error induced by repositioning the device is well
below the spatial resolution of the digitizer.
In principle, any instrument can be used for
3D navigation, provided that it does not introduce
too large a distortion of the magnetic field as a
Fig. 2. The components of the holder for mounting the
magnetic field sensors on the suction-imgation assembly.
The two halves snugly fit the Wolf suction-imgation hand-
piece in a unique way. The magnetic field sensor and its
cable are placed on one shell by the nurse.
Fig. 3. Complete sterile intraoperative assembly of our
3D-navigated endoscope. The light cable (bottom left) and
a sterile-draped three-chip zoom video camera (Storz, left)
are attached to a Wolf 4-mm endoscope in a suction-irriga-
tion handpiece and a shaft. The irrigation in-out tubes
connect to the two ports on the right of the light cable. To
the right of these components is the button for activating
suction-irrigation. On top of this assembly rests the mag-
netic sensor in the holder.
result of the amount of magnetizable material
present in the surgical field.24A sample instrument,
a straight suction tube, is shown in Figure 5 . In our
experience with magnetic digitizers to date, how-
ever, we have never found standard surgical instru-
ments to exert any influence on the accuracy of 3D
digitizing.
The essential components of the intraopera-
tive setup are shown in Figure 4.
Software
We are using the MedScan 1.2 software from
ARTMA, which allows the presentation of the
“raw” medical images and 3D renderings of the
C T M R data sets. In addition, the software allows
live internet connections to be established to realize
tele-consulting by a remote expert.19
The relevant images and information of a
patient are stored in a “study.” This contains infor-
mation concerning the type of surgery, viz., the
number of tracking sensors used, and their assign-
ments on the patient, the endoscope, a tool, or
similar. First, the patient is assigned a coordinate
system and a sensor, and the available images and
the video camera are placed in this coordinate sys-
tem. Next, the endoscope, the tool, and a measuring
probe are assigned magnetic sensors and coordinate
systems accordingly. Because the positions of all
measuring probes are determined relative to the
source of the magnetic field, the coordinate systems
are linked to the “world.” All of this is done sym-
bolically with icons, the goal being to determine the
88 Freysinger et al.: A Full 3D-Navigation System in a Suitcase
Fig. 4. (a) Preoperative view: the components of the
system as set up in the operating room. The PC is on the
right, and is linked with the video monitor at left and the
camera unit just below. Underneath the camera unit, the
FASTRAK digitizer rests on the light source. The PC and
digitizer communicate via the serial port. The three probes
and the stylus are connected to the digitizer, and the endo-
scope and endoscope lighting are connected. This is the
actual surgeon’s view. The positional information calcu-
lated by the system is displayed on the video monitor. The
resulting overall transformations needed to visual-
ize positions of tools and superimposed graphical
structures in the images used.18 This procedure is
standardized for the types of surgeries used (e.g.,
video-endoscopic, microscopic, or macroscopic),
and it is sufficient to grab the icons of the appro-
priate image and drop it into the proper location
(coordinate system) in the study file. The informa-
tion for an endoscopic endonasal procedure is
shown in Figure 6(b). This action can be compared
to the preoperative steps necessary for other navi-
gation systems, but these steps can be automated, if
so desired. If, for example, a line is assigned to a
straight suction tube tracked by the navigation sys-
tem (see Fig. 5 ) , then the alignment of this line with
the tool needs to be verified and optimized in the
live endoscopic video or two (ideally) perpendicu-
lar still video shots of the tool, on which the line is
overlaid. The latter option is most convenient for
use with the Zoomed Video card.
Basically, intraoperative navigation is real-
ized by correlating the patient with his or her 2D
and 3D data sets and also with two 2D views of the
patient, which are ideally arranged orthogonally to
each other. We currently use a dental splint23 to
define a preoperative patient-image registration
template. A sensor of the magnetic tracker is at-
tached to this in a reproducible manner, and the
complete device is inserted into the patient’s mouth
once general anesthesia is induced. Thereafter, two
orthogonal intraoperative still video images are
shot. The planar patient images are linked to the
patient by means of the Direct-Linear Transforma-
t i ~ n and
, ~ the
~ 3D-CT volume data set is linked to
the patient either with the well-known rigid-body
transformation26 or the Besl-McKay alg~rithm.~’
Patient-to-image registration is done in the usual
way28-31by either touching structures on the ref-
erence element, radiopaque markers, or anatomical
landmarks32 of the ~ a t i e n t ~ 8and
- 3 ~correlating these
3D positions to the appropriate location in the 2D
images or the 3D CT data set of the patient.34In
VBH mouthpiece with a magnetic sensor attached to it is
placed at the headrest of the OR table, beneath the cube
generating the magnetic field. The navigated endoscope can
be Seen in the foreground. (b) Intraoperative view with the
Wolf (Knitdingen, Germany) video unit. To the left of the
video unit, the computer is placed on top of the Polhemus
digitizer, while the pc is connected to the video unit and the
monitor. The patient is already anesthetized, draped, and
washed, and wears the VBH mouthpiece (sterile) with a
magnetic sensor (also sterile) attached to it. The patient’s
head remains fully mobile throughout surgery.
 Freysinger et al.: A Full 3D-Navigation System in a Suitcase 89
Fig. 5. Navigating a suction tube during the removal of
polyps. The magnetic sensor is mounted on a Plexiglas
holder on a standard straight 4-mm sucker. Intraoperatively,
the suction tube’s tip is shown in relation to the preoperative
CT images. The Plexiglas holder of the magnetic probe is
designed so as to provide a mechanically stable mounting
on the suction tube.
principle, the optic system of the endoscope and the
video camera should be calibrated using the DLT25
or Tsai35 or similar algorithms, but this is skipped
when the portable system is used (see later). Once
the quality of the registration is determined intra-
operatively, the system shows the position of tools
like the endoscope or a suction tube as graphical
structures drawn directly on the medical images
used [see Fig. 6(a) and (b)].
The software provides tools for the surgeon
to create guiding and warning structures, which
are displayed on all the medical and other images
used for navigation, as well as in the live video
images.
Preoperative Imaging, Preparation, and
Data Handling
Three-dimensional CT imaging is routinely done
on Siemens Somatom 4 and General Electric scan-
ners readily available in our hospital. Detailed in-
formation about the scanning protocol can be found
elsewhere.I6 In brief, spiral CT-scans are recon-
structed to 1-mm slices and transferred to a surgical
planning station the same day. A DICOM 3.0 server
(Digital Jacket, DesAcc, Inc., Chicago, IL, http://
www.desacc.com) reads the slices coming in from
our PACS system over a 100-base T Ethernet net-
work, and stores them as ACR-NEMA or DICOM
3.0 images for further processing.
Preoperatively, coronal and sagittal images are
calculated from these axial slices, and all the images
(axial, coronal and sagittal) are stored as QuickTime
movies (http://www.apple.comlquicktime) for surgi-
cal navigation. At this point, the gray values of
these movies are carefully chosen to meet the sur-
geon’s needs. Using the same gray values, a 3D
reconstruction of the patient is created for informa-
tional purposes. This surface model is not used
intraoperatively, due to the inherent drawbacks of
perspective distortions when 3D images are dis-
played in two dimensions.16 The CT images for
navigation are created by the VoxMac utility
(ARTMA GmbH, Vienna, Austria). Next, two still
video shots of the patient are made, and transferred
to the navigation system via the Zoomed Video
PCMCIA card.
Once a so-called study of the patient (see
above) is created, all data are transferred from the
planning station via network to the navigation com-
puter.
On the day of surgery, the hardware is placed
in the operating room on or adjacent to the video
unit. It is connected to the standard video tower to
allow direct intraoperative viewing of positional
information on the usual video monitor if desired.
This entire preoperative procedure allows
enough flexibility for data transfer (if problems
with the PACS system should arise), planning and
simulation of the surgery.
LABORATORY STUDY
In the laboratory, the essential functionality was
demonstrated to ensure that all components worked
as expected. The display speed of the live video
was rather slow, but we nevertheless wished to
obtain intraoperative experience. The laboratory
study revealed an unexpected problem with the
display of graphical structures, which can be super-
imposed on the live video images: the present im-
plementation of MedScan in combination with the
Zoomed Video technology does not allow a proper
redraw of the screen presenting the window with
the video images, so the graphical structures dis-
played filled the entire window. As a consequence,
the use of the augmented-reality display had to be
90 Freysinger et al.: A Full 3D-Navigation System in a Suitcase

Fig. 6. (a) Corresponding intraoperative view as shown on the computer monitor. The screen shows the tip of an instrument
as a small circle and a line assigned to it. The system shows the perspective projection of the line (tool) onto the axial CT slice.
This display allows quick and reliable positional information to be obtained from the computer monitor. The specific drawing
parameters of the graphical structures (tool), such as color and line thickness, can be changed to match the surgeon’s needs.
(b) Screenshot of the navigation system showing the underlying graphical definition of the navigational setup with four sensors
and the imaging used (left); positional information as visualized in the axial CT images with a line and a point symbolizing
a suction tube; and a small live endoscopic video window to guarantee continuous live information for the surgeon while he
looks away from the genuine video monitor to the navigation system. The small floating window to the right shows the other
applications running on the computer and can, of course, be hidden.
 Freylsinger et al.: A Full 3D-Navigation System in a Suitcase 91
suspended. We decided to use the system as a
“classical” navigator, which shows the spatial po-
sition inside the patient in relation to the image data
sets acquired preoperatively. The surgeon decides
whether to use lines, structures, or something else
for optimizing his surgical orientation. When the
graphical overlay to the live video was turned off,
the display of the spatial position in the CTMR
images followed the movements of the surgeon
almost in real time, and the display of the video is
almost in real time also.
INTRAOPERATIVE HANDLING AND
EVALUATION
Once the patient is positioned and anesthetized, the
VBH mouthpiece is inserted onto the patient’s up-
per dentition. If a preoperative registration of the
patient exists, this is activated and checked. If not,
registration is performed. Washing and draping of
the patient starts after successfully completing the
registration of all images and 3D data sets to the
patient. Prior to the actual start of surgery, the
surgeon again evaluates the validity of the patient-
to-image registration by touching anatomical land-
marks, fiducial markers, or the VBH mouthpiece,
and comparing the calculated and displayed posi-
tion with the actual one in the images used. Once
this is successfully completed, the surgery com-
mences.
So far, the system has been tested on a few
“simple” cases, for example, first surgeries for the
removal of polyps, where 3D-assisted navigation
was not essential. As a safety measure, we used the
large-scale navigation system as a backup. The
patient information was stored on both machines,
so that switching of hardware could easily be ac-
complished if required. As in the laboratory inves-
tigations, the system performed well when the aug-
mentation of reality was turned off, i.e., when no
graphical structures were overlaid on the live video.
As a consequence, we used the positional informa-
tion relative to preoperative CT images, as shown
in Figure 6. Having completed the initial cases, we
now use the notebook-based 3D system as a,stand-
alone implementation in all cases where 3D navi-
gation is indicated,36 as exemplified on the CT-
images of the patient in Figure 6(a) and (b). This
patient, a 45-year-old male with recurrent massive
polyppis, underwent revision surgery of the para-
nasal sinuses. The application of the system was
successful and provided valuable positional infor-
mation for the surgeon.
RESULTS AND DISCUSSION
All applications of the 3D-navigation system based
on the Macintosh G3 PowerBook computer were
successful intraoperatively. In all cases, we could
achieve a satisfactory navigation of the endoscope
or the navigated probe in the preoperative data set
of the patient. The clinical accuracies determined
were in the millimetric range, which is comparable
with the accuracies of the other navigation systems
we have used, such as the Zeiss STN and MKM
systems, the Philips EasyGuide, and the ISG/
ELEKTA Viewing Wand.
For a system like the ARTMA system, which
allows unrestricted mobility of the patient’s head
intraoperatively, special care must be taken to as-
sure a spatially constant relationship between the
3D sensor mounted on the endoscope and the ori-
entation of the video camera.
Due to the construction of the C-mount three-
chip video camera on the endoscope, rotations of
the camera along the axis of the endoscope are
possible. As we did not overlay any graphics on the
live endoscopic video, this is not critical. However,
if superposition of graphical structures on the live
endoscopic video is required, a reliable mechanical
fixation of the camera head on the endoscope will
be needed.
For our setup and the instruments used (typ-
ical small and thin ENT tools: suction tubes,
Blakesly forceps, etc.; see Fig. 5), the Polhemus
digitizer implemented did not have any significant
influence on the performance of the system and its
accuracy. Intraoperatively, no effect could be de-
tected. As an intraoperative test environment, a
graphical structure (a dot or line) was attached to a
tool or the pointer and visualized in the medical
images. Within the specified measuring volume,
the point did not drift away from the tip of the tool.
This means that the perturbations induced by the
magnetizable materials we use are small, and hence
magnetic digitizing can be used for ENT videoen-
doscopic procedures. This is a rather qualitative
statement, but more detailed investigations are un-
der way and will be published in due course.
In the course of our clinical applications of
the system, we did not encounter any patients with
excessive dental fillings or dental work. Qualita-
tively, however, the amount of magnetizable mate-
rial in dental work is much less than the amount of
metal in a tool like a suction tube. Nevertheless,
this issue deserves special attention, because the
presence of magnetizable masses close to a sensor
of the magnetic digitizer could have a significant
92 Freysinger et al.: A Full 3D-Navigation System in a Suitcase
influence on the tracking accuracy of the 3D digi-
tizer.
It may also become problematic if clamps for
holding surgical drapings or cables of instruments
are placed directly over the source of the magnetic
field positioned at the head of the patient. This was
detected on occasions when the quality of the pa-
tient-to-image registration deteriorated suddenly
after sterile draping was completed. The MedScan
I1 system does not need patient fixation, and thus
movements of the head are not problematic; the
mounting of the 3D sensor to the patient is reliable
and stable. Careful inspection of the surgical site
revealed a clamp on top of the cube generating the
magnetic field. Removal of this clamp restored the
original good registration parameters.
In the course of our intraoperative evaluation,
we evaluated several different ways of displaying
navigational information for the surgeon. These
included the following:
1. A large 21-inch high-resolution computer
monitor next to the endoscopic video mon-
itor. This approach can provide full naviga-
tional information, but is too heavy and
destroys the idea of a navigation system in a
suitcase.
2. Switching of the endoscopic video monitor
to full-featured navigation display. This pro-
vides too much information on the video
display with its relative low resolution and
can be potentially dangerous for the patient.
3. The notebook display next to the endo-
scopic video monitor on the video unit. On
the display, axial (or coronal or sagittal)
slices and tool position information are
shown. However, the surgeon still needs to
look away from the video monitor, if only
slightly.
4. We found the fourth solution to be the most
convenient one: on the PC display, a display
similar to that in approach 3 is chosen with
a small window showing the live endo-
scopic video [see Fig. 6(a) and (b)].
Of course, the display setup chosen can be
changed at the demand of the surgeon, F t our
intention was to find the most suitable setup for
presentation of positional information during 3D-
assisted endonasal video-endoscopic surgery. We
therefore typically use the last setup for intraoper-
ative navigation with the “navigation system in a
suitcase.” The last visualization modality, however,
can be integrated seamlessly with the use of a
head-up display (work in progress).
Our solution is designed as a proof of con-
cept. Before this system can enter widespread use,
the handling of the intraoperative video in which
augmented-reality features are created needs fur-
ther refinement: the digitization of the video fed
into the system is currently too slow, and causes a
lag between the real action of a surgeon and the
appropriate video display. Implementation of a
standard digital video linked to the workstation via
a “firewire” connection is considered to be useful.
These initial results are promising, and we
will pursue this route further. It will eventually lead
to the design of a 3D navigation system that opti-
mally integrates into the operating room (and ide-
ally the video tower in standard use) and provides
maximum information to the surgeon. To realize
this, we will have to solve problems associated with
the display of graphical structures on the live video,
possibly by using the now-emerging digital firewire
video standard. As a next step, the user interface
will need refinement to gain simplicity and to per-
mit use of the MedScan system on both the note-
book computer and the large-scale system on a
daily routine basis.
ACKNOWLEDGMENT
This work was supported by the Jubilee Fund of the
Austrian National Bank under grant No. 7188.
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