Interview Questions for Image-Guided Therapy

Image registration in Image-Guided Therapy (IGT) is the process of aligning images from different modalities or from the same modality at different times. Think of it like matching up two puzzle pieces – we need to precisely overlay images of the patient’s anatomy taken from different sources to create a single, comprehensive view. This is crucial because the treatment plan is often created using one imaging modality (pre-operative CT scan, for example), while the intervention is guided by a different modality in real-time (fluoroscopy during the procedure). Accurate registration ensures that the planned treatment is delivered to the correct location.

The process involves identifying corresponding points (landmarks) in the different images and using mathematical algorithms to calculate the transformation that aligns them. These algorithms can be complex, involving rigid-body transformations (rotation and translation) or more sophisticated deformable registrations to account for tissue movement.

For instance, imagine a neurosurgeon planning a brain biopsy. A pre-operative MRI shows the tumor’s location. During the surgery, the surgeon uses a fluoroscopy system to guide the needle. Image registration aligns the MRI with the real-time fluoroscopy images, allowing the surgeon to see precisely where the needle is relative to the tumor in real-time.

Several imaging modalities are used in IGT, each with its strengths and weaknesses. These include:

• Fluoroscopy: Uses X-rays to produce real-time images of the patient’s anatomy. It’s excellent for visualizing bones and contrast agents, making it ideal for guiding needle placements and catheter insertions.
• Computed Tomography (CT): Provides high-resolution cross-sectional images of the body. CT scans are valuable for pre-operative planning and for visualizing dense structures.
• Magnetic Resonance Imaging (MRI): Offers superior soft tissue contrast, allowing excellent visualization of organs and tissues. MRI is frequently used for pre-operative planning, especially in neuro-interventions, where visualizing subtle anatomical details is crucial.
• Ultrasound: Uses sound waves to create real-time images. It’s non-ionizing, portable, and relatively inexpensive, making it useful for various procedures, including biopsies and regional anesthesia.

Each imaging modality has limitations:

• Fluoroscopy: High radiation exposure, limited soft tissue contrast.
• CT: Relatively high radiation dose, motion artifacts can be a problem.
• MRI: Long scan times, sensitive to patient motion, contraindicated for patients with certain metallic implants.
• Ultrasound: Image quality is operator-dependent, limited penetration depth, struggles with bone and air.

These limitations need to be carefully considered when selecting the imaging modality for a specific IGT procedure. Often, a combination of modalities is used to leverage the strengths of each while mitigating their weaknesses.

Image-guidance systems vary widely in their complexity and capabilities. They can range from simple fluoroscopy systems with basic image manipulation capabilities to sophisticated systems integrating multiple imaging modalities, advanced registration algorithms, and robotic assistance.

Simpler systems might consist of a C-arm fluoroscopy unit with a monitor, allowing the physician to view the images in real-time and manually adjust the instrument position. More advanced systems may incorporate intraoperative CT or MRI, 3D visualization software, and even robotic arms for precise instrument control. The choice of system depends greatly on the type of procedure, the level of precision required, and the available resources.

For example, a minimally invasive spine surgery might use a system integrating fluoroscopy and CT, while a complex neurosurgical procedure might require a system with intraoperative MRI and robotic assistance.

Fiducial markers are small, radiopaque markers (often metallic) surgically implanted in the patient’s body prior to the procedure. They serve as easily identifiable landmarks in the images, aiding in accurate image registration. Think of them as reference points that are common across different imaging modalities and time points. The position of these markers allows the system to align the pre-operative plan with the real-time images, improving the accuracy of treatment delivery.

In a liver biopsy, for example, fiducial markers might be placed near the target lesion. During the procedure, the surgeon can track the position of the needle relative to the markers, improving the accuracy of the biopsy.

My experience encompasses a broad range of image-guided interventions, including:

• Neuro-interventions: Stereotactic biopsies, minimally invasive neurosurgery, aneurysm coiling, and thrombectomy.
• Cardiovascular interventions: Cardiac catheterization, angioplasty, and stent placement.
• Oncology interventions: Radiofrequency ablation, brachytherapy, and biopsies of various tumors.
• Orthopedic interventions: Image-guided joint injections and minimally invasive orthopedic procedures.

Each procedure requires a specific approach to image acquisition, processing, and guidance, and necessitates a deep understanding of the underlying anatomy and pathology.

Patient safety is paramount in IGT. Several strategies are employed to ensure patient safety:

• Minimizing radiation exposure: Using low-dose imaging techniques, employing pulse fluoroscopy, and shielding critical organs.
• Accurate image registration: Ensuring precise alignment of images to minimize the risk of misplacement of instruments.
• Proper sterile technique: Adhering to strict sterilization protocols to prevent infection.
• Monitoring vital signs: Continuously monitoring patient’s heart rate, blood pressure, and oxygen saturation.
• Emergency preparedness: Having plans in place to address potential complications and emergencies.
• Thorough pre-procedural planning: Carefully reviewing the patient’s medical history and imaging studies to identify potential risks and contraindications.

A multidisciplinary approach involving physicians, nurses, and technologists is crucial in ensuring patient safety throughout the entire procedure.

Image-guided therapy (IGT), while offering minimally invasive advantages, carries inherent risks. These can be broadly categorized into those related to the procedure itself, the imaging modality used, and the patient’s underlying condition.

• Procedure-related risks: Bleeding, infection, nerve damage, perforation of organs (depending on the target area), pain, and allergic reactions to contrast agents are possibilities. The risk profile varies significantly based on the specific procedure (e.g., biopsy vs. brachytherapy).
• Imaging-related risks: Radiation exposure is a concern with modalities like fluoroscopy and CT. Although doses are kept as low as reasonably achievable (ALARA principle), cumulative radiation exposure over multiple procedures can pose long-term risks. Allergic reactions to contrast agents are also a possibility.
• Patient-related risks: Pre-existing conditions, such as bleeding disorders or compromised immune systems, increase the likelihood of complications. Patient-specific factors like body habitus (size and shape) can also influence risk.

For example, during a liver biopsy guided by ultrasound, the risk of bleeding is higher than in a bone biopsy because of the liver’s vascularity. Minimizing these risks requires meticulous planning, careful execution, and a comprehensive understanding of the patient’s medical history.

Managing unexpected events during an IGT procedure requires immediate action and a well-rehearsed protocol. The response is heavily dependent on the nature of the complication.

• Bleeding: Immediate pressure application, potentially followed by angiographic embolization if necessary, is crucial.
• Infection: Prophylactic antibiotics are typically administered pre-procedure, and post-procedure antibiotic therapy is initiated if an infection develops.
• Organ perforation: Depending on the organ and extent of damage, surgical intervention might be required.
• Nerve damage: Immediate cessation of the procedure is necessary, and the patient’s neurological status needs to be closely monitored.

A multidisciplinary approach is often needed. In situations involving severe complications, the procedure might be aborted, and consultation with specialists such as surgeons or interventional radiologists might be necessary. Post-procedure monitoring is essential to assess the patient’s recovery.

For instance, if unexpected bleeding occurs during a percutaneous kidney stone removal, immediate pressure would be applied, and if bleeding persists, embolization using interventional radiology techniques may be performed to stop the bleeding.

My experience with image-guided biopsies spans a wide range of organs and pathologies. I’ve performed numerous biopsies guided by ultrasound, CT, and MRI, obtaining samples from the liver, kidney, lung, prostate, breast, and lymph nodes. The key to success in biopsy procedures lies in precise needle placement, which is heavily reliant on accurate image interpretation and meticulous technique.

For example, in a liver biopsy guided by ultrasound, I use real-time imaging to visualize the needle’s trajectory, ensuring it avoids major blood vessels and reaches the target lesion. This minimizes the risk of bleeding and maximizes the yield of diagnostic tissue.

Proper patient positioning, selection of appropriate needle size and type, and careful attention to anatomical landmarks are crucial steps. Post-procedure monitoring for complications like bleeding and infection is also paramount.

Image-guided brachytherapy involves placing radioactive sources precisely within or near a tumor. My experience encompasses both external beam and interstitial brachytherapy techniques, predominantly using CT and fluoroscopy for guidance. Accurate placement of the radioactive sources is paramount to maximizing tumor dose while minimizing radiation exposure to surrounding healthy tissues.

For example, in prostate brachytherapy, CT scans are used to create a three-dimensional map of the prostate, allowing for precise calculation of seed placement. Fluoroscopy is used during the procedure to verify the position of each seed in real-time.

Careful planning, including dosimetry calculations and 3D treatment planning, is critical to ensure the effectiveness and safety of the procedure. Radiation safety protocols are stringently adhered to throughout the process, minimizing exposure to both patients and healthcare professionals.

Interpreting imaging data to guide interventions requires a deep understanding of anatomy, pathology, and imaging physics. I utilize multi-planar reconstructions (MPRs), 3D visualizations, and other advanced imaging techniques to create a comprehensive understanding of the target and surrounding structures.

For example, in a minimally invasive surgery guided by fluoroscopy, I interpret the real-time images to assess the location and size of the target tissue. This visual guidance ensures that the surgical instruments are accurately placed and the procedure is performed safely and effectively.

The process frequently involves fusion of data from multiple imaging modalities (e.g., CT and fluoroscopy) to enhance accuracy and visualization. This helps me precisely navigate instruments around critical structures, minimizing the risk of complications. Software tools like image registration and navigation systems greatly assist in this process.

Planning an image-guided procedure is a multi-step process that begins with a comprehensive assessment of the patient and their condition.

1. Patient Assessment: Review medical history, imaging studies (e.g., CT, MRI, ultrasound), and laboratory results to determine suitability for the procedure and identify potential risks.
2. Image Acquisition: Appropriate imaging modality (CT, MRI, ultrasound, fluoroscopy) is selected based on the anatomy and the nature of the procedure.
3. Target Identification and Planning: Careful analysis of imaging data to precisely locate the target lesion and plan the optimal approach for intervention. This often involves using specialized software for 3D planning and simulation.
4. Procedure Simulation: In some cases, virtual simulation of the procedure is performed to predict potential challenges and refine the approach. This is particularly valuable for complex cases.
5. Equipment Preparation and Setup: Ensuring that all necessary equipment (e.g., needles, catheters, imaging systems) is available and correctly calibrated.
6. Radiation Safety Check: Verifying that appropriate radiation safety protocols are in place and the ALARA principle is followed.

This systematic approach helps minimize complications and increases the chances of a successful outcome. It’s important to keep adapting the plan based on the findings during the procedure itself, which is where real-time image guidance plays a critical role.

Radiation safety is of paramount importance in IGT. We strictly adhere to the ALARA principle – As Low As Reasonably Achievable – to minimize radiation exposure to both patients and healthcare personnel. This involves:

• Lead Shielding: Using lead aprons, gloves, and other shielding materials to reduce radiation exposure.
• Distance: Maintaining a safe distance from the radiation source whenever possible.
• Time: Limiting the duration of radiation exposure by using pulsed fluoroscopy and minimizing the use of high-dose imaging techniques.
• Optimization of Imaging Techniques: Employing techniques such as low-dose fluoroscopy and image intensification to minimize radiation while maintaining image quality.
• Dosimetry: Using dosimeters to monitor the radiation dose received by personnel.
• Regular Equipment Calibration and Maintenance: Ensuring that the imaging equipment is functioning properly and delivering the appropriate radiation dose.

Radiation safety training and adherence to established protocols are mandatory for all staff involved in IGT procedures. Regular audits and assessments ensure compliance and identification of potential areas for improvement. For example, the use of dose tracking software and radiation safety monitoring tools significantly helps us in maintaining a safe working environment and reducing the collective effective dose.

Ensuring accuracy and reliability in image-guided therapy (IGT) systems is paramount. It’s a multi-faceted process involving rigorous calibration, quality control, and validation at every stage. Think of it like building a high-precision instrument – each component needs to be meticulously checked.

• Calibration: We regularly calibrate all imaging equipment (e.g., fluoroscopy, ultrasound, CT) using standardized phantoms and procedures. This ensures the accuracy of image registration and measurements. For instance, we might use a phantom with known dimensions to verify the accuracy of the system’s spatial measurements.
• Image Registration: Precise image registration – aligning images from different modalities or time points – is critical. We use sophisticated algorithms and techniques to ensure accurate fusion of images. Incorrect registration could lead to inaccurate targeting of a lesion, for example. We regularly assess registration accuracy by comparing registered images with known anatomical landmarks.
• Quality Control (QC): Routine QC checks involve testing the entire imaging chain – from image acquisition to display – using test patterns and phantoms. This allows us to detect and address potential malfunctions before they impact clinical procedures. Daily QC checks are often mandatory for crucial parameters like image resolution and distortion.
• Validation: Regular validation studies ensure the system meets performance specifications. This may involve measuring things like accuracy, precision, and resolution, possibly with clinical data or simulated scenarios. This level of validation ensures the system meets our expectations over time and with changes.

By employing these strategies, we minimize the risk of errors and ensure the highest level of patient safety and treatment efficacy.

My experience with image-guided navigation software spans several years, involving various platforms for different applications like neurosurgery, interventional radiology, and orthopedics. I’m proficient in using software for image fusion, 3D reconstruction, and trajectory planning. I’ve worked with both commercially available systems and research-based software platforms.

For example, I’ve extensively used software to plan complex trajectories for minimally invasive procedures, such as placing screws in a precisely determined location within the spine, guided by pre-operative CT or MRI images. The software allows for real-time tracking of instruments and provides feedback on the accuracy of placement. This minimizes the invasiveness and maximizes precision, crucial factors in patient outcomes.

I’m also familiar with programming aspects of some navigation software, enabling customization for specific clinical needs and integration with other medical devices. This customization ability is very valuable in streamlining workflows and optimizing treatment delivery.

3D image reconstruction is a fundamental aspect of IGT. It involves creating a three-dimensional representation of an anatomical structure from multiple two-dimensional images (e.g., CT scans, MRI slices). This is similar to assembling a jigsaw puzzle but with sophisticated mathematical algorithms.

Several techniques are employed, including:

• Volume Rendering: This technique assigns different opacities or colors to voxels (volume elements) based on their intensity values, creating a 3D representation that can be rotated and viewed from different angles. This is widely used for visualizing soft tissues.
• Surface Rendering: This approach identifies and extracts surfaces from the volumetric data, creating a 3D surface model. It’s particularly useful for visualizing bones and organs with well-defined boundaries.
• Maximum Intensity Projection (MIP): MIP selects the maximum intensity value along each ray to create a projection image, enhancing the visibility of high-intensity structures like blood vessels.

The choice of reconstruction technique depends on the specific clinical application and the type of image data available. The quality of the 3D reconstruction is crucial for accurate surgical planning and guidance. Artifacts and inaccuracies in reconstruction can lead to errors in treatment.

Robotic-assisted IGT offers several advantages, enhancing precision, reducing invasiveness, and potentially improving patient outcomes. However, limitations also exist.

• Benefits:
  • Enhanced Precision: Robots offer sub-millimeter accuracy in instrument placement, surpassing the capabilities of human hands. This is crucial in delicate procedures such as neurosurgery.
  • Minimally Invasive Procedures: Smaller incisions are often possible, leading to less trauma, reduced pain, and faster recovery.
  • Improved Repeatability: Robotic systems can perform repetitive tasks with high consistency, minimizing human error.
  • Enhanced Surgeon Ergonomics: The surgeon controls the robot from a console, potentially improving comfort and reducing fatigue.
• Limitations:
  • Cost: Robotic systems are expensive to purchase and maintain.
  • Complexity: Operating robotic systems requires specialized training and expertise.
  • Technical Challenges: System malfunctions or software glitches can disrupt procedures.
  • Limited Dexterity: In some scenarios, the robot’s dexterity may be limited compared to the human hand.

The decision of whether or not to use robotic assistance in IGT depends on several factors, including the type of procedure, the patient’s condition, and the availability of resources. For example, robotic systems are frequently used in complex neurosurgical procedures, where high precision and minimal invasiveness are critical but might not be as common for simpler procedures.

Effective communication within the IGT team is critical for patient safety and procedural success. It’s a collaborative effort, and open, clear communication is crucial. Imagine a well-orchestrated symphony – each instrument plays its part, coordinated by the conductor (the lead surgeon/physician).

We use a multi-faceted approach:

• Pre-operative Planning: Detailed discussions involve reviewing patient data, outlining the procedure’s goals, and assigning roles and responsibilities.
• Real-time Communication: During the procedure, we maintain constant communication, using a combination of verbal updates, visual cues, and shared displays.
• Structured Communication Protocols: We follow standard protocols for reporting critical events, changes in the patient’s status, and any unexpected findings.
• Documentation: Meticulous documentation is essential for maintaining a clear record of the procedure and facilitating knowledge transfer.
• Post-procedural Debriefing: After the procedure, we conduct a debriefing session to review what went well, identify areas for improvement, and share learning points.

Building trust and rapport within the team is paramount. Respect for everyone’s expertise and contributions fosters a safe and collaborative environment.

Quality assurance (QA) and quality control (QC) are integral to ensuring the safety and effectiveness of IGT. It’s a continuous process aiming to maintain the high standards of quality throughout the entire process, from equipment to personnel performance. Think of it like regular maintenance for your car – necessary for its optimal performance and longevity.

My experience includes:

• Equipment QA: This involves regular calibration, preventative maintenance, and performance testing of all imaging and navigation equipment, adhering to manufacturer’s recommendations and regulatory guidelines.
• Software QC: Software updates, validation, and verification procedures are meticulously followed. This ensures the software is functioning correctly and safely.
• Procedural QA: We review and improve procedures to optimize workflow and minimize errors. We regularly analyze data for quality indicators, like procedure times and complication rates.
• Personnel Training: Regular training programs for staff ensure competency in using equipment, following protocols, and maintaining high standards.
• Compliance: We maintain strict adherence to regulatory requirements and guidelines, ensuring compliance with relevant safety and quality standards.

By prioritizing QA and QC, we continuously strive to improve the quality of IGT services and enhance patient safety.

Staying current in the rapidly evolving field of IGT requires continuous effort and a multi-pronged approach.

• Professional Societies and Conferences: Active participation in professional societies like the Society for Interventional Radiology (SIR) and attending international conferences allows access to cutting-edge research and technological advancements.
• Peer-Reviewed Journals: Regularly reviewing leading journals in the field ensures I remain informed about the latest research findings and clinical practices. This includes both methodological advances and clinical outcome studies.
• Online Resources and Continuing Education: Utilizing online learning platforms and participating in continuing medical education (CME) courses helps maintain and update existing skills and knowledge.
• Collaboration and Networking: Networking with colleagues and researchers in the field facilitates the exchange of information and fosters collaborative efforts. This includes attending workshops and sharing ideas with peers.
• Hands-on Experience: Participating in workshops and courses offering hands-on experience with new equipment and techniques is invaluable for practical application of new knowledge.

This combination of formal and informal learning ensures that my knowledge and skills remain current and allow me to effectively adopt new technologies and approaches in IGT.

One of the most challenging cases I encountered involved a patient requiring a transarterial chemoembolization (TACE) for a hepatocellular carcinoma (HCC) located in a highly vascularized segment of the liver. The tumor was close to major hepatic veins and bile ducts, making precise placement of the embolic agents critical to avoid complications such as hepatic vein thrombosis or bile duct injury.

Overcoming this challenge involved a multi-pronged approach. First, we utilized a combination of high-quality CT angiography and 3D rotational angiography to obtain a detailed three-dimensional map of the hepatic vasculature. This allowed us to precisely identify the target tumor vessels and their relationship to adjacent structures. Second, we employed a microcatheter system capable of navigating the complex anatomy of the liver with precision. Third, we used a slow, controlled injection technique of the embolic agent combined with real-time imaging monitoring to meticulously observe the distribution and to immediately respond to any potential issues. Careful post-procedural monitoring with repeat imaging was essential to detect any complications. Through this careful planning and precise execution, we successfully achieved complete tumor embolization with no major complications.

Image fusion in Image-Guided Therapy (IGT) is a crucial technique that integrates data from multiple imaging modalities to create a single, unified view. Imagine trying to assemble a jigsaw puzzle with only a few pieces – it’s difficult! Image fusion is like providing you with all the pieces, but more importantly, it shows you how those pieces fit together.

Commonly used modalities include CT, MRI, and fluoroscopy. For example, a pre-operative CT scan provides high-resolution anatomical details, while intra-operative fluoroscopy shows the real-time position of the interventional tools. Image fusion software aligns these images, overlaying the static anatomical information onto the dynamic fluoroscopic image. This allows the clinician to accurately target the lesion and track the position of the interventional devices in relation to the anatomy during the procedure. Different fusion techniques exist, from rigid registration (assuming minimal movement between scans) to deformable registration (accounting for tissue movement and deformation).

The benefits are numerous: improved accuracy in targeting lesions, reduced procedure times, and lower risk of complications. Think of it as having a GPS system for your interventional devices, providing continuous guidance during the procedure.

My experience encompasses a wide range of interventional needles and catheters, chosen based on the specific procedure and patient anatomy. For example, in neurointerventional procedures, microcatheters with varying lengths, diameters, and tip designs are used to navigate the complex vasculature of the brain. The choice depends on the vessel size, tortuosity, and the desired location of the treatment. In oncology, specialized needles are used for biopsy or ablation procedures, with features such as coaxial designs or stylet-guided access enabling precise puncture and tissue sampling.

Furthermore, I’m familiar with catheters designed for delivering embolic agents, balloons for angioplasty, and specialized needles for delivering drugs or radioisotopes. Selection criteria always include considering the patient’s anatomy, the target location, and the desired outcome. For instance, stiffer catheters might be preferred for accessing tortuous vessels, while softer, more flexible catheters are used for navigating more delicate vasculature. The choice of material (e.g., polyurethane, PTFE) also influences the catheter’s properties, like flexibility and biocompatibility.

I am highly proficient in using various image-guided navigation systems, from basic fluoroscopy-based systems to advanced robotic and augmented reality systems. My experience includes using systems that provide real-time 3D visualization of the anatomy, tracking of instruments, and guidance for accurate placement of interventional devices. I am comfortable with both pre-operative planning using these systems and intra-operative guidance and control.

For example, I routinely use navigation systems to plan and execute procedures like biopsies, drain placements, and tumor ablations. The systems calculate the optimal trajectory for the needle or catheter, minimizing the risk of injury to critical structures and improving the accuracy of the intervention. This minimizes invasiveness and improves the therapeutic outcome. Furthermore, I regularly use advanced visualization tools, such as 3D reconstructions and virtual reality simulations, to enhance procedural planning and execution. Continuing education and hands-on experience keep my skills sharp and up-to-date with the latest technological advancements in this rapidly evolving field.

Managing and interpreting data from image-guided systems involves a combination of technical expertise and clinical judgment. The process starts with acquiring high-quality images, ensuring proper image registration and fusion. Then, the data is analyzed visually by carefully examining anatomical structures and correlating them with the procedural goals. Quantitative data, like measurements of distances or angles, may be obtained and analyzed using the system’s software. This is particularly valuable when planning complex procedures.

Beyond visual interpretation, the data needs to be correlated with the patient’s clinical history, physical examination findings, and other relevant laboratory results. For example, while an image may show a lesion, the overall clinical picture is crucial to determine the best course of action. After a procedure, careful review of the post-procedural images confirms successful placement of devices and assesses any potential complications. All data, including procedural notes and images, are meticulously documented according to established clinical protocols for future reference and quality assurance. This ensures that future decisions can leverage prior experience.

Regulatory requirements for IGT procedures are stringent and designed to ensure patient safety and the quality of care. These regulations vary depending on the specific procedure and the governing body (e.g., FDA in the US, EMA in Europe). Key aspects include equipment safety and performance standards, operator training and certification, and adherence to established protocols for infection control and sterilization. Documentation of the entire process, including image acquisition, data management, and procedural steps, is crucial to satisfy audit requirements.

Specific regulations might cover aspects such as the validation of image-guided systems, the use of specific software and hardware components, and quality assurance procedures for maintaining equipment accuracy and reliability. As a practitioner, I meticulously follow all established protocols and ensure that all equipment is regularly inspected and calibrated to meet safety standards. Compliance is not just a regulatory requirement but a cornerstone of providing safe and effective care.

My experience with image-guided surgical robots is growing, with particular exposure to systems used in minimally invasive surgery and interventional radiology. These robots provide enhanced precision, dexterity, and control compared to traditional manual techniques. For example, robotic systems are used in various procedures including prostate biopsies, minimally invasive cardiac procedures, and neurosurgery. They offer advantages such as smaller incisions, reduced trauma, and improved visualization via their image-guided interface.

Specific systems I’ve encountered provide haptic feedback, allowing the surgeon to ‘feel’ the tissue during the procedure, and advanced visualization capabilities, offering three-dimensional reconstructions and real-time guidance overlays. While each system has its unique features and capabilities, the common thread is the use of imaging data to enhance precision and safety during minimally invasive procedures. The field of robotic surgery in conjunction with image guidance is continuously evolving with new robotic systems and functionalities being developed which increase precision and reduce invasiveness.