Systems and methods for using registered fluoroscopic images in image-guided surgery

Abstract

To provide a medical system.SOLUTION: A medical system comprises: an instrument including an instrument shape sensor; a display system; and a processing unit including one or more processors. The processing unit is configured to: receive an anatomic model of a patient anatomy, where an area of interest is identified in the anatomic model; receive shape sensor data from the instrument shape sensor while the instrument is positioned within the patient anatomy and registered to the anatomic model; and determine a fluoroscopic image plane for display on the display system based on the received shape sensor data and the area of interest.SELECTED DRAWING: Figure 1

Description

[Technical Field]

[0001] (Related Applications) This patent application claims the benefit of priority and the filing date of U.S. Provisional Patent Application No. 62 / 294,870, filed February 12, 2016, entitled "SYSTEMS AND METHODS FOR USING FLUOROSCOPY TO ASSIST INSTRUMENT NAVIGATION IN IMAGE-GUIDED SURGERY," and U.S. Provisional Patent Application No. 62 / 294,879, filed February 12, 2016, entitled "SYSTEMS AND METHODS FOR USING REGISTERED FLUOROSCOPIC IMAGES IN IMAGE-GUIDED SURGERY," both of which are incorporated by reference in their entireties.

[0002] The present disclosure is directed to systems and methods for performing image-guided procedures, and more particularly, to systems and methods for using registered real-time fluoroscopic images and prior anatomical images during image-guided procedures. [Background technology]

[0003] Minimally invasive medical techniques are intended to reduce the amount of tissue damaged during a medical procedure, thereby reducing patient recovery time, discomfort, and adverse side effects. Such minimally invasive techniques can be performed through natural orifices in the patient's anatomy or through one or more surgical incisions. Through these natural orifices or incisions, clinicians can insert minimally invasive medical instruments (including surgical, diagnostic, therapeutic, or biopsy instruments) to reach the target tissue location. To aid in reaching the target tissue location, the position and movement of the medical instrument may be correlated with pre-operative or prior intra-operative still images of the patient's anatomy. Using image-guided instruments associated with the images, the instruments can be passed through natural orifices or surgically created passageways in anatomical systems such as the lungs, colon, intestines, kidneys, heart, and circulatory system. Traditionally, pre-operative or intra-operative images of a patient's anatomy are detailed and often three-dimensional. However, they are static, preliminary representations of the patient's anatomy. Fluoroscopy is an imaging modality that provides real-time images of a patient's anatomy, including radiopaque instruments used during medical procedures on the patient's anatomy. However, fluoroscopic images may not capture high-quality images of certain types of tissue. What is needed are systems and methods for registering real-time fluoroscopic images and prior static images to provide improved navigation information for performing image-guided surgery. [Prior art documents] [Patent documents]

[0004] [Patent Document 1] International Publication No. 2016 / 018646 Summary of the Invention

[0005] Embodiments of the present invention are summarized by the claims that follow the description.

[0006] In one embodiment, a method implemented by a computer system includes receiving a fluoroscopic image of a patient's anatomy while a portion of a medical instrument is positioned within the patient's anatomy. The fluoroscopic image has a fluoroscopic frame of reference. The portion may also be referred to as an indicator portion, and the portion may comprise any length of the medical instrument, including, by way of non-limiting example, the proximal section, midsection, distal section, and / or distal end of the medical instrument. The portion has a sensed or otherwise known position in an anatomical model frame of reference. The method further includes identifying a position of the portion in the fluoroscopic image and identifying an extracted position of the portion in the fluoroscopic frame of reference using the position of the portion in the fluoroscopic image. The method further includes registering the fluoroscopic frame of reference to the anatomical model frame of reference based on the sensed position of the portion and the extracted position of the portion.

[0007] In another embodiment, a method performed by a computer system includes identifying a set of positions of a plurality of anatomical landmarks, the plurality of anatomical landmarks being rendered within an anatomical model of a passageway of the patient's anatomy in a model frame of reference, and receiving fluoroscopic image data of the patient's anatomy while a portion of a medical instrument traverses the plurality of anatomical landmarks in the passageway of the patient's anatomy, the fluoroscopic image data having the fluoroscopic frame of reference. The method further includes identifying a set of feature positions of the plurality of anatomical landmarks in the fluoroscopic frame of reference, and registering the set of locations of the plurality of anatomical landmarks in the model frame of reference and the set of feature positions in the fluoroscopic frame of reference to a common frame of reference.

[0008] In another embodiment, a method performed by a computer system includes receiving a set of model points for an anatomical model of a passageway in the patient's anatomical structure in a model frame of reference, and receiving fluoroscopic image data of the patient's anatomy while an indicator portion of a medical instrument passes through the passageway in the patient's anatomy. The fluoroscopic image data has the fluoroscopic frame of reference. The method further includes identifying, from the fluoroscopic image data, a set of indicator portion location points in the fluoroscopic frame of reference, and matching each indicator portion location point with a model point in the set of model points to generate a set of matches. The method further includes registering the model frame of reference to the fluoroscopic frame of reference based on the set of matches.

[0009] In another embodiment, a computer-assisted medical system includes a fluoroscopic imaging device having a plane of orientation within a surgical coordinate space and one or more processors. The one or more processors are configured to execute a method including the steps of: receiving a fluoroscopic image of a patient's anatomy while a portion of a medical instrument is positioned at a location within the patient's anatomy, the fluoroscopic image having the plane of orientation. The method also includes receiving a command to drive a movement of the portion of the medical instrument, constraining the actuation of the portion such that the actuated movement of the portion is constrained to the plane of orientation of the fluoroscopic image, and driving the movement of the portion with the constrained actuation. In one aspect, the system includes receiving sensor information from the medical instrument while driving the movement of the portion with the constrained actuation, recognizing movement of the portion outside the plane of orientation of the fluoroscopic image from the received sensor information, and receiving a signal to adjust the portion into the plane of orientation of the fluoroscopic image.

[0010] In another embodiment, a method performed by a computer system includes receiving an anatomical model of a patient's anatomy, where a region of interest is identified in the anatomical model, the method further includes receiving shape sensor data from an instrument shape sensor of an instrument positioned within the patient's anatomy and registered to the anatomical model, and determining a fluoroscopic image plane for display based on the received shape sensor data and the region of interest.

[0011] It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory in nature and are intended to provide an understanding of the present disclosure without limiting the scope thereof. In that regard, additional aspects, features, and advantages of the present disclosure will become apparent to those skilled in the art from the following detailed description. [Brief explanation of the drawings]

[0012] Aspects of the present disclosure are best understood from the following detailed description when read in conjunction with the accompanying drawings. It is emphasized that, according to standard industry practice, various features are not drawn to scale. In fact, the dimensions of various features may be arbitrarily increased or decreased for clarity of discussion. In addition, the present disclosure may repeat reference numerals and / or letters in various instances. This repetition is for the purposes of brevity and clarity and does not in itself dictate a relationship between the various embodiments and / or configurations discussed.

[0013] [Figure 1] 1 is a remotely operated medical system according to an embodiment of the present disclosure.

[0014] [Figure 2A] 1 illustrates a medical device system employing aspects of the present disclosure.

[0015] [Figure 2B] 2B illustrates the distal end of the medical device system of FIG. 2A with an extended medical device, according to an embodiment of the present disclosure.

[0016] [Figure 3] 2B shows the distal end of the medical device system of FIG. 2A positioned within a human lung.

[0017] [Figure 4] 10 is a flowchart illustrating a method used to provide guidance in an image-guided surgical procedure according to an embodiment of the present disclosure.

[0018] [Figure 5] FIG. 1 is a side view of a surgical coordinate space including a medical instrument and a fluoroscopic imaging system according to an embodiment of the present disclosure.

[0019] [Figure 6] 1 shows a flowchart of an image-guided surgical procedure according to an embodiment of the present disclosure.

[0020] [Figure 7] 10 shows a flowchart of an image-guided surgical procedure according to another embodiment of the present disclosure.

[0021] [Figure 8] 10 shows a flowchart of a portion of an image-guided surgical procedure according to another embodiment of the present disclosure.

[0022] [Figure 9A] 10A-10C illustrate fluoroscopic images for determining instrument portion positions in a fluoroscopic reference frame according to an embodiment of the present disclosure.

[0023] [Figure 9B] 10A-10C illustrate fluoroscopic images for determining instrument portion positions in a fluoroscopic reference frame according to an embodiment of the present disclosure.

[0024] [Figure 9C] 10A-10C illustrate fluoroscopic images for determining instrument portion positions in a fluoroscopic reference frame according to an embodiment of the present disclosure.

[0025] [Figure 10]1 is a display device displaying aligned fluoroscopic and anatomical model images according to an embodiment of the present disclosure.

[0026] [Figure 11] 1 is a display device displaying an anatomical structure model image registered and overlaid on a fluoroscopic image according to an embodiment of the present disclosure.

[0027] [Figure 12] 1 shows a correlation table representing related anatomical landmarks between perspective and anatomical reference frames.

[0028] [Figure 13A] 1 shows segmentation of a perspective image.

[0029] [Figure 13B] 1 shows segmentation of a perspective image.

[0030] [Figure 14] 10 shows a flowchart of a portion of an image-guided surgical procedure according to another embodiment of the present disclosure.

[0031] [Figure 15] A method for determining a preferred perspective viewing plane is shown.

[0032] [Figure 16] A method for driving a medical instrument under two-dimensional fluoroscopic guidance is presented. DETAILED DESCRIPTION OF THE INVENTION

[0033] In the following detailed description of aspects of the present invention, numerous specific details are set forth in order to provide a thorough understanding of the disclosed embodiments. However, it will be apparent to those skilled in the art that the embodiments in this disclosure may be practiced without these specific details. In other instances, well-known methods, procedures, components, and circuits have not been described in detail so as not to unnecessarily obscure aspects of the embodiments of the present invention. Furthermore, to avoid unnecessary repetition, one or more components or operations described in accordance with one embodiment may be used or omitted as applicable to other embodiments.

[0034] The following embodiments describe various instruments and instrument portions in terms of their state in three-dimensional space. As used herein, the term "position" refers to the location of an object or object portion in three-dimensional space (e.g., three degrees of freedom of translation along Cartesian coordinates X, Y, and Z). As used herein, the term "orientation" refers to the rotational placement of an object or object portion (e.g., three degrees of freedom of rotation: roll, pitch, and yaw). As used herein, the term "pose" refers to the position of an object or object portion in at least one translational degree of freedom and the orientation of that object or object portion in at least one rotational degree of freedom (up to a total of six degrees of freedom). As used herein, the term "shape" refers to a set of poses, positions, or orientations measured along an object.

[0035] Referring to Figure 1 of the drawings, a teleoperated medical system for use in, for example, surgical, diagnostic, therapeutic, or biopsy procedures is generally shown as teleoperated medical system 100. As shown in Figure 1, teleoperated system 100 generally includes a teleoperated manipulator assembly 102 that manipulates a medical instrument system 104 in performing various procedures on a patient P. The teleoperated manipulator assembly 102 may also be referred to as a teleoperated assembly 102 or a manipulator assembly 102. The medical instrument system 104 may also be referred to as a medical instrument 104. The manipulator assembly 102 is mounted on or near an operating table O. An operator input system 106 (also referred to as a "master assembly 106") allows a clinician or surgeon S to view the intervention site and control the manipulator assembly 102.

[0036] The operator input system 106 can be located in a surgeon's console, which is typically located in the same room as the operating table O. However, it should be understood that the surgeon S can be located in a different room than the patient P, or in a different building entirely. The operator input assembly 106 generally includes one or more controllers for controlling one or more manipulator assemblies 102. The controllers can include many different input devices, such as joysticks, trackballs, data gloves, trigger guns, manual controls, voice recognition devices, motion sensors, or presence sensors. In some embodiments, the controllers have the same degrees of freedom as the associated medical instrument 104 to provide the surgeon with telepresence, or the perception that the controllers are integral with the instrument 104, so that the surgeon has a strong sense of direct control over the instrument 104. In other embodiments, the controllers can have more or fewer degrees of freedom than the associated medical instrument 104 and still provide telepresence to the surgeon. In some embodiments, the control device is a manual input device that moves in six degrees of freedom and may also include an actuatable handle for actuating the instrument (e.g., closing the grasping jaws, applying a potential to an electrode, administering a drug treatment, etc.).

[0037] The teleoperated assembly 102 supports the medical instrument system 104 and may include one or more non-servo controlled links (e.g., one or more links that can be manually positioned and locked in place, commonly referred to as a setup structure) and the kinematic structure of the teleoperated manipulator. The teleoperated assembly 102 includes multiple actuators or motors that drive inputs to the medical instrument system 104 in response to commands from a control system (e.g., control system 112). The motors include drive systems that, when coupled to the medical instrument system 104, can advance the medical instrument through natural or surgically created anatomical openings. Other motor drive systems can move the distal end of the medical instrument with multiple degrees of freedom, which may include three degrees of linear motion (e.g., linear motion along the X, Y, and Z Cartesian axes) and three degrees of rotational motion (e.g., rotation about the X, Y, and Z Cartesian axes). Additionally, motors can be used to actuate an articulatable end effector of an instrument to grasp tissue with jaws, such as a biopsy device. Motor position sensors, such as resolvers, encoders, potentiometers, and other mechanisms, can provide sensor data to a remotely manipulated assembly that represents the rotation and orientation of the motor shaft. This position sensor data can be used to determine the movement of an object manipulated by the motor.

[0038] The teleoperated medical system 100 also includes a sensor system 108 with one or more subsystems for receiving information related to the instruments of the teleoperated assembly. Such subsystems can include a position / location sensor system (e.g., an electromagnetic (EM) sensor system), a shape sensor system for determining the position, orientation, speed, velocity, attitude, and / or shape of the catheter tip and / or one or more segments along the flexible body of the medical instrument system 104, and / or a visualization system for capturing images from the distal end of the catheter system.

[0039] The visualization system (e.g., visualization system 231 of FIG. 2A) may include a viewing scope assembly that records simultaneous or real-time images of the surgical site and provides the images to the clinician or surgeon S. The simultaneous images may be, for example, two-dimensional or three-dimensional images captured by an endoscope positioned within the surgical site. In this embodiment, the visualization system includes an endoscopic component that may be integrally or removably coupled to the medical instrument 104. However, in alternative embodiments, a separate endoscope attached to a separate manipulator assembly may be used in conjunction with the medical instrument to image the surgical site. The visualization system may be implemented as hardware, firmware, software, or a combination thereof that interacts with or is otherwise executed by one or more computer processors, which may include the processor of the control system 112 (described below). The processor of the control system 112 may execute instructions, including instructions corresponding to the processes disclosed herein.

[0040] The teleoperated medical system 100 also includes a display system 110 (also "display 110") for displaying images or representations of the surgical site and medical instrument system(s) 104 generated by subsystems of the sensor system 108. The display system 110 and the operator input system 106 may be oriented to allow an operator to control the medical instrument system 104 and the operator input system 106 with a sense of telepresence.

[0041] The display system 110 may also display images of the surgical site and medical instruments captured by the visualization system. The display system 110 and controls are oriented so that the relative positions of the imaging device and medical instruments in the scope assembly resemble the relative positions of a surgeon's eyes and hands, allowing the operator to manipulate the medical instruments 104 and hand controls as if they were viewing the workspace in substantially true presence. True presence means that the image presentation is a true perspective image that simulates the perspective of the operator physically manipulating the instruments 104.

[0042] Alternatively or additionally, the display system 110 may present images of the surgical site recorded pre- or intra-operatively using imaging data from imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), fluoroscopy, thermography, ultrasound, optical coherence tomography (OCT), thermal imaging, impedance imaging, laser imaging, nanotube x-ray imaging, etc. The pre- or intra-operative image data may be presented as two-dimensional, three-dimensional, or four-dimensional (e.g., including time-based or velocity-based information) images, or as images from a model created from the pre- or intra-operative image dataset.

[0043] In some embodiments, often for image-guided surgical procedures, the display system 110 may display a virtual navigation image in which the actual position of the medical instrument 104 is aligned (i.e., dynamically referenced) with the preoperative image or concurrent image / model to present the clinician or surgeon S with a virtual image of the internal surgical site from the perspective of the position of the tip of the instrument 104. An image of the tip of the instrument 104 or other graphical or alphanumeric indicator may be superimposed on the virtual image to assist the surgeon in controlling the instrument 104. Alternatively, the instrument 104 may not be visible in the virtual image.

[0044] In other embodiments, the display system 110 may display a virtual navigation image in which the actual location of the medical instrument is aligned with the pre-operative or simultaneous image to present the clinician or surgeon S with a virtual image of the medical instrument within the surgical site from an external perspective. Images of portions of the medical instrument or other graphical or alphanumeric indicators may be superimposed on the virtual image to assist the surgeon in controlling the instrument 104.

[0045] The teleoperated medical system 100 also includes a control system 112. The control system 112 includes at least one memory and at least one computer processor (not shown), typically multiple processors, for controlling among the medical instruments 104, the operator input system 106, the sensor system 108, and the display system 110. The control system 112 also includes program instructions (e.g., a computer-readable medium storing instructions) for implementing some or all of the methods described in accordance with the embodiments disclosed herein, including instructions for providing a registered image to the display system 110. While the control system 112 is shown as a single block in the simplified schematic diagram of FIG. 1 , the system may include two or more data processing circuits, with some portion of the processing optionally performed on or adjacent to the teleoperated assembly 102 and another portion of the processing performed in the operator input system 106. Any of a wide variety of centralized or distributed data processing architectures may be used. Similarly, the programmed instructions may be implemented as several separate programs or subroutines, or may be integrated into several other aspects of the teleoperated systems described herein. In one embodiment, the control system 112 supports wireless communication protocols such as Bluetooth, IrDA, HomeRF, IEEE 802.11, DECT, and wireless telemetry.

[0046] In some embodiments, the control system 112 may include one or more servo controllers that receive force and / or torque feedback from the medical instrument system 104. In response to the feedback, the servo controllers send signals to the operator input system 106. The servo controller(s) may also send signals that direct the teleoperated assembly 102 to move the medical instrument system(s) 104 that extend through a body orifice to an internal surgical site within the patient's body. Any suitable conventional or dedicated servo controller may be used. In some embodiments, the servo controllers and teleoperated assembly are provided as part of a teleoperated arm cart that is positioned adjacent to the patient's body.

[0047] The control system 112 may further include a virtual visualization system that provides navigational assistance to the medical instrument system(s) 104 when used in an image-guided surgical procedure. Virtual navigation using the virtual visualization system is based on referencing acquired pre-operative or intra-operative datasets of anatomical passageways. More specifically, the virtual visualization system processes images of the surgical site imaged using imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), fluoroscopy, thermography, ultrasound, optical coherence tomography (OCT), thermal imaging, impedance imaging, laser imaging, nanotube x-ray imaging, and the like. Software, alone or in combination with manual input, is used to convert the recorded images into a segmented two-dimensional or three-dimensional composite representation of a partial or entire anatomical organ or anatomical region. An image dataset is associated with the composite representation. The composite representation and image dataset describe the various positions and shapes of passageways and their connectivity. The images used to generate the composite representation may be recorded pre-operatively or intra-operatively at a prior time during the medical procedure. In alternative embodiments, the virtual visualization system may use standard representations (i.e., not patient-specific) or a hybrid of standard representations and patient-specific data. The composite representations and any virtual images generated by the composite representations may represent the static pose of a deformable anatomical region during one or more stages of motion (e.g., during the lung inspiratory / expiratory cycle).

[0048] During a virtual navigation procedure, the sensor system 108 can be used to calculate the approximate position of the instrument relative to the patient's anatomy. The position can be used to generate both a macro-level (external) tracking image of the patient's anatomy and a virtual internal image of the patient's anatomy. Various systems are known that use electromagnetic (EM), fiber optic, or other sensors to register and display medical instruments together with pre-operatively recorded surgical images, such as those from a virtual visualization system. For example, U.S. Patent Application No. 13 / 107,562 (filed May 13, 2011) (disclosing "Medical System Providing Dynamic Registration of a Model of an Anatomic Structure for Image-Guided Surgery"), which is incorporated herein by reference in its entirety, discloses one such system.

[0049] The teleoperated medical system 100 may further include optional manipulation and support systems (not shown), such as a lighting system, a navigation control system, an irrigation system, and / or a suction system. In alternative embodiments, the teleoperated system may include more than one teleoperation assembly and / or more than one operator input system. The exact number of manipulator assemblies depends, among other factors, on the surgical procedure and space constraints within the operating room. The operator input systems may be co-located or located in separate locations. Multiple operator input systems allow more than one operator to control one or more manipulator assemblies in various combinations.

[0050] 2A shows a medical instrument system 200 (also "medical instrument 200" or "instrument system 200") that may be used as the medical instrument system 104 in an image-guided medical procedure performed by the teleoperated medical system 100. Alternatively, the medical instrument system 200 may be used for non-teleoperated exploratory procedures or in procedures involving conventional manually operated medical instruments, such as endoscopes. Additionally or alternatively, the medical instrument system 200 may be used to collect (i.e., measure) a set of data points corresponding to the location of an anatomical passageway in a patient.

[0051] The instrument system 200 includes a catheter system 202 (also "catheter 202") coupled to an instrument body 204, which may be referred to as a "housing 204" when used to house components. The catheter system 202 includes an elongated, flexible catheter body 216 having a proximal end 217 and a distal end 218 (which may be referred to as a "tip section 218" when it is the tip section of the catheter body 216). In one embodiment, the flexible body 216 has an outer diameter of approximately 3 mm. The outer diameter of other flexible bodies may be larger or smaller. The catheter system 202 may optionally include a shape sensor system 222 (also "shape sensor 222") for determining the position, orientation, speed, velocity, attitude, and / or shape of the catheter tip at the distal end 218 and / or of one or more segments 224 along the catheter body 216. The entire length of the catheter body 216 between the distal end 218 and the proximal end 217 may be effectively divided into segments 224. If the instrument system 200 is a teleoperated medical system 100 medical instrument 104, the shape sensor system 222 may be a component of the sensor system 108. If the instrument system 200 is manually operated or used for a non-teleoperated procedure, the shape sensor system 222 may be coupled to a tracking system 230 that interrogates the shape sensors and processes the received shape data.

[0052] The shape sensor system 222 may include an optical fiber aligned with the flexible catheter body 216 (e.g., disposed within an internal channel (not shown) or mounted externally). In one embodiment, the optical fiber has a diameter of approximately 200 μm. In other embodiments, the dimensions may be larger or smaller. The optical fiber of the shape sensor system 222 forms a fiber optic bend sensor for determining the shape of the catheter system 202. In one alternative, an optical fiber including a fiber Bragg grating (FBG) is used to provide strain measurements of the structure in one or more dimensions. Various systems and methods for monitoring the shape and relative position of optical fibers in three dimensions are described in U.S. patent application Ser. No. 11 / 180,389, filed July 13, 2005 (disclosing "Fiber optic position and shape sensing device and method relating thereto"); U.S. patent application Ser. No. 12 / 047,056, filed July 16, 2004 (disclosing "Fiber-optic shape and relative position sensing"); and U.S. Patent No. 6,389,187, filed June 17, 1998 (disclosing "Optical Fiber Bend Sensor"), all of which are incorporated herein by reference in their entireties. Sensors in alternative embodiments may use other suitable strain detection techniques, such as Rayleigh scattering, Raman scattering, Brillouin scattering, and fluorescence scattering. In other alternative embodiments, the shape of the catheter may be determined using other techniques. For example, the history of the catheter's distal tip orientation can be used to reconstruct the shape of the device over a time interval. As another example, historical pose, position, or orientation data may be stored for known points of the instrument system along a cycle of alternating motion, such as breathing. This stored data may be used to reveal shape information about the catheter. Alternatively, a series of position sensors, such as electromagnetic (EM) sensors, placed along the catheter can be used for shape sensing.Alternatively, historical data from position sensors, such as EM sensors, on the instrument system during a procedure may be used to represent the shape of the instrument, especially if the anatomical passage is generally static. Alternatively, a wireless device having a position or orientation controlled by an external magnetic field may be used for shape sensing. The position history of the wireless device may be used to determine the shape of the navigated passage.

[0053] The medical instrument system may optionally include a position sensor system 220. The position sensor system 220 may be a component of an EM sensor system, with the sensor system 220 including one or more conductive coils that may be exposed to an externally generated electromagnetic field. In such an embodiment, each coil in the EM sensor system with the position sensor system 220 generates an induced electrical signal having characteristics that depend on the position and orientation of the coil relative to the externally generated electromagnetic field. In one embodiment, the EM sensor system may be configured and arranged to measure six degrees of freedom, e.g., three position coordinates X, Y, Z and three orientation angles indicative of the pitch, yaw, and roll of a reference point, or five degrees of freedom, e.g., three position coordinates X, Y, Z and two orientation angles indicative of the pitch and yaw of a reference point. Further description of EM sensor systems is provided in U.S. Pat. No. 6,380,732, filed August 11, 1999, which discloses "Six-Degree of Freedom Tracking System Having a Passive Transponder on the Object Being Tracked," which is incorporated herein by reference in its entirety. In some embodiments, the shape sensor can also function as a position sensor, as the shape of the sensor, along with information about the position of the base of the shape sensor (in a patient-fixed coordinate system), allows the positions of various points on the shape sensor, including the distal tip, to be calculated.

[0054] The tracking system 230 may include a position sensor system 220 and a shape sensor system 222 for determining the position, orientation, velocity, attitude, and / or shape of the distal end 218 and one or more segments 224 along the instrument system 200. The tracking system 230 may be implemented as hardware, firmware, software, or a combination thereof that interacts with or is otherwise executed by one or more computer processors, which may include the processor(s) of the control system 116.

[0055] The flexible catheter body 216 includes a channel 221 (see FIG. 2B) sized and shaped to receive a medical instrument 226. The medical instrument may include, for example, an image capture probe, a biopsy instrument, a laser ablation fiber, or other surgical, diagnostic, or therapeutic tool. The medical tool may include an end effector having a single actuating member such as a scalpel, a blunt blade, an optical fiber, or an electrode. Other end effectors may include, for example, forceps, graspers, scissors, or clip appliers. Examples of electrically actuated end effectors include electrosurgical electrodes, transducers, sensors, etc.

[0056] In various embodiments, the medical instrument(s) 226 may be an image capture probe that includes a distal portion with a stereoscopic or monoscopic camera at or near the distal end 218 of the flexible catheter body 216 to capture images (including video) that are processed by the visualization system 231 for display. The image capture probe may include a cable coupled to the camera for transmitting captured image data. Alternatively, the image capture instrument may be a fiber optic bundle, such as a fiberscope, that couples to the visualization system. The image capture instrument may be single-spectrum or multi-spectral, capturing image data in one or more of the visible, infrared, or ultraviolet spectrums, for example.

[0057] In various embodiments, medical instrument 226 is a biopsy instrument used to remove a sampling of sample tissue or cells from a target anatomical location. Instrument 226 may be advanced through the opening of channel 221 to perform a procedure and then retracted back into the channel once the procedure is complete. Medical instrument 226 may be removed from proximal end 217 of the catheter flexible body or from another optional instrument port (not shown) along the flexible body.

[0058] The medical instrument 226 may contain a cable, linkage, or other actuation control (not shown) extending between the proximal and distal ends of the instrument for controllably bending the distal end of the instrument. Steerable instruments are described in detail in U.S. Patent No. 7,316,681, filed October 4, 2005 (disclosing "Articulated Surgical Instrument for Performing Minimally Invasive Surgery with Enhanced Dexterity and Sensitivity") and U.S. Patent Application No. 12 / 286,644, filed September 30, 2008 (disclosing "Passive Preload and Capstan Drive for Surgical Instruments"), which are incorporated by reference herein in their entireties.

[0059] The flexible catheter body 216 may also house a cable, linkage, or other steering control (not shown) extending between the housing 204 and the distal end 218 for controllably bending the distal end, as indicated, for example, by the dashed-line depiction 219 of the distal end. Steerable catheters are described in detail in U.S. Patent Application No. 13 / 274,208, filed October 14, 2011 (disclosing "Catheter with Removable Vision Probe"), which is incorporated herein by reference in its entirety. In embodiments in which the instrument system 200 is operated by a remotely controlled assembly, the housing 204 may include a drive input that removably couples to and receives power from a motor drive element of the remotely controlled assembly. In embodiments in which the instrument system 200 is manually operated, the housing 204 may include a gripping mechanism, manual actuator, or other component for manually controlling the operation of the instrument system. The catheter system can be steerable; alternatively, the system may be non-steerable without an integrated mechanism for operator control of instrument bending. Also or alternatively, one or more lumens are defined in the wall of flexible body 216 through which medical instruments are deployed and used at the target surgical site.

[0060] In various embodiments, medical instrument system 200 may include a flexible bronchial instrument, such as a bronchoscope or bronchial catheter, for use in lung examination, diagnosis, biopsy, or treatment. Instrument system 200 is also suitable for navigating and treating other tissues through natural or surgically created connecting passageways in any of a variety of anatomical systems, including the colon, intestines, kidneys, brain, heart, circulatory system, etc.

[0061] Information from the tracking system 230 may be sent to a navigation system 232 where it is combined with information from a visualization system 231 and / or a pre-operatively acquired model to provide the surgeon or other operator with real-time position information on the display system 110 for use in controlling the instrument system 200. The control system 116 may use the position information as feedback to position the instrument system 200. Various systems using fiber optic sensors to register surgical instruments to surgical images are provided in U.S. patent application Ser. No. 13 / 107,562, filed May 13, 2011, which discloses "Medical System Providing Dynamic Registration of a Model of an Anatomic Structure for Image-Guided Surgery," which is incorporated herein by reference in its entirety.

[0062] 2A, the instrument system 200 is remotely operated within the teleoperated medical system 100. In an alternative embodiment, the remote operation assembly 102 may be replaced by direct operator control. In lieu of direct operation, various handles and operator interfaces may be included for handheld operation of the instrument.

[0063] In alternative embodiments, the teleoperation system may include more than one slave manipulator assembly and / or more than one master assembly. The exact number of manipulator assemblies depends on, among other things, the medical procedure and space constraints within the operating room. The master assemblies may be co-located or located in separate locations. Multiple master assemblies allow more than one operator to control one or more slave manipulator assemblies in various combinations.

[0064] 3 shows a catheter system 202 positioned within an anatomical passageway of a patient's anatomy. In this embodiment, the anatomical passageway is the airway of a person's lungs 201. In alternative embodiments, the catheter system 202 may be used in other passageways of the anatomy.

[0065] FIG. 4 is a flowchart illustrating a general method 300 for use in an image-guided surgical procedure. While various examples provided describe use in a procedure performed within an anatomical structure, in alternative embodiments, the disclosed devices and methods need not be used within an anatomical structure, but rather may be used outside the patient's anatomy. In process 302, prior image data, including pre- or intra-operative image data, is obtained from imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), thermography, ultrasound, optical coherence tomography (OCT), thermal imaging, impedance imaging, laser imaging, or nanotube x-ray imaging. The pre- or intra-operative image data may correspond to two-dimensional, three-dimensional, or four-dimensional (e.g., including time-based or velocity-based information) images. For example, the image data may represent the human lung 201 of FIG. 3 .

[0066] In process 304, computer software, alone or in combination with manual input, is used to convert the recorded images into a segmented, two-dimensional or three-dimensional composite representation or model of a partial or entire anatomical organ or region. The composite representation and image dataset describe the various locations and shapes of passageways and their connectivity. More specifically, during the segmentation process, the image is divided into segments or elements (e.g., pixels or voxels) that share specific or calculated properties, such as color, density, intensity, and texture. This segmentation process results in a two-dimensional or three-dimensional reconstruction that forms a model of the target anatomical structure or anatomical structure model based on the acquired images. To represent the model, the segmentation process delineates a set of voxels representing the target anatomical structure and then applies a function, such as a marching cubes function, to generate a 3D surface that surrounds the voxels. The model can be created by generating a mesh, volume, or voxel map. Additionally or alternatively, the model may include a centerline model that includes a set of interconnected lines or points that extend through the center of the modeled passage. If the model includes a centerline model that includes a collection of interconnected lines, those lines may be converted into a cloud or collection of points. By converting the line segments, a desired amount of points corresponding to the interconnected line segments can be selected manually or automatically.

[0067] In process 306, the anatomical structure model, the medical instrument used to perform the medical procedure (e.g., instrument system 200), and the patient's anatomical structure are co-registered to a common reference frame before and / or during an image-guided surgical procedure on the patient. The common reference frame may be, for example, a surgical environment reference frame or a patient reference frame. Process 306 includes localizing the medical instrument relative to the patient. Process 306 also includes registering the anatomical structure model relative to the patient. Generally, registration includes matching measurement points to points on the model using rigid and / or non-rigid transformations. The measurement points may be generated using landmarks in the anatomical structure, electromagnetic coils scanned and tracked during the procedure, or a shape sensor system. The measurement points may be generated for use in iterative closest point (ICP) techniques. ICP and other registration techniques are described in U.S. Provisional Patent Application Nos. 62 / 205,440 and 62 / 205,433, both filed August 14, 2015, which are incorporated by reference herein in their entireties. In process 308, a medical procedure can be performed using the anatomical model data to guide the movement of a medical instrument.

[0068] Anatomical models created using previous image data, such as CT scans (i.e., computed tomography scans), are used in image-guided surgery to provide fine anatomical detail suitable for many procedures. However, models based on previous image data are prone to registration errors and do not represent the real-time configuration of the anatomy, including deformations due to cyclic or non-cyclic anatomical motion, the presence of and deformation of biological tissue by medical instruments, or other changes to the patient's anatomy that may have occurred since the previous image data was acquired. Fluoroscopy is a fluoroscopic imaging modality that uses X-rays to obtain real-time, moving images of a patient's anatomy. Conventional radiographs are X-ray images obtained by placing a portion of a patient in front of an X-ray detector and then irradiating it with short X-ray pulses. In a similar manner, fluoroscopy uses X-rays to obtain real-time, moving images of a patient's interior, including radiopaque medical instruments, radiopaque dyes, and / or radiopaque fiducial markers within the surgical environment. Fluoroscopy systems offer flexibility in positioning and may include C-arm systems capable of orbital, horizontal, and / or vertical movement via manual or automated control. Non-C-arm systems are stationary and offer less flexibility in movement. Fluoroscopy systems generally use either an image intensifier or a flat-panel detector to generate two-dimensional, real-time images of the patient's anatomy. Bi-planar fluoroscopy systems simultaneously capture two fluoroscopy images from different (often orthogonal) perspectives. The quality and usefulness of x-ray images can vary depending on the type of tissue being imaged. Dense materials, such as bone and metal, are generally more visible on x-ray images than the air-filled soft tissues of the lungs. For pulmonary procedures, CT models provide anatomical details of airways and tumors that are difficult to identify on fluoroscopic images, while fluoroscopic images provide real-time visualization of medical devices and dense anatomical tissue.Therefore, fluoroscopic images registered to an anatomical model can be useful to clinicians to navigate specific portions of an anatomy such as the lungs.

[0069] FIG. 5 illustrates a surgical coordinate system X in which a patient P is positioned on a platform 352. S , Y S , Z S 1 illustrates an exemplary surgical environment 350 according to some embodiments, having a patient P. The patient P may be stationary within the surgical environment, in the sense that significant patient motion is limited by sedation, restraints, or other means. Cyclic anatomical motion, including respiratory and cardiac motion, of the patient P may continue unless the patient temporarily suspends respiratory motion. Within the surgical environment 350, a medical instrument 354 is coupled to an instrument carriage 356. The instrument carriage 356 is attached to an insertion stage 358 that is fixed or movable within the surgical environment 350. The instrument carriage 356 is adapted to move the insertion motion (i.e., X SThe instrument 354 may be a component of a teleoperated manipulator assembly (e.g., manipulator assembly 102) that couples to the instrument 354 to control movement of the distal end of the instrument in multiple directions, including yaw, pitch, and roll (direction of motion) and, optionally, yaw, pitch, and roll. The instrument carriage 356 or insertion stage 358 may include servo motors (not shown) that control movement of the instrument carriage along the insertion stage. The medical instrument 354 may include a flexible catheter 360 coupled to a proximal rigid instrument body 362. The rigid instrument body 362 is coupled to and fixed relative to the instrument carriage 356. A fiber optic shape sensor 364 extends along the instrument 354 and is operable to measure the shape from a fixed or known point 366 to a portion 368 of the catheter 360. In the illustrated embodiment, the portion 368 is shown as the distal end portion. In other embodiments, the portion 368 may be located elsewhere along the length of the catheter 360, including the central portion of the catheter. Portion 368 is shaped and configured to function as an indicator portion of catheter 360 (e.g., portion 368 may be identified in image data). Medical instrument 354 may be substantially similar to medical instrument system 200. A fluoroscopic imaging system 370 (also referred to as fluoroscopy system 370) is positioned near patient P to acquire fluoroscopic images of the patient while catheter 360 is extended within the patient. System 370 may be, for example, a mobile C-arm fluoroscopic imaging system. In some embodiments, system 370 may be a multi-axis Artis Zeego fluoroscopic imaging system from Siemens Corporation of Washington, D.C.

[0070] FIG. 6 is a flow chart illustrating a method 450 for performing image-guided surgery in a surgical environment 350. The methods of this description, including method 450, are illustrated in FIG. 6 as a set of blocks, steps, operations, or processes. Not all of the illustrated enumerated operations are performed in all embodiments of method 450. In addition, some additional operations not explicitly shown in the method may be included before, after, between, or as part of the enumerated processes. Some embodiments of the methods of this description include instructions corresponding to the method processes stored in a memory. These instructions may be executed by a processor, such as the processor of control system 112.

[0071] Accordingly, some embodiments of method 450 may begin in process 452, where prior image data, including pre-operative or intra-operative image data, is acquired from an imaging technique such as CT, MRI, thermography, ultrasound, OCT, thermal imaging, impedance imaging, laser imaging, or nanotube X-ray imaging. The prior image data may correspond to two-dimensional, three-dimensional, or four-dimensional (e.g., including time-based or velocity-based information) images. As described above, an anatomical structure model is created from the prior image data in an anatomical structure model frame of reference. In process 454, an instrument sensor frame of reference (X ) is created, which may be associated with a shape sensor 222 included in the medical instrument 200. I , Y I , Z I ) is the anatomical model reference frame (X M , Y M , Z M ) This alignment between the model and instrument reference frames can be achieved using point-based ICP techniques, for example, as described in U.S. Provisional Patent Applications Nos. 62 / 205,440 and 62 / 205,433, which are incorporated by reference. Alternatively, the model reference frame can be aligned to the sensor reference frame, or the model and sensor reference frames can be aligned to another common reference frame. The common reference frame can be, for example, the surgical environment reference frame (XS , Y S , Z S ) or a patient reference frame. For example, aligning the anatomy model coordinate system and the sensor coordinate system includes: receiving a set of model points of the anatomy model; receiving a set of measurement points corresponding to positions measured by a position sensor within the anatomy passageway, each point having a coordinate in the sensor coordinate system; matching a measurement point of the set of measurement points to a model point of the set of model points to generate a set of matches; and moving the set of measurement points relative to the set of model points based on the set of matches.

[0072] In process 456, with reference to FIG. 9B , sensor data (as opposed to shape information determined from imaging) is used to calculate pose information. For example, in various examples, the sensed position and orientation of a portion of the medical instrument at location L within, near, adjacent to, or external to the patient's anatomy is used to determine pose information of the medical instrument. The sensed position and orientation may be obtained, measured, or calculated from the sensor data. In this embodiment, medical instrument portion 368 is referred to as the indicator portion and may include a radiopaque distal end portion. In other embodiments, any other radiopaque portion of the medical instrument visible on the fluoroscopic image may be the indicator portion. The indicator portion may include any length of medical instrument visible on the fluoroscopic image. Sensor information is received from the fiber optic shape sensor and used to calculate the sensed position and orientation of indicator portion 368 in the sensor frame of reference. Based on the alignment of the instrument sensor frame of reference to the anatomy model frame of reference (or other common frame of reference) in process 454, the position and / or orientation of the indicator portion in the sensor frame (i.e., the sensed pose) is transformed to the anatomy model frame of reference in process 458. For example, determining the detected position of the radiopaque portion of the medical device in the anatomical structure model coordinate system includes referencing a set of coordinates of the sensor position information in the sensor coordinate system with a corresponding set of coordinates in the anatomical structure model coordinate system.

[0073] In process 460, fluoroscopy system 370 captures fluoroscopic image data of patient P and catheter 360 extended within the patient. One or more fluoroscopic images rendered from the fluoroscopic image data are acquired while indicator portion 368 is located at or in contact with anatomical location L. The images acquired while indicator portion 368 is at location L may be from a single perspective or may be a multi-planar set of images (including a biplanar set of images) showing indicator portion 368 from multiple perspectives at the same time and location. In some examples, catheter 360 can be positioned outside the patient such that indicator portion 368 is visually adjacent to location L of the anatomical structure in one or more fluoroscopic images.

[0074] In process 462, indicator portion 368 is identified within the fluoroscopic image data, and thus the location of location L in the fluoroscopic frame of reference. In various embodiments, fluoroscopy system 370 is capable of generating multi-planar images, and thus a three-dimensional fluoroscopic frame of reference (X F , Y F , Z F ) The use of multiple images also allows for the determination of the orientation of indicator portion 368, thus providing pose information regarding the indicator portion. In other embodiments, the fluoroscopy system may provide a two-dimensional fluoroscopic reference frame.

[0075] Various techniques may be used to extract the location of indicator portion 368 within the fluoroscopic image, and thus the indicated location L within the fluoroscopic reference frame. In one embodiment, referring to FIGS. 9A and 9B , indicator portion 368 may be identified within the image data by comparing image 600, in which indicator portion 368 is absent, with image 610, in which indicator portion 368 is present. The two images are analyzed, for example, by a computer in control system 112, to determine graphical differences between the two images. Because the patient's anatomy in the images is the same in the two images, catheter 360, including indicator portion 368, is identifiable as a unique structure in image 610. By identifying graphical components (e.g., pixels, voxels) associated with the identified catheter 360, the presence and location of indicator portion 368 within the fluoroscopic frame may be calculated. Because indicator portion 368 is located at location L, the location of location L is also determined by the graphical analysis that extracts the indicator portion.

[0076] 9B and 9C , indicator portion 368 can be identified in the image data by comparing image 620, in which indicator portion 368 is at location K, with image 610, in which indicator portion 368 is at location L. The two images are analyzed, for example, by a computer in control system 112, to determine graphical differences between the two images. Because the patient's anatomical structure portions of the images are the same in the two images, catheter 360, including indicator portion 368, is identifiable as a unique structure in each image 610, 620. By identifying the graphical component associated with the identified distal end of catheter 360, the presence and location of indicator portion 368 in the fluoroscopic frame of each image can be calculated. Because indicator portion 368 is located at locations L and K, the locations of locations L and K are also determined by the graphical analysis that extracts the indicator portion.

[0077] 13A , the indicator portion 368 may be identified within the image data by a semi-automated extraction technique in which a fluoroscopic image 1000 including an instrument 1002 is displayed to a user. The user uses an input device, such as a touchscreen, mouse, trackball, or eye contact, to create an outline 1004 of the instrument 1002 or a portion of the instrument, such as the distal tip. Based on the outline 1004 input received from the user, a segmentation algorithm identifies features (e.g., pixel shading, size) of the instrument 1002 within the image 1000 and proceeds to segment (e.g., pixels or voxels) the image corresponding to the instrument.

[0078] 13B , the indicator portion 368 may be identified within the image data by a semi-automated extraction technique in which a fluoroscopic image 1010 including an instrument 1022 is displayed to the user. A search region 1014 may be identified by the user or predefined within the image (e.g., the lower left quadrant of the image) to search for an entry point 1016 of the medical instrument into the image. The segmentation algorithm may search for a predetermined shape related to the expected shape of the medical instrument (e.g., expected continuity or saturation of shading, expected width, expected length, expected curvature). After the segmentation algorithm identifies the medical instrument in the image 1010, the algorithm proceeds to segment (e.g., pixels or voxels) the image corresponding to the instrument.

[0079] In another embodiment, the expected shape is defined by shape information received from a shape sensor, and the expected shape is used to identify an initial search area for use by the semi-automated extraction technique. The segmentation algorithm may further search for the expected shape within the initial search area to minimize time and computational resources. After the segmentation algorithm identifies the expected shape, the algorithm proceeds to divide a segment (e.g., pixel or voxel) of the image corresponding to the instrument.

[0080] In another embodiment, indicator portion 368 can be identified by graphically analyzing and recognizing the captured fluoroscopic image for a predetermined (i.e., expected or previously known) radiopaque shape, such as a shape measured by a shape sensor or a predetermined (i.e., expected or previously known) shape or marker on the end of the catheter. For example, the known shape of a needle extending from the catheter or a fixture on the end of the catheter can be discovered and extracted from the image. Graphical recognition of these indicator portions in the fluoroscopic image provides the location of the touch location L in the fluoroscopic frame.

[0081] Referring again to FIG. 6 , in process 464, the fluoroscopic image frame of reference is registered to the anatomical model frame of reference. Alternatively, both the fluoroscopic image frame of reference and the anatomical model frame of reference are registered to a common frame of reference, such as a surgical frame of reference. Since process 462 provides the position and orientation of indicator portion 368 at position L in the fluoroscopic image frame of reference and process 458 provides the position and orientation of indicator portion 368 at position L in the model frame of reference, the respective frame positions of indicator portion 368 are correlated to register the frames together. Processes 456, 458, 460, and 462 may be repeated for multiple positions of indicator portion 368 at multiple locations within the patient's anatomy. The registration in process 464 can be performed or enhanced by relating these multiple positions in the respective frames and performing rigid or non-rigid transformations of the points corresponding to the multiple positions.

[0082] In process 466, with reference to FIGS. 10 and 11, as the catheter traverses the patient's anatomy, the registered frame of reference is displayed, allowing the clinician viewing the displayed image(s) to take advantage of real-time instrument tracking within the fluoroscopic image along with the anatomical details of the prior-time image (e.g., CT image). FIG. 10 illustrates the fluoroscopic frame of reference (X F , Y F , Z F ) and the model reference frame (X M , Y M , Z M 7 shows a display 700 displaying a prior-time model image 720 (such as, by way of non-limiting example, a CT image acquired by CT technology or an image acquired by any other suitable imaging technology) having a fluoroscopic frame of reference. The fluoroscopic frame of reference and the model frame of reference are aligned, and the aligned images are displayed side-by-side. With the frames of reference aligned, structures from one image may optionally be superimposed or overlaid on the other image to assist the clinician in performing the medical procedure. For example, catheter 360, which is visible in fluoroscopic image 710, can be extracted and overlaid on image 710. Additionally or alternatively, target tissue 730 (e.g., a tumor), which is visible in image 720, may be extracted and overlaid on fluoroscopic image 720.

[0083] 11 shows a display 800 displaying a single image 810 in which previous image data 820 is overlaid on fluoroscopic image data 830. In some embodiments (not shown), a path to the target tissue may be planned in the previous model image data and displayed in the previous model image (e.g., a CT image). The path may then be extracted and overlaid on the fluoroscopic image data.

[0084] Optionally, after the fluoroscopic image data is registered to the anatomical model, important features can be viewed and analyzed from two-dimensional or three-dimensional images generated from the fluoroscopic image data, the anatomical model, or a combination of the two. For example, shading in the fluoroscopic image data can indicate a tumor or indicate where to look for a tumor in the segmented CT data used to generate the anatomical model.

[0085] Optionally, a virtual fluoroscopic view may be generated after the fluoroscopic image data is registered to the anatomical model. This registration indicates the fluoroscopic image plane relative to the model, so that a virtual view of the patient's anatomy from another plane of view may be generated. For example, a virtual view from a plane orthogonal to the actual fluoroscopic image plane may be generated from the anatomical model to provide the clinician with an experience closer to a biplanar fluoroscopic image.

[0086] Additionally or optionally, with the fluoroscopic view registered to the anatomical model, anatomical features such as target tissue, tumors, or other landmarks can be identified in the fluoroscopic image and used to locate corresponding features in the anatomical model. For example, a tumor can be visible in the fluoroscopic view to help identify the corresponding tumor in the anatomical model. Once identified in the anatomical model, the tumor can be labeled as a target, and a navigation path to the target can be planned within the anatomical model.

[0087] FIG. 7 is a flow chart illustrating another method 500 for performing image-guided surgery in a surgical environment 350. The methods of this description, including method 500, are illustrated in FIG. 7 as a set of blocks, steps, operations, or processes. Not all of the illustrated, enumerated operations are performed in all embodiments of method 500. In addition, some additional operations not explicitly illustrated in the method may be included before, after, between, or as part of the enumerated processes. Some embodiments of the methods of this description include instructions corresponding to the method processes stored in a memory. These instructions may be executed by a processor, such as the processor of control system 112.

[0088] Method 500 includes the aforementioned process 452 of acquiring prior imaging data of the patient's anatomy, such as a pre-operative CT scan, and process 454 of aligning the instrument sensor frame of reference to the anatomical model frame of reference. The series of processes 502 describes subprocesses for collecting and matching anatomical landmark points and aligning the fluoroscopic and model frames of reference. In process 508, fluoroscopy system 370 captures fluoroscopic image data of patient P and catheter 360 while indicator portion 368 is placed in contact with or adjacent to an anatomical landmark visible in a fluoroscopic image generated from the image data. The anatomical landmark may be any unique structure visible under fluoroscopy, such as the spine, rib cage, sternum, collarbone, diaphragm, vasculature, or a visible portion of the airway tree. In process 510, indicator portion 368 is identified in the fluoroscopic image data, thus identifying the location of the indicated anatomical landmark in the fluoroscopic frame of reference. In various embodiments, the fluoroscopy system 370 is capable of generating multi-planar images and therefore a three-dimensional fluoroscopic reference frame (X F , Y F , Z F) can be provided. In other embodiments, the fluoroscopy system can provide a two-dimensional fluoroscopic reference frame. Methods for extracting indicator portions from fluoroscopic image data are described above. In process 512, the same anatomical landmark is selected in the anatomical model and correlated with the anatomical landmark in the fluoroscopic image data. For example, while the indicator portion of the catheter is in contact with the anatomical landmark (as seen by the clinician in the real-time fluoroscopic image), the user can touch a touchscreen displaying the anatomical model at the location of the anatomical landmark. Other marking methods for locating the anatomical landmark in the model may also be used. Thus, the coordinates of the anatomical landmark in the fluoroscopic reference frame and the coordinates of the anatomical landmark in the model reference frame can be correlated. In FIG. 12, a correlation table 900 can be compiled that references each landmark 910 to a location 920 in the fluoroscopic reference frame and a location 930 in the model reference frame. Process 502 can be repeated for each of multiple anatomical landmarks. For example, three or more anatomical landmarks can be selected.

[0089] In process 514, the fluoroscopic image frame of reference is registered to the anatomical model frame of reference. Anatomical landmark point registration is described in U.S. Provisional Patent Applications Nos. 62 / 205,440 and 62 / 205,433, which are incorporated herein by reference. For example, a set of anatomical reference points in the fluoroscopic image are matched with anatomical landmark points in the model. One or both sets of matched points are then rotated, translated, or otherwise manipulated by rigid or non-rigid transformations to align the fluoroscopic and model frames of reference. In process 516, with reference to FIGS. 10 and 11 , the registered frame of reference is displayed as the catheter passes through the patient's anatomy, allowing a clinician viewing the displayed image to take advantage of real-time instrument tracking within the fluoroscopic image along with the anatomical details of previous images (e.g., CT images).

[0090] 8 is a flowchart illustrating a sub-process 550 that may be used in method 500 to replace process 502. In process 552, a fluoroscopy system 370 captures fluoroscopic image data of the patient P and catheter 360 while indicator portion 368 passes through a passageway in the patient's anatomy. In process 554, multiple location points of indicator portion 368 are identified within the fluoroscopic image data, and thus the positions of the location points within the fluoroscopic frame of reference. In this embodiment, fluoroscopy system 370 is capable of generating multi-planar images, and thus a three-dimensional fluoroscopic frame of reference (X ). F , Y F , Z F) can be provided. In other embodiments, the fluoroscopy system can provide a two-dimensional fluoroscopic reference frame. Methods for extracting indicator portions from fluoroscopic image data are described above. In process 556, the fluoroscopic image reference frame is registered to the anatomical model reference frame. Point cloud registration is described in U.S. Provisional Patent Applications Nos. 62 / 205,440 and 62 / 205,433, which are incorporated herein by reference. For example, a set of anatomical reference points in the fluoroscopic image are rotated, translated, or otherwise manipulated by rigid or non-rigid transformations to match model points in the anatomical model (e.g., model points received from a previous or simultaneous CT scan of the passageway). ICP or other point registration techniques register the fluoroscopic and model reference frames.

[0091] 14 is a flowchart illustrating a method 1100 for performing image-guided surgery in a surgical environment 350. Method 1100 begins with process 1102, in which previous image data, including pre-operative or intra-operative image data, is acquired from an imaging technique such as CT, MRI, thermography, ultrasound, OCT, thermal imaging, impedance imaging, laser imaging, or nanotube X-ray imaging. The previous image data may correspond to two-dimensional, three-dimensional, or four-dimensional (e.g., including time-based or velocity-based information) images. As described above, an anatomical structure model is created from the previous image data. In process 1104, shape sensor information is received from the medical instrument while an indicator portion of the medical instrument is positioned at location L within the patient's anatomy.

[0092] In process 1106, fluoroscopy system 370 captures fluoroscopic image data of patient P and catheter 360 extended within the patient. One or more fluoroscopic images rendered from the fluoroscopic image data are acquired while indicator portion 368 is located at or in contact with the anatomical structure at location L. The images acquired while indicator portion 368 is at location L may be from a single viewpoint or may be a multi-planar image set (including a bi-planar image set) showing indicator portion 368 from multiple viewpoints at the same time and in the same location.

[0093] In process 1108, the shape of the catheter 360 is identified in the fluoroscopic image data, and thus the location of location L (at the distal tip of the catheter) in the fluoroscopic frame of reference is also identified. In various embodiments, the fluoroscopy system 370 is capable of generating multi-planar images, and thus a three-dimensional fluoroscopic frame of reference (X F , Y F , Z F ) in a fluoroscopy image. In other embodiments, the fluoroscopy system can provide a two-dimensional fluoroscopic reference frame. Various embodiments for extracting the catheter shape and / or indicator portion pose are described above. In process 1110, the shape sensor information from process 1110 is compared to shape information determined from the fluoroscopic image data. If the shape sensor becomes twisted or sharply bent, the shape information determined from the fiber optic shape sensor may contain inaccuracies. Additionally, because errors accumulate over the length of the fiber optic shape sensor, the shape and distal tip position may become more inaccurate for longer instruments. The accuracy of the sensor information may be improved by fusing instrument shape information received from multiple sources. In process 1110, the shape sensor information from the medical instrument is corrected based on the fluoroscopic image shape information. For example, the distal tip position in the shape sensor information may be adjusted to the distal tip position in the fluoroscopic image shape information. In another example, the shape information may be averaged or corrected only along portions where inaccuracies are expected (e.g., the distal tip portion).

[0094] In process 1112, the modified instrument sensor information is registered to the anatomical model using any of the registration methods previously described. In process 1114, an image-guided medical procedure is performed using the medical instrument with the modified sensor information providing more accurate localization of the instrument distal tip. Based on the localized distal tip of the instrument, a virtual image of the patient's anatomy from the perspective (position and orientation) of the distal tip can be generated from the anatomical model. Additionally, based on the localized distal tip of the instrument, a virtual image of the medical instrument overlaid on an image from the anatomical model can be used to guide the movement of the medical instrument.

[0095] FIG. 15 illustrates a method 1200 for determining a preferred fluoroscopic view plane. In process 1202, previous image data, including pre-operative or intra-operative image data, is acquired from an imaging technique such as CT, MRI, thermography, ultrasound, OCT, thermal imaging, impedance imaging, laser imaging, or nanotube X-ray imaging. The previous image data may correspond to two-dimensional, three-dimensional, or four-dimensional (e.g., including time-based or velocity-based information) images. As described above, an anatomical structure model is created from the previous image data. In process 1204, the instrument sensor 222 of the medical instrument 200 is registered to the anatomical structure model as described above for process 454 of method 450. In process 1206, a preferred fluoroscopic view plane is determined to enable the clinician to visualize the movement of the distal tip of the catheter, the movement of a biopsy needle or other tool exiting the distal tip of the catheter, and / or tissue regions engaged by the tool (e.g., tumor) or avoided by the tool (e.g., lung pleura to avoid perforation). More specifically, a preferred fluoroscopy plane can be selected by determining the pose of the distal tip of the instrument from the shape sensor information. The preferred fluoroscopy plane can be generally parallel to the pose of the distal tip of the instrument (e.g., the view plane of FIG. 13B ). Additionally or alternatively, the preferred fluoroscopy plane may be determined by measuring the distance between the distal tip of the instrument and the tissue region of interest and determining the fluoroscopy view plane that provides the greatest distance. This fluoroscopy view plane will be generally parallel to the trajectory between the distal tip of the instrument and the tissue region, and therefore will provide the clinician with the most accurate information as to whether the biopsy needle intercepted the target tissue region or avoided regions that would injure the patient.

[0096] 16 illustrates a method 1300 for driving a medical instrument under two-dimensional fluoroscopic guidance. In process 1302, fluoroscopic image data of a patient's anatomy in a surgical reference frame is acquired from a fluoroscopy system 370. The orientation of the fluoroscopy system, and therefore the orientation of the imaging plane, can be determined by a variety of methods, including the use of an external tracking system, imaged reference points, or shape-sensing data as described above for method 450. A description of determining the fluoroscopic imaging plane can be found in U.S. Provisional Application No. 62 / 216,494, filed September 10, 2015, entitled "Systems and Methods of Pose Estimation and Calibration of Perspective Imaging System in Image Guided Surgery," which is incorporated herein by reference in its entirety. In some examples, a graphical rendering of the fluoroscopy system can be generated to facilitate acquiring a fluoroscopic image in the desired fluoroscopic image plane. In particular, such rendering may assist a user in positioning elements of the fluoroscopy system (e.g., a fluoro arm or an X-ray imager) to properly capture a fluoroscopic image in a desired or predetermined fluoroscopic plane. In some examples, the system or user may receive a set of joint configurations for the fluoroscopy system to better achieve a system configuration for acquiring fluoroscopic images in a desired or predetermined fluoroscopic image plane. In process 1304, a two-dimensional fluoroscopic image is generated for display from the fluoroscopic image data. The displayed image has an orientation plane based on the orientation plane of the imaging plane. In process 1306, the control system 112 receives commands to drive the movement of the catheter system 202. In process 1308, the movement of the catheter system 202 or a portion of the catheter is constrained to the plane of the orientation plane of the displayed fluoroscopic image. In one embodiment, only the movement of an indicator portion of the catheter may be constrained to the orientation plane of the fluoroscopic image.Movement of the indicator portion of the catheter can be constrained by limiting the movement of an operator control in the teleoperated system, thereby preventing the operator from moving the control in a direction that would move the catheter portion out of the constraining plane. Additionally or alternatively, movement of the indicator portion of the catheter may be constrained by limiting the movement of at least one actuator or actuation cable in the teleoperated manipulator assembly. Despite the constraints on the operator control or the instrument's actuation mechanism in the open-loop constraining system described above, the indicator portion of the catheter may still experience constrained out-of-plane movement due to anatomical forces from adjacent tissue. In a closed-loop system, sensor information received from shape, position, or other sensors of the medical instrument can be received and analyzed by the control system to recognize movement of the indicator portion out of the plane of orientation of the fluoroscopic image. In response to the recognized out-of-plane movement, the control system can provide a signal or command to adjust the indicator portion back into the plane of orientation. In some examples, the signal and / or command to adjust the indicator portion may be overridden or ignored. In other examples, the signal and / or command to adjust the indicator portion may automatically adjust the indicator portion back into the plane of orientation. In various embodiments, one or more additional fluoroscopic images can be acquired from an orthogonal or other non-parallel plane to the constraining plane, allowing the clinician to observe movement of the indicator portion outside of the constraining plane. In various embodiments, constraining movement of the indicator portion to the orientation plane of the displayed fluoroscopic image can be initiated by activation of an operator-controlled switch, which may include a manual switch, a voice-activated switch, a foot-activated switch, or another operator control mechanism. Additionally or alternatively, constraining movement of the indicator portion to the orientation plane of the displayed fluoroscopic image may be initiated by control system 112 in response to the display of a fluoroscopic image or a recognition that the operator is viewing a fluoroscopic image.

[0097] While this disclosure describes various systems and methods for teleoperated systems, they are also contemplated for use in non-teleoperated systems in which the manipulator assemblies and instruments are directly controlled. While the various examples provided illustrate use in procedures performed within the anatomy, in alternative embodiments, the devices and methods of this disclosure need not be used within the anatomy, but rather can be used outside the patient's anatomy.

[0098] One or more elements of an embodiment of the present invention may be implemented in software to run on a processor of a computer system such as the control system 112. When implemented in software, the elements of an embodiment of the present invention are essentially code segments to perform the necessary tasks. Programs or code segments can be stored in a non-transitory processor-readable storage medium or device, including any medium capable of storing information, including optical, semiconductor, and magnetic media. Examples of processor-readable storage devices include electronic circuits; semiconductor devices, semiconductor memory devices, read-only memories (ROMs), flash memories, erasable programmable read-only memories (EPROMs); floppy diskettes, CD-ROMs, optical disks, hard disks, or other storage devices. Code segments can be downloaded via a computer network such as the Internet, an intranet, or the like.

[0099] It should be noted that the presented processes and displays are not inherently related to any particular computer or other apparatus. The necessary components for a variety of these systems may appear as elements in the claims. Additionally, embodiments of the present invention are not described with reference to any particular programming language. It will be understood that a variety of programming languages ​​may be used to implement the teachings of the present invention as described herein.

[0100] While certain exemplary embodiments of the present invention have been described and are shown in the accompanying drawings, it is to be understood that such embodiments are merely illustrative of the broad invention and are not limiting, and that since various other modifications may occur to those skilled in the art, the embodiments of the present invention are not limited to the specific constructions and configurations shown and described.

[0101] The following additional note is added: (Supplementary Note 1) A method implemented by a computer system, comprising: receiving a fluoroscopic image of a patient's anatomy while a portion of a medical instrument is positioned within the patient's anatomy, the fluoroscopic image having a fluoroscopic frame of reference, the portion having a sensed position in an anatomical model frame of reference; identifying the portion in the fluoroscopic image; using the portion identified in the fluoroscopic image to identify an extraction location of the portion in the fluoroscopic reference frame; registering the fluoroscopic frame of reference to the anatomical structure model frame of reference based on the sensed position of the portion and the extracted position of the portion; A method comprising: (Supplementary Note 2) The method further includes using the portion identified in the fluoroscopic image to identify an extracted orientation of the portion in the fluoroscopic reference frame; the portion has a sensed orientation in the anatomical model frame of reference; registering the fluoroscopy frame of reference to the anatomical structure model frame of reference further comprises: registering the fluoroscopy frame of reference to the anatomical structure model frame of reference based on the detected orientation of the part and the extracted orientation of the part; The method described in Appendix 1. (Supplementary Note 3) The step of identifying the portion in the fluoroscopic image includes the step of identifying an expected shape of the portion in the fluoroscopic image. The method described in Appendix 1. (Supplementary Note 4) The step of identifying the portion in the fluoroscopic image includes comparing the fluoroscopic image of the patient's anatomical structure while the portion of the medical instrument is positioned within the patient's anatomical structure with a fluoroscopic image of the patient's anatomical structure recorded when the portion of the medical instrument is not positioned within the patient's anatomical structure. The method described in Appendix 1. (Supplementary Note 5) The step of identifying the portion in the fluoroscopic image includes comparing the fluoroscopic image of the patient's anatomical structure while the portion of the medical instrument is positioned at a first position within the patient's anatomical structure with a fluoroscopic image of the patient's anatomical structure recorded when the portion of the medical instrument is positioned at a second position within the patient's anatomical structure. The method described in Appendix 1. (Supplementary Note 6) The method further includes receiving a set of model points for an anatomical structure model of a passageway of the patient's anatomical structure in the anatomical structure model reference frame. The method described in Appendix 5. (Supplementary Note 7) The set of model points for the anatomical structure model of the passageway is generated from a computed tomography scan. The method described in Appendix 6. (Supplementary Note 8) The method further includes displaying the portion of the medical instrument within a co-registered image of a portion of the fluoroscopic image and a portion of the anatomical structure model. The method described in Appendix 6. (Supplementary Note 9) Identifying and displaying a target tissue within the anatomical structure model; overlaying the target tissue in the co-registered image of the portion of the fluoroscopic image; further comprising: The method described in Appendix 8. (Supplementary Note 10) Planning a path to the target tissue in the anatomical structure model; overlaying the pathway in the co-registered image of the portion of the fluoroscopic image; further comprising: The method described in Appendix 9. (Supplementary Note 11) receiving sensor position information from a position sensor of the medical instrument to determine the sensed position of the portion of the medical instrument, the sensor position information being within a sensor reference frame; aligning the anatomy model frame of reference and the sensor frame of reference, the anatomy model frame of reference being associated with an anatomy model of an anatomy passageway of the patient's anatomy; determining the sensed position of the portion in the anatomical model frame of reference from the alignment of the anatomical model frame of reference and the sensor frame of reference; further comprising: The method described in Appendix 1. (Supplementary Note 12) The position sensor is a fiber optic shape sensor extending along the medical instrument. The method described in Appendix 11. (Supplementary Note 13) The step of determining the sensed position of the portion of the medical instrument in the anatomical structure model frame of reference comprises referencing a set of coordinates of the sensor position information in the sensor frame of reference with a corresponding set of coordinates in the anatomical structure model frame of reference. The method described in Appendix 11. (Supplementary Note 14) The step of aligning the anatomical structure model reference frame and the sensor reference frame comprises: receiving a set of model points for the anatomical structure model; receiving a set of measurement points collected within the anatomical passageway, each point having coordinates within the sensor reference frame; matching the measurement points of the set of measurement points to the model points of the set of model points to generate a set of matches; moving the set of measurement points relative to the set of model points based on the set of matches; Including, The method described in Appendix 11. (Supplementary Note 15) A method implemented by a computer system, comprising: identifying a set of locations of a plurality of anatomical landmarks, the plurality of anatomical landmarks being rendered within an anatomical model of a passageway of the patient's anatomy in a model reference frame; receiving fluoroscopic image data of the patient's anatomy while a portion of a medical instrument passes through the plurality of anatomical landmarks in the passageway of the patient's anatomy, the fluoroscopic image data having a fluoroscopic frame of reference; identifying a set of locations of the portion of the medical instrument at the plurality of anatomical landmarks in the fluoroscopic reference frame; registering the set of positions of the plurality of anatomical landmarks in the model frame of reference and the set of positions of the portion of the medical instrument at the plurality of anatomical landmarks in the fluoroscopic frame of reference to a common frame of reference; A method comprising: (Supplementary Note 16) The step of identifying the set of positions of the portion of the medical instrument in the fluoroscopy frame of reference includes identifying a predetermined shape of the portion of the medical instrument in the fluoroscopy frame of reference. The method described in Appendix 15. (Supplementary Note 17) The step of identifying the set of positions of the portion of the medical instrument in the fluoroscopic reference frame includes comparing the fluoroscopic image data of the patient's anatomical structure while the portion of the medical instrument is positioned at at least one of the plurality of anatomical landmarks with fluoroscopic image data of the patient's anatomical structure recorded when the portion of the medical instrument is not positioned in the patient's anatomical structure. The method described in Appendix 15. (Supplementary Note 18) The step of identifying the set of positions in the fluoroscopic reference frame includes comparing the fluoroscopic image data of the patient's anatomy while the portion of the medical instrument is positioned at at least one of the plurality of anatomical landmarks with images of the patient's anatomy recorded when the portion of the medical instrument is positioned elsewhere in the patient's anatomy. The method described in Appendix 15. (Supplementary Note 19) The method further includes displaying co-registered images of a portion of the fluoroscopic image, a portion of the anatomical structure model, and the portion of the medical instrument. The method described in Appendix 15. (Supplementary Note 20) The common reference frame is the model reference frame. The method described in Appendix 15. (Supplementary Note 21) The common reference frame is the fluoroscopy reference frame. The method described in Appendix 15. (Supplementary Note 22) A method implemented by a computer system, comprising: receiving a set of model points for an anatomical model of a passageway of the patient's anatomy in a model reference frame; receiving fluoroscopic image data of the patient's anatomy while an indicator portion of a medical instrument passes through the passageway of the patient's anatomy, the fluoroscopic image data having a fluoroscopic frame of reference; identifying a set of indicator portion location points in the fluoroscopic reference frame from the fluoroscopic image data; matching each said indicator portion location point with a model point in said set of model points to generate a set of matches; registering the model frame of reference to the fluoroscopic frame of reference based on the set of matches; A method comprising: (Supplementary Note 23) The step of identifying the set of indicator portion location points in the fluoroscopic reference frame includes identifying an expected shape of the indicator portion in the fluoroscopic reference frame. 23. The method described in Appendix 22. (Supplementary Note 24) The step of identifying the set of indicator portion location points in the fluoroscopic reference frame includes comparing the fluoroscopic image data of the patient's anatomical structure while the indicator portion of the medical instrument is positioned with the patient's anatomical structure recorded when the indicator portion of the medical instrument is not positioned within the patient's anatomical structure. 23. The method described in Appendix 22. (Supplementary Note 25) The method further includes displaying a co-registered image of a portion of the fluoroscopic image generated from the fluoroscopic image data, a portion of the anatomical structure model, and the indicator portion of the medical instrument. 23. The method described in Appendix 22. (Supplementary Note 26) The step of registering the model reference frame to the fluoroscopic reference frame based on the set of matches comprises moving the set of indicator portion location points relative to the set of model points based on the set of matches. 23. The method described in Appendix 22. (Supplementary Note 27) A computer-assisted medical system comprising: a fluoroscopic imaging device within the surgical coordinate space; a processing unit including one or more processors; The processing unit: receiving a fluoroscopic image having an orientation plane of the patient's anatomy from the fluoroscopic imaging device while a portion of the medical device is positioned at a location within the patient's anatomy; receiving a command to drive movement of the portion of the medical instrument; constraining actuation of the portion such that actuated movement of the portion is constrained to the orientation plane of the fluoroscopic image; driving the movement of said part with said constrained actuation; It is configured as follows: Computer-assisted medical systems. (Supplementary Note 28) The processing unit is further configured to display the fluoroscopic image. 28. The computer-assisted medical system of claim 27. (Supplementary Note 29) The processing unit is further configured to display a second fluoroscopic image having a second orientation plane in which the unactuated movement of the portion is visible. 29. The computer-assisted medical system of claim 28. (Supplementary Note 30) The processing unit: receiving sensor information from the medical instrument while driving the movement of the portion with the constrained actuation; recognizing movement of the portion of the fluoroscopic image outside the orientation plane from the received sensor information; transmitting a signal to adjust the portion of the medical instrument into the orientation plane of the fluoroscopic image; further configured as follows: 28. The computer-assisted medical system of claim 27. (Supplementary Note 31) The sensor information is received from an optical fiber shape sensor. 31. The computer-assisted medical system of claim 30. (Supplementary Note 32) Constraining the operation of the part includes constraining movement of an operator control device of a remote operation control system. 28. The computer-assisted medical system of claim 27. (Supplementary Note 33) Constraining the actuation of the part includes constraining movement of at least one actuator of a remotely operated manipulator assembly. 28. The computer-assisted medical system of claim 27. (Supplementary Note 34) The restraining of the operation of the part is in response to the operation of a control switch. 28. The computer-assisted medical system of claim 27. (Supplementary Note 35) A method implemented by a computer system, comprising: receiving an anatomical model of a patient's anatomy, wherein a region of interest is identified in the anatomical model; receiving shape sensor data from an instrument shape sensor of an instrument positioned within the patient's anatomy and registered to the anatomical model; determining a fluoroscopic image plane for display based on the received shape sensor data and the region of interest; A method comprising: (Supplementary Note 36) The instrument shape sensor is disposed at a distal tip portion of the instrument, and the step of determining the fluoroscopic image plane includes: determining a pose of the distal tip portion of the instrument from the received shape sensor data; determining a distance between the distal tip portion of the instrument and the region of interest; Including, The method described in Appendix 35. (Supplementary Note 37) The step of determining the fluoroscopic image plane further includes the step of determining the fluoroscopic image plane in which the distance between the distal tip portion of the instrument and the region of interest is maximum. The method described in Appendix 36. (Supplementary Note 38) The step of determining the fluoroscopy image plane further includes determining the fluoroscopy image plane to be parallel to the orientation of the distal tip portion. The method described in Appendix 36. (Supplementary Note 39) The instrument shape sensor is an optical fiber shape sensor. The method described in Appendix 35. (Supplementary Note 40) The method further includes providing a graphical rendering of a fluoroscopy system configured to acquire a fluoroscopy image at the determined fluoroscopy image plane. The method described in Appendix 35. (Supplementary Note 41) The method further includes providing a set of joint configurations for a fluoroscopy system to achieve a system configuration for acquiring a fluoroscopy image in the determined fluoroscopy image plane. The method described in Appendix 35.

Claims

1. A non-transitory computer-readable medium having stored thereon instructions that, when executed by one or more processors, cause the one or more processors to: receiving a set of model points for an anatomical model of a passageway of the patient's anatomy in a model coordinate system; receiving fluoroscopic image data of the patient's anatomy while an indicator portion of a medical instrument passes through the passageway of the patient's anatomy, the fluoroscopic image data having a fluoroscopic coordinate system; identifying a set of indicator portion location points in the fluoroscopic coordinate system from the fluoroscopic image data; matching each said indicator portion location point with a model point in said set of model points to generate a set of matches; registering the model coordinate system to the fluoroscopy coordinate system based on the set of matches; adapted to perform a method comprising: Non-transitory computer-readable medium.

2. and identifying the set of indicator portion location points in the fluoroscopy coordinate system includes identifying an expected shape of the indicator portion in the fluoroscopy coordinate system. The non-transitory computer-readable medium of claim 1 .

3. the expected shape of the indicator portion in the fluoroscopic coordinate system is determined from shape information received from a shape sensor of the medical instrument. The non-transitory computer-readable medium of claim 2 .

4. identifying the set of indicator portion location points in the fluoroscopic coordinate system includes comparing the fluoroscopic image data of the patient's anatomy while the indicator portion of the medical instrument is positioned within the patient's anatomy with image data of the patient's anatomy recorded when the indicator portion of the medical instrument is not positioned within the patient's anatomy; The non-transitory computer-readable medium of claim 1 .

5. the instructions are further adapted to cause the one or more processors to perform the step of displaying co-registered images of a portion of a fluoroscopic image generated from the fluoroscopic image data, a portion of the anatomical structure model, and the indicator portion of the medical instrument. The non-transitory computer-readable medium of claim 1 .

6. and registering the model coordinate system to the fluoroscopy coordinate system based on the set of matches comprises moving the set of indicator portion location points relative to the set of model points based on the set of matches. The non-transitory computer-readable medium of claim 1 .

7. the fluoroscopy image data includes multiplanar image data, and the fluoroscopy coordinate system is a three-dimensional coordinate system; The non-transitory computer-readable medium of claim 1 .

8. the fluoroscopic image data includes single-plane image data, and the fluoroscopic coordinate system is a two-dimensional coordinate system; The non-transitory computer-readable medium of claim 1 .

9. a fluoroscopic imaging system; medical devices and; A processing unit comprising: receiving a set of model points for an anatomical model of a passageway of the patient's anatomy in a model coordinate system; receiving fluoroscopic image data of the patient's anatomy from the fluoroscopic imaging system while an indicator portion of the medical instrument passes through the passageway of the patient's anatomy, the fluoroscopic image data having a fluoroscopic coordinate system; identifying a set of indicator portion location points in the fluoroscopic coordinate system from the fluoroscopic image data; matching each of the indicator portion location points with a model point in the set of model points to generate a set of matches; registering the model coordinate system to the fluoroscopy coordinate system based on the set of matches; a processing unit including one or more processors configured to: Computer-assisted medical systems.

10. and identifying the set of indicator portion location points in the fluoroscopy coordinate system includes identifying an expected shape of the indicator portion in the fluoroscopy coordinate system. The computer-assisted medical system of claim 9.

11. the expected shape of the indicator portion in the fluoroscopic coordinate system is determined from shape information received from a shape sensor of the medical instrument. The computer-assisted medical system of claim 10.

12. identifying the set of indicator portion location points in the fluoroscopic coordinate system includes comparing the fluoroscopic image data of the patient's anatomy while the indicator portion of the medical instrument is positioned within the patient's anatomy with image data of the patient's anatomy recorded when the indicator portion of the medical instrument is not positioned within the patient's anatomy. The computer-assisted medical system of claim 9.

13. the one or more processors are further configured to display co-registered images of a portion of the fluoroscopic image generated from the fluoroscopic image data, a portion of the anatomical model, and the indicator portion of the medical instrument. The computer-assisted medical system of claim 9.

14. and registering the model coordinate system to the fluoroscopic coordinate system based on the set of matches includes moving the set of indicator portion location points relative to the set of model points based on the set of matches. The computer-assisted medical system of claim 9.

15. the fluoroscopy image data includes multiplanar image data, and the fluoroscopy coordinate system is a three-dimensional coordinate system; The computer-assisted medical system of claim 9.

16. the fluoroscopic image data includes single-plane image data, and the fluoroscopic coordinate system is a two-dimensional coordinate system; The computer-assisted medical system of claim 9.

17. A method executed by a computer system comprising: receiving a set of model points for an anatomical model of a passageway of the patient's anatomy in a model coordinate system; receiving fluoroscopic image data of the patient's anatomy while an indicator portion of a medical instrument passes through the passageway of the patient's anatomy, the fluoroscopic image data having a fluoroscopic coordinate system; identifying a set of indicator portion location points in the fluoroscopic coordinate system from the fluoroscopic image data; matching each said indicator portion location point with a model point in said set of model points to generate a set of matches; and registering the model coordinate system to the fluoroscopy coordinate system based on the set of matches. method.

18. and identifying the set of indicator portion location points in the fluoroscopy coordinate system includes identifying an expected shape of the indicator portion in the fluoroscopy coordinate system.

18. The method of claim 17.

19. the expected shape of the indicator portion in the fluoroscopic coordinate system is determined from shape information received from a shape sensor of the medical instrument.

20. The method of claim 18.

20. identifying the set of indicator portion location points in the fluoroscopic coordinate system includes comparing the fluoroscopic image data of the patient's anatomy while the indicator portion of the medical instrument is positioned within the patient's anatomy with image data of the patient's anatomy recorded when the indicator portion of the medical instrument is not positioned within the patient's anatomy; 18. The method of claim 17.

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