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Tracking and Navigation Systems
455
example, the intraoperative matching of the actual anatomy with the preop­eratively gained 3D dataset could be significantly enhanced by intracanalicular FBGs. Likewise , the configuration of an endoscope could easily be described in real-time (which is currently done by EM tracking) (see
Section 11.2:
Electromagnetic Tracking Systems).

11.4 RADIO-BASED TRACKING SYSTEMS

Wireless indoor positioning systems have also become very popular in recent years in medicine, partly even in the surgical OR.
As compared to optical, EM, and fiber bragg tracking, the spatial reso­lution is lower which makes them suitable for the tracking of persons or larger devices, but not for, e.g., surgical instruments or smaller items.
Fig. 11.10 gives an overview.
Figure 11.10 The most common radio-based positioning technologies suitable for biomedical use classified by resolution and scale in comparison to optical and elec­tromagnetical tracking technologies. UWB: Ultrawide band, transmitting in micro­wave wavelength from 3.1 to 10.6 GHz; RuBee: transmitting in long wave at about 131 kHz; RF systems: working in four frequency bands: LF (125 kHz), HF (13.56 MHz), UHF (433, 868-915 MHz) and Microwave (2.45, 5.8 GHz); Wi-Fi, Bluetooth and ZigBee are already implemented techniques in many devices working in frequencies of 868 and 915 MHz, 2.4 and 5 GHz. Modified according to Liu H, Darabi H, Banerjee P, Liu J.
Survey of wireless indoor positioning techniques and systems. IEEE Trans SystMan Cybern Appl Rev 2007;37(6):106780
[17].
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Biomedical Engineering in Gastrointestinal Surgery
Radio-based real-time location systems (Radio RTLS) application can be categorized into asset tracking, workflow improvement, and patient/ staff location
[18].
A major issue in surgery are Radio Identification Devices (RFID).

11.4.1 Radio-Frequency Identification Devices

RFID use electromagnetic fields to localize specific markers (tags) attached to an object.
Currently, four different types of RFID exist.
Low-Frequency RFID (LF RFID) with frequencies from 30 to
500 kHz (typically 125 kHz)
High-Frequency RFID (HF RFID) with frequencies from 3 to
30 MHz (typically 13.56 MHz)
Ultrahigh Frequency RFID (UHF RFID) with frequencies from 433/
850 to 950 MHz
Microwave/Super Ultrahigh Frequency (S-UHF) with frequencies
from 2.4 to 2.5 and 5.8 GHz.
The higher the frequency, the better the range and data transfer rate. On the downside, the modules become more prone to interference caused by metallic objects or liquid in the area ways to operate RFID tags: active or passive ( powered by batteries and send out information to the anchors whereas in passive systems, the antenna coil of the RFID reader generates a high fre­quent electromagnetic field. This induces a voltage in the antenna coil of the transponder tag. Additionally, there are semiactive tags available, which operate similarly to the passive tag. Semiactive tags can power
[19]. There are two main
Fig. 11.11). Active tags are
Figure 11.11 Structure of a passive (A) and an active (B) RFID tag. It becomes clearly visible that the design of the active tag is much more complex compared to the pas­sive one. Miniaturization is challenging since a battery is necessary. All from MITI.
Tracking and Navigation Systems
Figure 11.12 Different types of passive RFID tags which can only hold a limited amout of data. Reading range is mainly dependent on antenna size and design.
From MITI.
457
electronics used in conjunction with off-board sensors like thermal sen­sors or accelerometers and can store information in a volatile memory. The range in active systems is specified as around 100 m with an achiev­able maximum of 500 m and in passive systems as under 10 m.
Simple transponders consist only of the antenna and the chip and can hold a 96-bit long Electronic Product Code, while more sophisticated tags are equipped with a EEPROM which can also be filled with data by special RFID readers (
Fig. 11.12).
RFID readers
The RFID reader is a crucial hardware device which is establishing the connection over one or more antennas to the transponder. The RFID reader initiates and controls the communication with one or more transponders.
A microcontroller or an ASIC (Application Specific Integrated Circuit) communicates with the application software on one side with an integrated interface (LAN, Wi-Fi, USB, RS232/485, etc.) and controls the execution of software commands. In addition, the integrated control­ler is responsible for modulation of the signal for transmission and demodulation of received signals, while the high-frequency module gen­erates, after receiving the corresponding command, the electromagnetic field (
Fig. 11.13).
There are a variety of different RFID readers available. Main differ­ences are the working frequencies and transmission protocols which must fit to the used tags, transmitting power, and communication interfaces. Further more, more sophisticated readers can prevent interferences by
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Biomedical Engineering in Gastrointestinal Surgery
Figure 11.13 Principle of an RFID reader: The ASIC communicates with the host computer and controls the data stream in both directions with the HF-Interface con­nected to the internal or external antenna(s). From MITI.
different anticollision mechanisms. Depending on the application, three major interferences can occur:
1. Tag-to-tag interferences (collision), when multiple tags are simulta­neously energized by the reader and reflect the respective signals back. Because of the scattered waves, then the reader cannot differentiate the individual IDs of the tags. This can be overcome by integrated anticollision algorithms
[20].
2. Reader-to-tag interferences, where a tag is located at the intersection of two or more reader interrogation ranges and the readers attempt to communicate with the tag simultaneously. This interference can be eliminated by separating the interrogation range of the reader s
[21].
3. Reader-to-reader interference is induced when a signal from one reader reaches other readers which can be overcome by integrated RFID dense reader modes
[22].
In addition to powerful readers with connectors for one or more
antennas, RFID readers with already integrated antennas as mobile devices or for less demanding applications are available.
RFID Antennas
There are several different designs of antennas available, which strongly
influence reading distance by the specific gain and beamwidth (
Fig. 11.14).
Higher beamwidth creates a broader area of coverage, but the beam will travel
Tracking and Navigation Systems
Figure 11.14 Comparison of RFID antennas for passive HF (13.56 MHz) RFID tags (A) and for active (2.5 GHz) RFID tags (B). Because of the required energy transmis­sion and technology, antennas for passive RFID tags are much larger than for active technology. All from MITI.
459
a shorter distance. In addition, the maximal allowed energy for generating the electromagnetic field depends on the antenna design. Also installation of sev­eral antennas with an overlapping field influences the data transmission—null zones may occur where waves with the same circular motion overlap .

11.4.2 RFID Applications in Health Care

In recent years RFID technology has found its way into health care. Applications to reduce the potential occurrence of adverse events in the process of administration of drugs patient flow instruments were developed
[24], or even systems to count and track consumables and
[25] (Fig. 11.15).
[23], tracking systems to measure

11.4.3 Bluetooth

Bluetooth is part of the 802.15.1 standard and its recent iteration consists of two types of operation modes:
Classic Bluetooth works in the 2.4 GHz frequency band just as ZigBee or
Wi-Fi but uses channels which do not overlap with the existing ones from the two other technologies. An integrated frequency-hopping tries to send messages automatically on free Bluetooth channels.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 11.15 (A) Prototype of a surgical RFID application: Counting and localizing of abdominal sponges. In total nine towels are prepared, five are on the Mayo stand, two in the patient, one is used in the bin and one is missing. (B) Surgical sponge with integrated passive RFID tag
[25]. All from MITI.
Low Energy In recent years, the 4.0 standard for Bluetooth was introduced. The
new specification included “Low Energy” which, compared to the classic version, offered a compelling price-performance ratio for modules with predefined services, excellent battery performance but a slow update-rate.
According to
[26], Bluetooth modules consume 80% less power and
are, in general, less expensive compared to similar modules using Wi-Fi, but the data throughput as well as the possible range with these modules is less than that of other comparable technologies
[27]. Bluetooth Classic
uses 79 channels with a bandwidth of 1 MHz for communication while Bluetooth Low Energy uses just 37 with a bandwidth of 2 MHz and three additional channels for advertising. Both operation modes come with “Adaptive Frequency-Hopping” which allows the modules to jump on frequencies with less interference. In general, Bluetooth Classic requires more channels for inquiry or connection pur poses which is why coexist­ing radio-based technologies in the same 2.4 GHz frequency band (such as Wi-Fi) can interfere. Bluetooth Low Energy, on the other hand, uses frequencies to avoid any interference problems (particularly with Wi-Fi).
Bluetooth trackers are relatively new and became fashionable with the introduction of Bluetooth Low Eenergy. Bluetooth tracking systems estimate the proximity to an anchor (beacon), but cannot calcu­late the exact location. Use of more than one beacon, however, gener­ates overlapping areas resulting in sectors where something or someone is located.
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11.4.4 Wi-Fi

Advantages: based on standards; networks can be used for other things beside location tracking; high range; already deployed infrastructure can be used.
Disadvantage: problems with influences/interferences coming from other networks or technologies in the same frequency band. Access points of routers are used as anchors and small battery-powered
Wi-Fi modules are used as tags. These can either work in the 2.4 or 5 GHz frequency band. Infor mation is sent between the anchors and tags to calculate/estimate a position for the user, based on measuring the intensity of the received signal (received signal strength). A big disadvan­tage is the possibility of interference problems when using Wi-Fi on the same channels/frequencies as other devices that create huge amounts of data traffic. Also, metallic objects or liquid can cause signal fluctuations and subsequently result in inaccurately calculated positions. But on the other hand, existing Wi-Fi infrastructure can be used for location tracking purposes and the possible detection range as well as data throughput rates are high
[28].

11.4.5 ZigBee

Advantages: b ased on standards; good performance even in difficult environments; long battery lif e; cheap; tags communicating with each other which can lead to building a bigger network consisting of tags.
Disadvantage: problems with interference still exist. ZigBee is based on the IEEE 802.15.4 standard and extends it with a
specification regarding radio-based networks with a maximum range of 100 m. One of the features of ZigBee is the ability to link modules to a network of tags (also called “Wireless Sensor Networks”) where each device can communicate directly or through neighboring devices with other devices in the network. The connections between the nodes are dynamically updated and optimized in difficult conditions which leads to accuracies of 1 m and a good battery life. ZigBee works in the 2.4 GHz frequency band and is often used in the home automation as well as in the location tracking sector. Problems with ZigBee arise through interfer­ence when it is used in coexistence with other technologies in the same frequency band
[29].
462 Biomedical Engineering in Gastrointestinal Surgery

11.4.6 Ultra-Wide Band

Advantages: high accuracy; no problems with interferences or difficult environments; high range.
Disadvantage: high costs. Ultra-wide band (UWB) uses the frequency spectrum of 3.1 to
10.6 GHz and features a high-frequency bandwidth of more than
500 MHz and very short pulse signals (, 1 ns) which lead to very high data rates overlapping signals
[17]. These help to reduce reflections, multipath fading, and
[30]. UWB is being used more frequently in the last
years for accurate location tracking in research but has the big disadvan­tage of being too expensive. Due to its limited signal power, the maxi­mum range of UWB is usually specified as 50 m
[31].

11.4.7 RuBee

RuBee is a radio-based technology designed for military and medical asset tracking. It was developed by the company Visible Assets (Stratham, NH, United States) and is represented by the IEEE standard 1902.1. The tech­nology serves as an alternative to RFID and tries to overcome the problems of this technology.
According to the batteries of RuBee tags can last between 5 and 15 years. Low fre­quencies (131 kHz) lead to less power consumption and with a long wavelength of 2289 m, it is less prone to interferences than other compa­rable technologies, such as RFID, even penetrating steel and water
Another advantage of RuBee is the high scalability with an anchor being capable of managing up to 1000 tags. The tags come in a really slim form factor (usually credit card size). On the downside, the data throughput is worse than with Wi-Fi or ZigBee.
Although the technology comes with many advantages, such as being classified as a “Non-Significant Risk” class 1 device in medical visibility applications by the FDA or having no electromagnetical interference (EMI) or electromagnetical compatibility (EMC) issues in the operating room, we omitted it from the comparison in that there was hardly any literature or empirical data available on RuBee. In addition, we could not get any development kits from providers in order to test and analyze the technology for ourselves.
[32], the detection range can be up to 100 feet and
[33].
Table 11.4. The reason is
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Table 11.4 Comparison between radio-based technologies
Update-
Technology Scalability Price Accuracy
RFID / o 1 oo1 Wi-Fi 1 oo 11o Bluetooth o 1 oo o11 ZigBee 11 o 1 o 11 1 UWB 1 2 11 11 1 1
rate Range Durability

11.5 ACOUSTIC TRACKING SYSTEMS

The efficiency and effectiveness of acoustic tracking and navigation is impressively demonstrated by nature: Bats rely entirely—and very successfully—on this sense. It is amazing how modifications of frequency, loudness, etc., are harnessed to gain maximal infor­mation. In medicine, the first applications were in ambient assisted living.
Acoustic sensors receive signals which are emitted by ultrasonic emitters with frequencies above the audible range of the human ear, at approximately 20 kHz, and determine their location via time-of-flight. A si mple emitterreceiver pair delivers the distance obtained from the simple beat timing. For estimation of a position in a three-dimensional space at least one emitter and three receivers are required. An incre ase in resolution can be achieved by three emitters and three receivers tune d at different frequencies. Similar to infrared, the signals are distributed and mostly stay in a room, which is why the technology is commonly used to achieve room level o r subroom level accuracy. Its low propaga­tion speed of about 340 m/s returns results with a l ow time resolution. In addi tion, precision is affected by environmental variables like me dia density, reflections of the signal wave, temperature, and humidity. The limited accu racy and working volume limits the use of an acoustic tracking system to applicat ions where low resolution is required. However, with improvements of the tracking algorithm and within a short tracking range, acoustic trackers are used to realize nonelectro­magnetic tracking, achieving submillimeter accuracy, and h ave been found u seful in cardiology studies where minimum electrical signal is expected
[34].
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Biomedical Engineering in Gastrointestinal Surgery

11.6 INERTIAL TRACKING SYSTEMS

In general, an inertial navigation system (INS) is used with the method “Dead Reckoning” and requires two components: inertial sensors and a starting position. Inertial sensors can include accelerometers, gyroscopes, or magnetometers. They measure the (non)gravitational acceleration, the ori­entation, or the strength/direction of a magnetic field. With measurements like these, distances, angles, or the cardinal position can be calculated and used for further computation. Since the sensors can only detect changes from one state to another (the difference between state s position has to be set and known to the INS. From the state s ing position, all changes/measurements are added up to determine the cur­rent state. Extremely precise laser-based inertial tracking systems are large, expensive, and mainly developed for military use. However, in recent years small and cheap microelectromechanical systems (MEMS), with sufficient precision for most applications have become available. In contrast to laser­based systems, these have a sensor drift dur ing long-term use. Typically, MEMS-based inertial tracking systems are used for control of robots, axes, acceleration measurements, body tracking, and stabilizations. On the basis of an inertial measurement unit, recently a system to determine the center
and s2), a starting
1
at the start-
0
Figure 11.16 A tiny triaxial MEMS is placed on the tip of an endoscope. The impact of gravity on each of the three axes is determined. If the measuring frequency of the sensor is sufficiently higher than the usual endoscopic video frame rate of about 25 Hz, angle rectification of each single image is feasible
EIT Health e.V., Erlangen, Germany.
[36]. Courtesy: Dr. K. Höller,