SecretariatComputer Assisted Radiology and Surgery (CARS)
Erik Schreiber, University of Leipzig, ICCAS
ChairHeinz U. Lemke, PhD, International Society for Computer Aided Surgery
Last strategy update2014-10-02
MinutesWG-24 minutes


“To develop DICOM objects and services related to image guided surgery (IGS)”.


  1. Identify and build up a user community of IGS disciplines in WG-24. Initially five surgical disciplines (Neuro, ENT, orthopaedics, cardiovascular, thoracoabdominal) and interventional radiology are selected. Anaesthesia is included as long as surgery is affected.
  2. Encourage experts from vendor and academic institutions to join WG-24. Vendors of endoscopic and microscopic devices as well as implants (templates) should be included in addition to the classic vendors of medical imaging and PACS.
  3. Compile a representative set of surgical workflows (with a suitable high level of granularity and appropriate workflow modeling standards and surgical ontologies) as a work reference for the scope of WG-24. Initially, 3-5 workflows, characteristic for each discipline, should be recorded with sufficient level of detail. Workflow tools can be provided by the Innovation Center Computer Assisted Surgery, Leipzig, Germany.
  4. Derive potential DICOM services from these surgical workflows.
  5. Design an information/knowledge model based on electronic medical record (EMR) related work and identify IOD extensions to DICOM. Because of similarities to the IHE activities, a close relationship to IHE should be established.
  6. Take account of the special image communication (1D – 5D) requirements for surgery and mechatronic devices. A close cooperation with WG-02 and WG-17 should be established.
  7. Work in close cooperation with DICOM experts from radiology, cardiology, radiotherapy and related fields which are represented in other DICOM working groups.
  8. Encourage close cooperation with working groups in the International Society for Computer Aided Surgery (ISCAS), Japan Institute of CARS (JICARS), German Society for Computer- and Robot-Assisted Surgery (CURAC), European Federation for Medical Informatics (EFMI), European Association for Endoscopic Surgery, American College of Surgery, International Society for Surgery, International Foundation of Computer Assisted Radiology and Surgery (IFCARS), etc.
  9. Disseminate knowledge gained following the roadmap through workshops, conferences and special seminars. Special presentations should be planned each year for CARS, RSNA, DICOM-Meeting, and at a minimum for one surgical conference.
  10. Connect to integration profiles specified in existing IHE Domains or in an IHE Domain in surgery (still to be determined).

Short Term Goals

  1. Specify the scope of WG-24 relating to intra- and peri-operative workflows, in particular to managerial and clinical decision support for the digital operating room (DOR).
  2. Consolidate the relatively large number of interested individuals of WG-24 into effective project groups.
  3. The following project groups (PG) have been established:
    PG1 WF/MI Neurosurgery
    PG2 WF/MI ENT and CMF Surgery
    PG3 WF/MI Orthopaedic Surgery
    PG4 WF/MI Cardiovascular Surgery
    PG5 WF/MI Thoracoabdominal Surgery
    PG6 WF/MI Interventional Radiology
    PG7 WF/MI AnaesthesiaPG131 Supplement 131: Implant Templates
    PG132 Supplement 132: Surface Segmentation
    PG134 Supplement 134: Implantation Plan SR Document
  4. Have two WG-24 meetings per year scheduled for CARS and RSNA.

Current Status

  • A surgical PACS related IT meta architecture named Therapy Imaging and Model Management System (TIMMS) has been established. It serves as a reference for the identification of interfaces of IT systems which handle images and models for the purpose of surgical interventions.
  • Supplement 132 Surface Segmentation has been accepted as a DICOM standard.
  • Supplement 131 Implant Templates and Supplement 134 Implantation Pan SR Document are current work items and are expected to pass the public comment phase during 2010.

Work Items in Preparation

The following entities are being discussed with respect to their relevance as DICOM work items:

  • Coordinate Systems
  • Extension of Point Clouds by Colors, Properties and Observable Entities
  • IOD Optical Surface Scans
  • DICOM Workflows and Surgical Workflows


  • The complexity of surgical workflows (absence of good/best practice surgical procedures) render the implementation of a surgical PACS or TIMMS and the definition of DICOM objects and services a difficult task. To establish a balanced “voice of surgeons” in different surgical disciplines may require risky compromises and may not be achievable.


  • IGS takes on very different forms between the surgical disciplines. It is important to include the right spectrum of users from different fields of surgery and associated disciplines into WG-24. In order to reduce image communication and management functions from the different IGS disciplines to a canonical set suitable for DICOM supported services, it requires not only analytical but also innovative work.This innovative work relates mainly to the way images from different modalities and other information entities of the patient are integrated into a multi-dimensional model of a specific patient (PSM) as well as the management of these models. Realizations of appropriate PSMs are the basis of a model-guided therapy (MGT) which is in effect what many surgical settings are practicing in training and in their actual activities in the OR.It is therefore also important to include the right spectrum of experts from vendor and academic institutions into WG-24. An additional challenge is to achieve the above on an international level.
  • Workflows for surgical procedures need to be integrated within the overall workflow of patient care, with the aim to integrate the ICT (Information and Communication Technology) island of the OR with the rest of the hospital. Contrary to many other health care activities, a generally accepted surgical ontology and good/best surgical workflow practices are not available to serve as a basis for the activities of WG-24. Links to appropriate R&D activities as well as to IHE activities relating to integration profiles supporting clinical workflows need to be and have been established.


  • The digital operating room is becoming a reality. The market potential for those institutions which bring into the OR digital systems (e.g. a surgical PACS) which conform to standards, such as a suitable DICOM extension, is extremely high.
  • Last but not least, patients will benefit from every step taken towards an EMR (Electronic Medical Record) which is embedded in a standard DOR infrastructure.

Relationship to other Standards and StandardS Bodies

  1. Geometric models (stl, vtk, …)
  2. X-ray-dose
  3. Anaesthesia protocols / measurements
  4. Electronic patient record (IEEE/ISO 11073 part 5&6)
  5. DICOM working groups
  6. ISO 182 /SC2 Robots and Robotic Devices in Surgery and Medicine
  7. IHE


Any comments referring to the Strategic Summary of WG-24 should be mailed to the general chair ( of WG-24.


CMF – Cranio-Maxillofacial
DOR – Digital Operating Room
EMR – Electronic Patient Record
ENT – Ear, Nose and Throat
ICT – Information and Communication Technology
IGS – Image Guided Surgery
IOD – Information Object Definition
IPD – Image Processing and Display
MGT – Model-guided Therapy
MI – Medical Imaging
PSM – Patient-specific Model
S-PACS – Surgical PACS
TIMMS – Therapy Imaging and Model Management System
WF – Workflow
WFMS – Workflow Management System