A Survey on the Current Status and Future Challenges Towards Objective Skills Assessment in Endovascular Surgery

Minimally-invasive endovascular interventions have evolved rapidly over the past decade, facilitated by breakthroughs in medical imaging and sensing, instrumentation and most recently robotics. Catheter based operations are potentially safer and applicable to a wider patient population due to the reduced comorbidity. As a result endovascular surgery has become the preferred treatment option for conditions previously treated with open surgery and as such the number of patients undergoing endovascular interventions is increasing every year. This fact coupled with a proclivity for reduced working hours, results in a requirement for efficient training and assessment of new surgeons, that deviates from the “see one, do one, teach one” model introduced by William Halsted, so that trainees obtain operational expertise in a shorter period. Developing more objective assessment tools based on quantitative metrics is now a recognised need in interventional training and this manuscript reports the current literature for endovascular skills assessment and the associated emerging technologies. A systematic search was performed on PubMed (MEDLINE), Google Scholar, IEEXplore and known journals using the keywords, “endovascular surgery”, “surgical skills”, “endovascular skills”, “surgical training endovascular” and “catheter skills”. Focusing explicitly on endovascular surgical skills, we group related works into three categories based on the metrics used; structured scales and checklists, simulation-based and motion-based metrics. This review highlights the key findings in each category and also provides suggestions for new research opportunities towards fully objective and automated surgical assessment solutions

A Patient-Specific Cardiac Phantom for Training and Pre-Procedure Surgical Planning

Minimally invasive cardiac procedures requiring a transseptal puncture are becoming increasingly common. For cases of complex or diseased anatomy, clinicians may benefit from using a patient-specific cardiac phantom for training, surgical planning, and the validation of devices or techniques. An imaging compatible cardiac phantom was developed to simulate a MitraClip ® procedure. The phantom contained a patient-specific cardiac model manufactured using tissue mimicking materials. To evaluate accuracy, the patient-specific model was imaged using CT, segmented, and the resulting point cloud data set was compared using absolute distance to the original patient data. The phantom was validated using a MitraClip ® device to ensure anatomical features and tools are identifiable under image guidance. Patient-specific cardiac phantoms may allow for surgical complications to be accounted for in pre-operative planning. The information gained by clinicians involved in planning and performing the procedure should lead to shorter procedural times and better outcomes for patients

Surgical skills modeling in cardiac ablation using deep learning

Cardiovascular diseases, a leading global cause of death, can be treated using Minimally Invasive Surgery (MIS) for various heart conditions. Cardiac ablation is an example of MIS, treating heart rhythm disorders like atrial fibrillation and the operation outcomes are highly dependent on the surgeon's skills. This procedure utilizes catheters, flexible endovascular devices inserted into the patient's blood vessels through a small incision. Traditionally, novice surgeons' performance is assessed in the Operating Room (OR) through surgical tasks. Unskilled behavior can lead to longer operations and inferior surgical outcomes. However, an alternative approach can be capturing surgeons' maneuvers and using them as input for an AI model to evaluate their skills outside the OR. To this end, two experimental setups were proposed to study the skills modelling for surgical behaviours. The first setup simulates the ablation procedure using a mechanical system with a synthetic heartbeat mechanism that measures contact forces between the catheter's tip and tissue. The second one simulates the cardiac catheterization procedure for the surgeon’s practice and records the user's maneuvers at the same time. The first task involved maintaining the force within a safe range while the tip of the catheter is touching the surface. The second task was passing a catheter’s tip through curves and level-intersection on a transparent blood vessel phantom. To evaluate attendees' demonstrations, it is crucial to extract maneuver models for both expert and novice surgeons. Data from participants, including novices and experts, performing the task using the experimental setups, is compiled. Deep recurrent neural networks are employed to extract the model of skills by solving a binary classification problem, distinguishing between expert and novice maneuvers. The results demonstrate the proposed networks' ability to accurately distinguish between novice and expert surgical skills, achieving an accuracy of over 92%

The validity, reliability and responsiveness of procedure based assessment in simulated vascular procedures

IntroductionProcedure based assessment (PBA) has been shown to be valid and reliable in the workplace however whether this translates to the simulation setting has not yet been demonstrated. Therefore the aim of this thesis is to demonstrate that PBA is a valid, reliable and responsive assessment tool in simulated vascular procedures.MethodsThree experiments based on simulated vascular operations were designed to explore the validity, reliability and responsiveness of PBA utilising 3 commonly performed vascular procedures. The global and task specific checklist (GTSC) and global summary score (GSS) of a modified PBA were analysed separately. Validity was determined by correlating performance with prior operative experience (number of operations previously observed and performed) and stage in surgical training. Reliability and responsiveness was determined by use of multiple raters and assessingchange in performance over time.ResultsThe modified PBA was found to be a valid assessment method based on number of operations previously performed (r=0.446 p=0.029 for the GTSC and r=0.553 p= 0.005 for the GSS) but not for operations previously observed. Only the PBA GTSC was valid for stage of surgical training (r= 0.588 p=0.002). The modified PBA demonstrated good inter-rater reliability (r= 0.665 p= 0.005 for the GTSC and r= 0.843 p> 0.001 for the GSS) during simulated vascular procedures. Intra-rater reliability was not demonstrated. The PBA GSS was found to be responsive to improved performance (WSR p< 0.001) but the PBA GTSC was not (WSR p = 0.104).ConclusionThe modified PBA is a valid assessment of surgical skill when correlated with previous operative performance. Observation alone appears to contribute little to assessment outcomes. Performance is index specific and not fully dependant on training level. PBA has only partial reliability in simulated vascular procedure due to the lack of intra-rater reliability. PBA was responsive to practice effect suggesting it could be useful to monitor trainee performance in simulation. PBA potentially has a role in simulation assessment but did not demonstrate sufficient reliability for high stakes examination