NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

Purpose: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians. Methods: We developed NOViSE - the first force-feedback enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom built and the behaviour of the virtual flexible endoscope is based on an established theoretical framework – the Cosserat Theory of Elastic Rods. Results: We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES Conclusions: VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype and the initial results indicate that it provides promising foundations for further development

New haptic syringe device for virtual angiography training

Angiography is an important minimally invasive diagnostic procedure in endovascular interventions. Effective training for the procedure is expensive, time consuming and resource demanding. Realistic simulation has become a viable solution to addressing such challenges. However, much of previous work has been focused on software issues. In this paper, we present a novel hardware system-an interactive syringe device with haptics as an add-on hardware component to 3D VR angiography training simulator. Connected to a realistic 3D computer simulation environment, the hardware component provides injection haptic feedback effects for medical training. First, we present the design of corresponding novel electronic units consisting of many design modules. Second, we describe a curve fitting method to estimate injection dosage and injection speed of the contrast media based on voltage variation between the potentiometer to increase the realism of the simulated training. A stepper motor control method is developed to imitate the coronary pressure for force feedback of syringe. Experimental results show that the validity and feasibility of the new haptic syringe device for achieving good diffusion effects of contrast media in the simulation system. A user study experiment with medical doctors to assess the efficacy and realism of proposed simulator shows good outcomes

Modelling and simulation of flexible instruments for minimally invasive surgical training in virtual reality

Improvements in quality and safety standards in surgical training, reduction in training hours and constant technological advances have challenged the traditional apprenticeship model to create a competent surgeon in a patient-safe way. As a result, pressure on training outside the operating room has increased. Interactive, computer based Virtual Reality (VR) simulators offer a safe, cost-effective, controllable and configurable training environment free from ethical and patient safety issues. Two prototype, yet fully-functional VR simulator systems for minimally invasive procedures relying on flexible instruments were developed and validated. NOViSE is the first force-feedback enabled VR simulator for Natural Orifice Transluminal Endoscopic Surgery (NOTES) training supporting a flexible endoscope. VCSim3 is a VR simulator for cardiovascular interventions using catheters and guidewires. The underlying mathematical model of flexible instruments in both simulator prototypes is based on an established theoretical framework – the Cosserat Theory of Elastic Rods. The efficient implementation of the Cosserat Rod model allows for an accurate, real-time simulation of instruments at haptic-interactive rates on an off-the-shelf computer. The behaviour of the virtual tools and its computational performance was evaluated using quantitative and qualitative measures. The instruments exhibited near sub-millimetre accuracy compared to their real counterparts. The proposed GPU implementation further accelerated their simulation performance by approximately an order of magnitude. The realism of the simulators was assessed by face, content and, in the case of NOViSE, construct validity studies. The results indicate good overall face and content validity of both simulators and of virtual instruments. NOViSE also demonstrated early signs of construct validity. VR simulation of flexible instruments in NOViSE and VCSim3 can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. Moreover, in the context of an innovative and experimental technique such as NOTES, NOViSE could potentially facilitate its development and contribute to its popularization by keeping practitioners up to date with this new minimally invasive technique.Open Acces

VCSim3 - a VR Simulator for Cardiovascular Interventions

Purpose: Effective and safe performance of cardiovascular interventions requires excellent catheter / guidewire manipulation skills. These skills are currently mainly gained through an apprenticeship on real patients, which may not be safe or cost-effective. Computer simulation offers an alternative for core skills training. However, replicating the physical behaviour of real instruments navigated through blood vessels is a challenging task. Methods: We have developed VCSim3 – a virtual reality simulator for cardiovascular interventions. The simulator leverages an inextensible Cosserat rod to model virtual catheters and guidewires. Their mechanical properties were optimized with respect to their real counterparts scanned in a silicone phantom using x-ray CT imaging. The instruments are manipulated via a VSP haptic device. Supporting solutions such as fluoroscopic visualization, contrast flow propagation, cardiac motion, balloon inflation and stent deployment, enable performing a complete angioplasty procedure. Results: We present detailed results of simulation accuracy of the virtual instruments, along with their computational performance. In addition, the results of a preliminary face and content validation study conveyed on a group of 17 interventional radiologists are given. Conclusions: VR simulation of cardiovascular procedure can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. VCSim3 is still a prototype, yet the initial results indicate that it provides promising foundations for further development

Image-Based Force Estimation and Haptic Rendering For Robot-Assisted Cardiovascular Intervention

Clinical studies have indicated that the loss of haptic perception is the prime limitation of robot-assisted cardiovascular intervention technology, hindering its global adoption. It causes compromised situational awareness for the surgeon during the intervention and may lead to health risks for the patients. This doctoral research was aimed at developing technology for addressing the limitation of the robot-assisted intervention technology in the provision of haptic feedback. The literature review showed that sensor-free force estimation (haptic cue) on endovascular devices, intuitive surgeon interface design, and haptic rendering within the surgeon interface were the major knowledge gaps. For sensor-free force estimation, first, an image-based force estimation methods based on inverse finite-element methods (iFEM) was developed and validated. Next, to address the limitation of the iFEM method in real-time performance, an inverse Cosserat rod model (iCORD) with a computationally efficient solution for endovascular devices was developed and validated. Afterward, the iCORD was adopted for analytical tip force estimation on steerable catheters. The experimental studies confirmed the accuracy and real-time performance of the iCORD for sensor-free force estimation. Afterward, a wearable drift-free rotation measurement device (MiCarp) was developed to facilitate the design of an intuitive surgeon interface by decoupling the rotation measurement from the insertion measurement. The validation studies showed that MiCarp had a superior performance for spatial rotation measurement compared to other modalities. In the end, a novel haptic feedback system based on smart magnetoelastic elastomers was developed, analytically modeled, and experimentally validated. The proposed haptics-enabled surgeon module had an unbounded workspace for interventional tasks and provided an intuitive interface. Experimental validation, at component and system levels, confirmed the usability of the proposed methods for robot-assisted intervention systems

Angiography Simulation and Planning Using A Multi-Fluid Approach

Angiography is a minimally invasive diagnostic procedure in endovascular interventions. Training interventional procedures is a big challenge, due to the complexity of the procedures with the changes of measurement and visualization in blood flow rate, volume, and image contrast. In this paper, we present a novel virtual reality-based 3D interactive training platform for angiography procedure training. We propose a multi-fluid flow approach with a novel corresponding non-slip boundary condition to simulate the effect of diffusion between the blood and contrast media. A novel syringe device tool is also designed as an add-on hardware to the 3D software simulation system to model haptics through real physical interactions to enhance the realism of the simulation-based training. Experimental results show that the system can simulate realistic blood flow in complex blood vessel structures. The results are validated by visual comparisons between real angiography images and simulations. By combining the proposed software and hardware, our system is applicable and scalable to many interventional radiology procedures. Finally, we have tested the system with clinicians to assess its efficacy for virtual reality-based medical training

Haptic Interface for the Simulation of Endovascular Interventions

Endovascular interventions are minimally invasive surgical procedures that are performed to diagnose and treat vascular diseases. These interventions use a combination of long and flexible instruments known as guidewire and catheter. A popular method of developing the skills required to manipulate the instruments successfully is through the use of virtual reality (VR) simulators. However, the interfaces of current VR simulators have several shortcomings due to limitations in the instrument tracking and haptic feedback systems design. A major challenge of developing physics-based training simulations of endovascular interventional procedures is to unobtrusively access the central, co-axial guidewire for tracking and haptics. This work sets out to explore the state of the art, to identify and develop novel solutions to this concentric occlusion problem, and to perform a validation of a proof of concept prototype. This multi port haptic interface prototype has been integrated with a 3-D virtual environment and features novel instrument tracking and haptic feedback actuation systems. The former involves the use of an optical sensor to detect guidewire movements through a clear catheter, whereas the latter utilises the placement of a customised electromagnetic actuator within the catheter hub. During the proof of concept validation process, both systems received positive reviews. Whilst the haptic interface prototype designed in this work has met the original objectives, there are still important aspects which need to be addressed to improve its content and face validity. With further development, the prototype has the potential to evolve and become a significant improvement over the haptic interfaces that exist today.Open Acces

imaged-based tip force estimation on steerable intracardiac catheters using learning-based methods

Minimally invasive surgery has turned into the most commonly used approach to treat cardiovascular diseases during the surgical procedure; it is hypothesized that the absence of haptic (tactile) feedback and force presented to surgeons is a restricting factor. The use of ablation catheters with the integrated sensor at the tip results in high cost and noise complications. In this thesis, two sensor-less methods are proposed to estimate the force at the intracardiac catheter’s tip. Force estimation at the catheter tip is of great importance because insufficient force in ablation treatment may result in incomplete treatment and excessive force leads to damaging the heart chamber. Besides, adding the sensor to intracardiac catheters adds complexity to their structures. This thesis is categorized into two sensor-less approaches: 1- Learning-Based Force Estimation for Intracardiac Ablation Catheters, 2- A Deep-Learning Force Estimator System for Intracardiac Catheters. The first proposed method estimates catheter-tissue contact force by learning the deflected shape of the catheter tip section image. A regression model is developed based on predictor variables of tip curvature coefficients and knob actuation. The learning-based approach achieved force predictions in close agreement with experimental contact force measurements. The second approach proposes a deep learning method to estimate the contact forces directly from the catheter’s image tip. A convolutional neural network extracts the catheter’s deflection through input images and translates them into the corresponding forces. The ResNet graph was implemented as the architecture of the proposed model to perform a regression. The model can estimate catheter-tissue contact force based on the input images without utilizing any feature extraction or pre-processing. Thus, it can estimate the force value regardless of the tip displacement and deflection shape. The evaluation results show that the proposed method can elicit a robust model from the specified data set and approximate the force with appropriate accuracy

Constrained Stochastic State Estimation for 3D Shape Reconstruction of Catheters and Guidewires in Fluoroscopic Images

Minimally invasive fluoroscopy-based procedures are the gold standard for diagnosis and treatment of various pathologies of the cardiovascular system. This kind of procedures imply for the clinicians to infer the 3D shape of the device from 2D images, which is known to be an ill-posed problem. In this paper we present a method to reconstruct the 3D shape of the interventional device, with the aim of improving the navigation. The method combines a physics-based simulation with non-linear Bayesian filter. Whereas the physics-based model provides a prediction of the shape of the device navigating within the blood vessels (taking into account non-linear interactions between the catheter and the surrounding anatomy), an Unscented Kalman Filter is used to correct the navigation model using 2D image features as external observations. The proposed framework has been evaluated on both synthetic and real data, under different model parameterization, filter parameters tuning and external observations data-sets. Comparing the reconstructed 3D shape with a known ground truth, for the synthetic data-set, we obtained an average 3D Hausdorff distance of 0.07 ± 0.37 mm; the 3D distance at the tip equal to 0.021 ± 0.009 mm and the 3D mean distance at the distal segment of the catheter equal to 0.02 ± 0.008 mm. For the real data-set, the obtained average 3D Hausdorff Distance was of 0.95 ± 0.35 mm, the average 3D distance at the tip is equal to 0.7 ± 0.45 mm with an average 3D mean distance at the distal segment of 0.7 ± 0.46 mm. These results show the ability of our method to retrieve the 3D shape of the device, under a variety of filter parameterizations and challenging conditions: errors on the friction coefficient, ambiguous views and non-linear complex phenomena such as stick and slip motions

Patient Specific Systems for Computer Assisted Robotic Surgery Simulation, Planning, and Navigation

The evolving scenario of surgery: starting from modern surgery, to the birth of medical imaging and the introduction of minimally invasive techniques, has seen in these last years the advent of surgical robotics. These systems, making possible to get through the difficulties of endoscopic surgery, allow an improved surgical performance and a better quality of the intervention. Information technology contributed to this evolution since the beginning of the digital revolution: providing innovative medical imaging devices and computer assisted surgical systems. Afterwards, the progresses in computer graphics brought innovative visualization modalities for medical datasets, and later the birth virtual reality has paved the way for virtual surgery. Although many surgical simulators already exist, there are no patient specific solutions. This thesis presents the development of patient specific software systems for preoperative planning, simulation and intraoperative assistance, designed for robotic surgery: in particular for bimanual robots that are becoming the future of single port interventions. The first software application is a virtual reality simulator for this kind of surgical robots. The system has been designed to validate the initial port placement and the operative workspace for the potential application of this surgical device. Given a bimanual robot with its own geometry and kinematics, and a patient specific 3D virtual anatomy, the surgical simulator allows the surgeon to choose the optimal positioning of the robot and the access port in the abdominal wall. Additionally, it makes possible to evaluate in a virtual environment if a dexterous movability of the robot is achievable, avoiding unwanted collisions with the surrounding anatomy to prevent potential damages in the real surgical procedure. Even if the software has been designed for a specific bimanual surgical robot, it supports any open kinematic chain structure: as far as it can be described in our custom format. The robot capabilities to accomplish specific tasks can be virtually tested using the deformable models: interacting directly with the target virtual organs, trying to avoid unwanted collisions with the surrounding anatomy not involved in the intervention. Moreover, the surgical simulator has been enhanced with algorithms and data structures to integrate biomechanical parameters into virtual deformable models (based on mass-spring-damper network) of target solid organs, in order to properly reproduce the physical behaviour of the patient anatomy during the interactions. The main biomechanical parameters (Young's modulus and density) have been integrated, allowing the automatic tuning of some model network elements, such as: the node mass and the spring stiffness. The spring damping coefficient has been modeled using the Rayleigh approach. Furthermore, the developed method automatically detect the external layer, allowing the usage of both the surface and internal Young's moduli, in order to model the main parts of dense organs: the stroma and the parenchyma. Finally the model can be manually tuned to represent lesion with specific biomechanical properties. Additionally, some software modules of the simulator have been properly extended to be integrated in a patient specific computer guidance system for intraoperative navigation and assistance in robotic single port interventions. This application provides guidance functionalities working in three different modalities: passive as a surgical navigator, assistive as a guide for the single port placement and active as a tutor preventing unwanted collision during the intervention. The simulation system has beed tested by five surgeons: simulating the robot access port placemen, and evaluating the robot movability and workspace inside the patient abdomen. The tested functionalities, rated by expert surgeons, have shown good quality and performance of the simulation. Moreover, the integration of biomechanical parameters into deformable models has beed tested with various material samples. The results have shown a good visual realism ensuring the performance required by an interactive simulation. Finally, the intraoperative navigator has been tested performing a cholecystectomy on a synthetic patient mannequin, in order to evaluate: the intraoperative navigation accuracy, the network communications latency and the overall usability of the system. The tests performed demonstrated the effectiveness and the usability of the software systems developed: encouraging the introduction of the proposed solution in the clinical practice, and the implementation of further improvements. Surgical robotics will be enhanced by an advanced integration of medical images into software systems: allowing the detailed planning of surgical interventions by means of virtual surgery simulation based on patient specific biomechanical parameters. Furthermore, the advanced functionalities offered by these systems, enable surgical robots to improve the intraoperative surgical assistance: benefitting of the knowledge of the virtual patient anatomy