Methods and Tools for Objective Assessment of Psychomotor Skills in Laparoscopic Surgery

Training and assessment paradigms for laparoscopic surgical skills are evolving from traditional mentor–trainee tutorship towards structured, more objective and safer programs. Accreditation of surgeons requires reaching a consensus on metrics and tasks used to assess surgeons’ psychomotor skills. Ongoing development of tracking systems and software solutions has allowed for the expansion of novel training and assessment means in laparoscopy. The current challenge is to adapt and include these systems within training programs, and to exploit their possibilities for evaluation purposes. This paper describes the state of the art in research on measuring and assessing psychomotor laparoscopic skills. It gives an overview on tracking systems as well as on metrics and advanced statistical and machine learning techniques employed for evaluation purposes. The later ones have a potential to be used as an aid in deciding on the surgical competence level, which is an important aspect when accreditation of the surgeons in particular, and patient safety in general, are considered. The prospective of these methods and tools make them complementary means for surgical assessment of motor skills, especially in the early stages of training. Successful examples such as the Fundamentals of Laparoscopic Surgery should help drive a paradigm change to structured curricula based on objective parameters. These may improve the accreditation of new surgeons, as well as optimize their already overloaded training schedules

Technical evaluation of a third generation optical pose tracker for motion analysis and image-guided surgery

Laparoscopic instrument tracking systems are an essential component in image-guided interventions and offer new possibilities to improve and automate objective assessment methods of surgical skills. In this study we present our system design to apply a third generation optical pose tracker (Micron- Tracker®) to laparoscopic practice. A technical evaluation of this design is performed in order to analyze its accuracy in computing the laparoscopic instrument tip position. Results show a stable fluctuation error over the entire analyzed workspace. The relative position errors are 1.776±1.675 mm, 1.817±1.762 mm, 1.854±1.740 mm, 2.455±2.164 mm, 2.545±2.496 mm, 2.764±2.342 mm, 2.512±2.493 mm for distances of 50, 100, 150, 200, 250, 300, and 350 mm, respectively. The accumulated distance error increases with the measured distance. The instrument inclination covered by the system is high, from 90 to 7.5 degrees. The system reports a low positional accuracy for the instrument tip

Augmented reality (AR) for surgical robotic and autonomous systems: State of the art, challenges, and solutions

Despite the substantial progress achieved in the development and integration of augmented reality (AR) in surgical robotic and autonomous systems (RAS), the center of focus in most devices remains on improving end-effector dexterity and precision, as well as improved access to minimally invasive surgeries. This paper aims to provide a systematic review of different types of state-of-the-art surgical robotic platforms while identifying areas for technological improvement. We associate specific control features, such as haptic feedback, sensory stimuli, and human-robot collaboration, with AR technology to perform complex surgical interventions for increased user perception of the augmented world. Current researchers in the field have, for long, faced innumerable issues with low accuracy in tool placement around complex trajectories, pose estimation, and difficulty in depth perception during two-dimensional medical imaging. A number of robots described in this review, such as Novarad and SpineAssist, are analyzed in terms of their hardware features, computer vision systems (such as deep learning algorithms), and the clinical relevance of the literature. We attempt to outline the shortcomings in current optimization algorithms for surgical robots (such as YOLO and LTSM) whilst providing mitigating solutions to internal tool-to-organ collision detection and image reconstruction. The accuracy of results in robot end-effector collisions and reduced occlusion remain promising within the scope of our research, validating the propositions made for the surgical clearance of ever-expanding AR technology in the future

Augmented Reality (AR) for Surgical Robotic and Autonomous Systems: State of the Art, Challenges, and Solutions

Despite the substantial progress achieved in the development and integration of augmented reality (AR) in surgical robotic and autonomous systems (RAS), the center of focus in most devices remains on improving end-effector dexterity and precision, as well as improved access to minimally invasive surgeries. This paper aims to provide a systematic review of different types of state-of-the-art surgical robotic platforms while identifying areas for technological improvement. We associate specific control features, such as haptic feedback, sensory stimuli, and human–robot collaboration, with AR technology to perform complex surgical interventions for increased user perception of the augmented world. Current researchers in the field have, for long, faced innumerable issues with low accuracy in tool placement around complex trajectories, pose estimation, and difficulty in depth perception during two-dimensional medical imaging. A number of robots described in this review, such as Novarad and SpineAssist, are analyzed in terms of their hardware features, computer vision systems (such as deep learning algorithms), and the clinical relevance of the literature. We attempt to outline the shortcomings in current optimization algorithms for surgical robots (such as YOLO and LTSM) whilst providing mitigating solutions to internal tool-to-organ collision detection and image reconstruction. The accuracy of results in robot end-effector collisions and reduced occlusion remain promising within the scope of our research, validating the propositions made for the surgical clearance of ever-expanding AR technology in the future

Ανάπτυξη τεχνολογιών επαυξημένης πραγματικότητας στην ιατρική εκπαίδευση με προσομοιωτές

Στην παρούσα διδακτορική διατριβή παρουσιάζουμε ένα πρωτοπόρο σύστημα εκπαίδευσης και αξιολόγησης βασικών δεξιοτήτων λαπαροσκοπικής χειρουργικής σε περιβάλλον Επαυξημένης Πραγματικότητας (ΕΠ). Το προτεινόμενο σύστημα αποτελεί μια πλήρως λειτουργική πλατφόρμα εκπαίδευσης η οποία επιτρέπει σε χειρουργούς να εξασκηθούν χρησιμοποιώντας πραγματικά λαπαροσκοπικά εργαλεία και αλληλεπιδρώντας με ψηφιακά αντικείμενα εντός ενός πραγματικού περιβάλλοντος εκπαίδευσης. Το σύστημα αποτελείται από ένα τυπικό κουτί λαπαροσκοπικής εκπαίδευσης, πραγματικά χειρουργικά εργαλεία, κάμερα και συστοιχία αισθητήρων που επιτρέπουν την ανίχνευση και καταγραφή των κινήσεων του χειρουργού σε πραγματικό χρόνο. Χρησιμοποιώντας το προτεινόμενο σύστημα, σχεδιάσαμε και υλοποιήσαμε σενάρια εκπαίδευσης παρόμοια με τις ασκήσεις του προγράμματος FLS®, στοχεύοντας σε δεξιότητες όπως η αίσθηση βάθους, ο συντονισμός χεριού-ματιού, και η παράλληλη χρήση δύο χεριών. Επιπλέον των βασικών δεξιοτήτων, το προτεινόμενο σύστημα χρησιμοποιήθηκε για τον σχεδιασμό σεναρίου εξάσκησης διαδικαστικών δεξιοτήτων, οι οποίες περιλάμβανουν την εφαρμογή χειρουργικών clips καθώς και την απολίνωση εικονικής αρτηρίας, σε περιβάλλον ΕΠ. Τα αποτελέσματα συγκριτικών μελετών μεταξύ έμπειρων και αρχαρίων χειρουργών που πραγματοποιήθηκαν στα πλαίσια της παρούσας διατριβής υποδηλώνουν την εγκυρότητα του προτεινόμενου συστήματος. Επιπλέον, εξήχθησαν σημαντικά συμπεράσματα σχετικά με την πιθανή χρήση της ΕΑ στην λαπαροσκοπική προσομοίωση. Η συγκεκριμένη τεχνολογία προσφέρει αυξημένη αίσθηση οπτικού ρεαλισμού και ευελιξία στον σχεδιασμό εκπαιδευτικών σεναρίων, παρουσιάζοντας σημαντικά μικρότερες απαιτήσεις από πλευράς εξοπλισμού σε σύγκριση με τις υπάρχουσες εμπορικές πλατφόρμες. Βάσει των αποτελεσμάτων της παρούσας διατριβής μπορεί με ασφάλεια να εξαχθεί το συμπέρασμα πως η ΕΠ αποτελεί μια πολλά υποσχόμενη τεχνολογία που θα μπορούσε να χρησιμοποιηθεί για τον σχεδιασμό προσομοιωτών λαπαροσκοπικής χειρουργικής ως εναλλακτική των υπαρχόντων τεχνολογιών και συστημάτων.In this thesis we present what is, to the best of our knowledge, the first framework for training and assessment of fundamental psychomotor and procedural laparoscopic skills in an interactive Augmented Reality (AR) environment. The proposed system is a fully-featured laparoscopic training platform, allowing surgeons to practice by manipulating real instruments while interacting with virtual objects within a real environment. It consists of a standard laparoscopic box-trainer, real instruments, a camera and a set of sensory devices for real-time tracking of surgeons’ actions. The proposed framework has been used for the implementation of AR-based training scenarios similar to the drills of the FLS® program, focusing on fundamental laparoscopic skills such as depth-perception, hand-eye coordination and bimanual operation. Moreover, this framework allowed the implementation of a proof-of-concept procedural skills training scenario, which involved clipping and cutting of a virtual artery within an AR environment. Comparison studies conducted for the evaluation of the presented framework indicated high content and face validity. In addition, significant conclusions regarding the potentials of introducing AR in laparoscopic simulation training and assessment were drawn. This technology provides an advanced sense of visual realism combined with a great flexibility in training task prototyping, with minimum requirements in terms of hardware as compared to commercially available platforms. Thereby, it can be safely stated that AR is a promising technology which can indeed provide a valuable alternative to the training modalities currently used in MIS

Validación de un dispositivo electrónico para el aprendizaje y evaluación de técnicas endoquirúrgicas

Los abordajes quirúrgicos de mínima invasión poseen ventajas ampliamente contrastadas para pacientes y también para cirujanos. Como inconveniente, especialmente en laparoscopia, su dominio exige un específico programa de aprendizaje y evaluación en simuladores. El objetivo principal del trabajo fue poder disponer de de un nuevo elemento de simulación híbrida, LapPlate®, para la evaluación objetivo-numérica de habilidades laparoscópicas básicas en los programas de formación del Centro de Cirugía de Mínima Invasión de Cáceres (CCMIJU). Sesentaiocho asistentes participaron en el estudio, separados en tres grupos: Grupo noveles -GN-(n=34); grupo intermedio -GI- (n=13); grupo de expertos -GE-, (n=21). La validación subjetiva de LapPlate®, en términos globales, fue muy positiva por parte de los usuarios y de los expertos. Todas las respuestas estaban cercanas a la nota máxima y sólo una de ellas fue intermedia. Asimismo ninguna de las mismas fue de carácter negativo. En cuanto a la validación constructiva, ésta ha quedado demostrada en cuanto que los registros de los tres grupos se corresponden con el nivel de experiencia previo (GN<GI<GE). La curva de aprendizaje también se ha comprobado para los tres grupos, es decir, gradualmente ha habido una mejora en los registros. Sólo hubo una variación en cuanto a lo esperado ya que los registros del grupo intermedio en uno de los ejercicios fueron similares a los del grupo básico. En conclusión, a falta de realizar la validación concurrente del mismo, creemos que LapPlate® podría comenzar a ser incluido en el programa integral de formación del CCMIJU.Minimally invasive surgical approaches possess largely contrasted advantages for patients and also for surgeons. Disadvantages, especially in laparoscopy, include to accomplish a specific program of learning and assessment in simulators. The main objective of this work was to have a new element for laparoscopic hybrid simulation, LapPlate®, aimed to the objective-numerical evaluation of laparoscopic skills in the basic training programs of the “Jesús Usón” Minimally Invasive Surgery Centre (JUMISC), Cáceres. Sixty eight attendants participated in the study, divided in three groups: Novices group -GN- (n= 34); Intermediate group -GI- (n= 13); Expert group -GE- (n= 21). Subjective validation was globally rated as very positive by the users and experts. All of the answers were close to the highest rank and only one of them was intermediate. None of them was rated as negative. Constructive validation was demonstrated that the scores of the three groups were in accordance to the level of prior experience (GN<GI<GE).The learning curves were also proven for the three groups, i.e. There were gradually an improvement in scores of both tasks. There was only one unexpected variation because of the median times of GI in one of the tasks were similar to GN. In conclusion, although concurrent validation is still remaining, we believe that LapPlate® could already be included in the comprehensive training program of the JUMISC.Junta de Extremadura, Consejería de Economía, Comercio e Innovación

Analyse der Lernkurve und der applizierten Kräfte am Gewebe in der Roboter-assistierten Chirurgie

Die Roboter-assistierte Laparoskopie besitzt das Potenzial einer disruptiven Technologie, dennoch verbleiben trotz vielversprechender Entwicklungen etliche Fragestellungen bislang ungeklärt. Eine dieser Hypothesen ist, dass Operationsteams mit robotischen Assistenzsystemen eine zeitintensive Lernkurve durchschreiten. Um dies genauer zu untersuchen, wurde die Lernkurve roboterunterstützter Operationen anhand der Prozedurzeiten bei den ersten 20 Fällen der Roboter-assistierten ventralen Rektopexie am Universitätsklinikum Tübingen beschrieben. Der Begriff Lernkurve wurde anhand des quantitativen Parameters Zeit als Umschwung einer Lern- in eine Plateauphase definiert. Für die Gesamtdauer konnte ein Erreichen dieses stabilen Zustands nach fünf Eingriffen gezeigt werden. Diese Ergebnisse sind nicht zwangsläufig auf andere Teams und andere Szenarien übertragbar, suggerieren dennoch eine zügig mögliche Etablierung von Robotiksystemen. Ein weiterer relevanter Aspekt der Roboter-assistierten Chirurgie ist der genau dosierte Einsatz von Kräften. Um die eingebrachten Kräfte in der Gewebe-Instrumenten-Interaktion objektivieren zu können, wurde in einer zweiten wissenschaftlichen Zielsetzung die Konzeption, Entwicklung, Konstruktion, Programmierung und Anwendungsdemonstration eines Messsystems zur Erfassung räumlicher Position und applizierter Kräfte in der Laparoskopie beschrieben. Der auf einem kardanischen Gelenk basierende Kraft- und Positionsmessstand für laparoskopische Rohrschaftinstrumente wurde zuerst CAD-konstruiert und in mehreren Entwicklungsstufen als Prototyp umgesetzt. Hierfür kamen subtraktive und additive Fertigungsverfahren zum Einsatz. Integrierte Wägezellen dienen der Kraftmessung, während Potentiometer die Absolutposition erfassen. Die Datenerfassung erfolgt durch einen programmierbaren Mikrokontroller und die Datenausgabe ist über eine Kontrollkonsole sowie optional über einen angeschlossenen PC möglich. In der realitätsnahen Anwendungsdemonstration am Organmodell wurden die applizierten Kräfte bis zum Kontaktverlust von Instrument und Gewebe bei Zugmanövern am Hartmann-Pouch im Rahmen einer Cholezystektomie erfasst. Insgesamt wurden an sechs Organmodellen jeweils sechs verschieden konfigurierte Fasszangen evaluiert. Die Fasszangen mit traumatischen Oberflächenprofil konnten hierbei signifikant die höchsten Maximalkräfte aufbringen. Neben der Evaluation von Instrumenten hinsichtlich der Eignung für chirurgische Eingriffe können die ermittelten Daten der Roboterchirurgie als Referenzwerte, beispielsweise für die Definition von Grenzwerten eingesetzter Maximalkräfte, dienen. Darüber hinaus stellt der Kraft- und Positionsmessstand Messparameter zur Verfügung, durch welche chirurgisches Training in Zukunft effektiver gestaltet werden kann

Biomechatronics: Harmonizing Mechatronic Systems with Human Beings

This eBook provides a comprehensive treatise on modern biomechatronic systems centred around human applications. A particular emphasis is given to exoskeleton designs for assistance and training with advanced interfaces in human-machine interaction. Some of these designs are validated with experimental results which the reader will find very informative as building-blocks for designing such systems. This eBook will be ideally suited to those researching in biomechatronic area with bio-feedback applications or those who are involved in high-end research on manmachine interfaces. This may also serve as a textbook for biomechatronic design at post-graduate level

Liver Biopsy

Liver biopsy is recommended as the gold standard method to determine diagnosis, fibrosis staging, prognosis and therapeutic indications in patients with chronic liver disease. However, liver biopsy is an invasive procedure with a risk of complications which can be serious. This book provides the management of the complications in liver biopsy. Additionally, this book provides also the references for the new technology of liver biopsy including the non-invasive elastography, imaging methods and blood panels which could be the alternatives to liver biopsy. The non-invasive methods, especially the elastography, which is the new procedure in hot topics, which were frequently reported in these years. In this book, the professionals of elastography show the mechanism, availability and how to use this technology in a clinical field of elastography. The comprehension of elastography could be a great help for better dealing and for understanding of liver biopsy