AUTOMATIC PERFORMANCE LEVEL ASSESSMENT IN MINIMALLY INVASIVE SURGERY USING COORDINATED SENSORS AND COMPOSITE METRICS

Skills assessment in Minimally Invasive Surgery (MIS) has been a challenge for training centers for a long time. The emerging maturity of camera-based systems has the potential to transform problems into solutions in many different areas, including MIS. The current evaluation techniques for assessing the performance of surgeons and trainees are direct observation, global assessments, and checklists. These techniques are mostly subjective and can, therefore, involve a margin of bias. The current automated approaches are all implemented using mechanical or electromagnetic sensors, which suffer limitations and influence the surgeon’s motion. Thus, evaluating the skills of the MIS surgeons and trainees objectively has become an increasing concern. In this work, we integrate and coordinate multiple camera sensors to assess the performance of MIS trainees and surgeons. This study aims at developing an objective data-driven assessment that takes advantage of multiple coordinated sensors. The technical framework for the study is a synchronized network of sensors that captures large sets of measures from the training environment. The measures are then, processed to produce a reliable set of individual and composed metrics, coordinated in time, that suggest patterns of skill development. The sensors are non-invasive, real-time, and coordinated over many cues such as, eye movement, external shots of body and instruments, and internal shots of the operative field. The platform is validated by a case study of 17 subjects and 70 sessions. The results show that the platform output is highly accurate and reliable in detecting patterns of skills development and predicting the skill level of the trainees

Robot Assisted Object Manipulation for Minimally Invasive Surgery

Robotic systems have an increasingly important role in facilitating minimally invasive surgical treatments. In robot-assisted minimally invasive surgery, surgeons remotely control instruments from a console to perform operations inside the patient. However, despite the advanced technological status of surgical robots, fully autonomous systems, with decision-making capabilities, are not yet available. In 2017, a structure to classify the research efforts toward autonomy achievable with surgical robots was proposed by Yang et al. Six different levels were identified: no autonomy, robot assistance, task autonomy, conditional autonomy, high autonomy, and full autonomy. All the commercially available platforms in robot-assisted surgery is still in level 0 (no autonomy). Despite increasing the level of autonomy remains an open challenge, its adoption could potentially introduce multiple benefits, such as decreasing surgeons’ workload and fatigue and pursuing a consistent quality of procedures. Ultimately, allowing the surgeons to interpret the ample and intelligent information from the system will enhance the surgical outcome and positively reflect both on patients and society. Three main aspects are required to introduce automation into surgery: the surgical robot must move with high precision, have motion planning capabilities and understand the surgical scene. Besides these main factors, depending on the type of surgery, there could be other aspects that might play a fundamental role, to name some compliance, stiffness, etc. This thesis addresses three technological challenges encountered when trying to achieve the aforementioned goals, in the specific case of robot-object interaction. First, how to overcome the inaccuracy of cable-driven systems when executing fine and precise movements. Second, planning different tasks in dynamically changing environments. Lastly, how the understanding of a surgical scene can be used to solve more than one manipulation task. To address the first challenge, a control scheme relying on accurate calibration is implemented to execute the pick-up of a surgical needle. Regarding the planning of surgical tasks, two approaches are explored: one is learning from demonstration to pick and place a surgical object, and the second is using a gradient-based approach to trigger a smoother object repositioning phase during intraoperative procedures. Finally, to improve scene understanding, this thesis focuses on developing a simulation environment where multiple tasks can be learned based on the surgical scene and then transferred to the real robot. Experiments proved that automation of the pick and place task of different surgical objects is possible. The robot was successfully able to autonomously pick up a suturing needle, position a surgical device for intraoperative ultrasound scanning and manipulate soft tissue for intraoperative organ retraction. Despite automation of surgical subtasks has been demonstrated in this work, several challenges remain open, such as the capabilities of the generated algorithm to generalise over different environment conditions and different patients

Visual-Motor Learning in Minimally Invasive Surgery

The purpose of this thesis was to develop an in-depth understanding of motor control in surgery. This was achieved by applying current theories of sensorimotor learning and developing a novel experimental approach. A survey of expert opinion and a review of the existing literature identified several issues related to human performance and MIS. The approach of this thesis combined existing surgical training tools with state-of-the-art technology and adapted rigorous experimental psychology techniques (grounded in the principles of sensorimotor learning) within a controlled laboratory environment. Existing technology was incorporated into surgical scenarios via the Kinematic Assessment Tool - an experimentally validated, powerful and portable system capable of providing accurate and repeatable measures of visual-motor performance. The Kinematic Assessment Tool (KAT) was first established as an appropriate means of assessing visual-motor performance, subsequently the KAT was assessed as valid when assessing MIS performance. Following this, the system was used to investigate whether the principles of ‘structural learning’ could be applied to MIS. The final experiment investigated if there is any benefit of a standardised, repeatable laparoscopic warm-up to MIS performance. These experiments demonstrated that the KAT system combined with other existing technologies, can be used to investigate visual-motor performance. The results suggested that learning the control dynamics of the surgical instruments and variability in training is beneficial when presented with novel but similar tasks. These findings are consistent with structural learning theory. This thesis should inform current thinking on MIS training and performance and the future development of simulators with more emphasis on introducing variability within tasks during training. Further investigation of the role of structural learning in MIS is required

Robotic Assistant Systems for Otolaryngology-Head and Neck Surgery

Recently, there has been a significant movement in otolaryngology-head and neck surgery (OHNS) toward minimally invasive techniques, particularly those utilizing natural orifices. However, while these techniques can reduce the risk of complications encountered with classic open approaches such as scarring, infection, and damage to healthy tissue in order to access the surgical site, there remain significant challenges in both visualization and manipulation, including poor sensory feedback, reduced visibility, limited working area, and decreased precision due to long instruments. This work presents two robotic assistance systems which help to overcome different aspects of these challenges. The first is the Robotic Endo-Laryngeal Flexible (Robo-ELF) Scope, which assists surgeons in manipulating flexible endoscopes. Flexible endoscopes can provide superior visualization compared to microscopes or rigid endoscopes by allowing views not constrained by line-of-sight. However, they are seldom used in the operating room due to the difficulty in precisely manually manipulating and stabilizing them for long periods of time. The Robo-ELF Scope enables stable, precise robotic manipulation for flexible scopes and frees the surgeon’s hands to operate bimanually. The Robo-ELF Scope has been demonstrated and evaluated in human cadavers and is moving toward a human subjects study. The second is the Robotic Ear Nose and Throat Microsurgery System (REMS), which assists surgeons in manipulating rigid instruments and endoscopes. There are two main types of challenges involved in manipulating rigid instruments: reduced precision from hand tremor amplified by long instruments, and difficulty navigating through complex anatomy surrounded by sensitive structures. The REMS enables precise manipulation by allowing the surgeon to hold the surgical instrument while filtering unwanted movement such as hand tremor. The REMS also enables augmented navigation by calculating the position of the instrument with high accuracy, and combining this information with registered preoperative imaging data to enforce virtual safety barriers around sensitive anatomy. The REMS has been demonstrated and evaluated in user studies with synthetic phantoms and human cadavers

Biomechanics

Biomechanics is a vast discipline within the field of Biomedical Engineering. It explores the underlying mechanics of how biological and physiological systems move. It encompasses important clinical applications to address questions related to medicine using engineering mechanics principles. Biomechanics includes interdisciplinary concepts from engineers, physicians, therapists, biologists, physicists, and mathematicians. Through their collaborative efforts, biomechanics research is ever changing and expanding, explaining new mechanisms and principles for dynamic human systems. Biomechanics is used to describe how the human body moves, walks, and breathes, in addition to how it responds to injury and rehabilitation. Advanced biomechanical modeling methods, such as inverse dynamics, finite element analysis, and musculoskeletal modeling are used to simulate and investigate human situations in regard to movement and injury. Biomechanical technologies are progressing to answer contemporary medical questions. The future of biomechanics is dependent on interdisciplinary research efforts and the education of tomorrow’s scientists

Interpretable task planning and learning for autonomous robotic surgery with logic programming

This thesis addresses the long-term goal of full (supervised) autonomy in surgery, characterized by dynamic environmental (anatomical) conditions, unpredictable workflow of execution and workspace constraints. The scope is to reach autonomy at the level of sub-tasks of a surgical procedure, i.e. repetitive, yet tedious operations (e.g., dexterous manipulation of small objects in a constrained environment, as needle and wire for suturing). This will help reducing time of execution, hospital costs and fatigue of surgeons during the whole procedure, while further improving the recovery time for the patients. A novel framework for autonomous surgical task execution is presented in the first part of this thesis, based on answer set programming (ASP), a logic programming paradigm, for task planning (i.e., coordination of elementary actions and motions). Logic programming allows to directly encode surgical task knowledge, representing emph{plan reasoning methodology} rather than a set of pre-defined plans. This solution introduces several key advantages, as reliable human-like interpretable plan generation, real-time monitoring of the environment and the workflow for ready adaptation and failure recovery. Moreover, an extended review of logic programming for robotics is presented, motivating the choice of ASP for surgery and providing an useful guide for robotic designers. In the second part of the thesis, a novel framework based on inductive logic programming (ILP) is presented for surgical task knowledge learning and refinement. ILP guarantees fast learning from very few examples, a common drawback of surgery. Also, a novel action identification algorithm is proposed based on automatic environmental feature extraction from videos, dealing for the first time with small and noisy datasets collecting different workflows of executions under environmental variations. This allows to define a systematic methodology for unsupervised ILP. All the results in this thesis are validated on a non-standard version of the benchmark training ring transfer task for surgeons, which mimics some of the challenges of real surgery, e.g. constrained bimanual motion in small space

Development of a dexterity assessment method

This research was aimed at contributing to the understanding of dexterity through a scientific analysis of some of its more important features, as well as the development of viable methods to quantify these characteristics. The methods and procedures developed during this research were applied to evaluate traditional dexterity assessment methods, comparing dexterity features among tests and hand daily living tasks in order to characterise their reliability and robustness. The study makes use of visual, mathematical, and experimental methods to obtain, process, and analyse a series of hand function parameters that account for some of the main features that affect dexterity in modern daily living. Furthermore, the designed methods and analysis techniques provide fundamental insights into our understanding of the relationships between motor coordination, movement, and hand function. More importantly, the data and conclusions derived from this research have the potential to aid in the development of improved health care practice, assistive technologies, and quality of life research, by providing practitioners and researchers with updated knowledge on human movement analysis, hand function, and dexterity. The overall conclusion of this research is that the broad range of movements and patterns of the human hand, along with the infinite number of possible coordination strategies result in the need for the identification of movement patterns in order to accurately assess dexterity and hand function. Furthermore, although timed tests are time-efficient and cost-effective methods to measure dexterity, a truly objective and robust measurement of dexterity most cover all the factors and parameters that play a role in this phenomenon

Shared control for natural motion and safety in hands-on robotic surgery

Hands-on robotic surgery is where the surgeon controls the tool's motion by applying forces and torques to the robot holding the tool, allowing the robot-environment interaction to be felt though the tool itself. To further improve results, shared control strategies are used to combine the strengths of the surgeon with those of the robot. One such strategy is active constraints, which prevent motion into regions deemed unsafe or unnecessary. While research in active constraints on rigid anatomy has been well-established, limited work on dynamic active constraints (DACs) for deformable soft tissue has been performed, particularly on strategies which handle multiple sensing modalities. In addition, attaching the tool to the robot imposes the end effector dynamics onto the surgeon, reducing dexterity and increasing fatigue. Current control policies on these systems only compensate for gravity, ignoring other dynamic effects. This thesis presents several research contributions to shared control in hands-on robotic surgery, which create a more natural motion for the surgeon and expand the usage of DACs to point clouds. A novel null-space based optimization technique has been developed which minimizes the end effector friction, mass, and inertia of redundant robots, creating a more natural motion, one which is closer to the feeling of the tool unattached to the robot. By operating in the null-space, the surgeon is left in full control of the procedure. A novel DACs approach has also been developed, which operates on point clouds. This allows its application to various sensing technologies, such as 3D cameras or CT scans and, therefore, various surgeries. Experimental validation in point-to-point motion trials and a virtual reality ultrasound scenario demonstrate a reduction in work when maneuvering the tool and improvements in accuracy and speed when performing virtual ultrasound scans. Overall, the results suggest that these techniques could increase the ease of use for the surgeon and improve patient safety.Open Acces