Online model estimation and haptic characterization for robotic-assisted minimally invasive surgery

Online soft tissue characterization is important for robotic-assisted minimally invasive surgery (RAMIS) to achieve a precise and stable robotic control with haptic feedback. The traditional linear regression method (i.e. the recursive least square (RLS) method) is inappropriate to handle nonlinear Hunt-Crossley (H-C) model since its linearization process involves unacceptable errors. This thesis presents a new nonlinear estimation method for online soft tissue characterization. To deal with nonlinear and dynamic conditions involved in soft tissue characterization, the approach expands the nonlinearity and dynamics of the H-C model by treating parameter p as an independent variable. Based on this, an unscented Kalman filter (UKF) was adapted for online nonlinear soft tissue characterization. A comparison analysis of the UKF and RLS methods was conducted to validate the performance of the UKF-based method. The UKF-based method suffers from two major problems. The first one is that it requires prior noise statistics of the corresponding system to be precisely known. However, due to uncertainties in the dynamic environment of RAMIS, it is difficult to accurately describe noise characteristics. This leads to biased or even divergent UKF solutions. Therefore, in order to attain accurate estimation results from the UKF-based approach, it is necessary to estimate noise statistics online to restrain the disturbance of noise uncertainty. Secondly, the UKF performance depends on the pre-defined system and measurement models. If the models involve stochastic errors, the UKF-based solution will be unstable. In fact, the measurement model’s accuracy can be guaranteed by using high-precision measurement equipment together with a high volume of available measurement data. On the other hand, the system model is more often involved with the inaccuracy problem. In RAMIS, the system model is a theoretical approximation of the physical contact between robotic tool and biological soft tissue. The approximation is intended to fulfil the requirement of real-time performance in RAMIS. Therefore, it is essential to improve the UKF performance in the presence of system model (the contact model) uncertainty. To address the UKF problem for inaccurate noise statistics, this thesis further presents a new recursive adaptive UKF (RAUKF) method for online nonlinear soft tissue characterization. It was developed, based on the H-C model, to estimate system noise statistics in real-time with windowing approximation. The method was developed under the condition that system noises are of small variation. In order to account for the inherent relationship between the current and previous states of soft tissue deformation involved in RAMIS, a recursive formulation was further constructed by introducing a fading scaling factor. This factor was further modified to accommodate noise statistics of a large variation, which may be caused by rupture events or geometric discontinuities in RAMIS. Simulations and comparison analyses verified the performance of the proposed RAUKF. The second UKF limitation regarding the requirement of the accurate system model was also addressed. A random weighting strong tracking unscented Kalman filter (RWSTUKF) was developed based on the Hunt-Crossley model for online nonlinear soft tissue characterization. This RWSTUKF overcomes the problem of performance degradation in the UKF due to system model errors. It adopts a scaling factor in the predicted state covariance to compensate the inaccuracy of the system model. This scaling factor was derived by combining the orthogonality principle with the random weighting concept to prevent the cumbersome computation from Jacobian matrix and offer the reliable estimation for innovation covariances. Simulation and comparison analyses demonstrated that the proposed RWSTUKF can characterise soft tissue parameters in the presence of system model error for RAMIS in on online mode. Using the proposed methods, a master-slave robotic system has been developed with a nonlinear state observer for soft tissue characterization. Robotic indentation and needle insertion tests conducted to evaluate performances of the proposed methods. Further, a rupture detection approach was established based on the RWSTUKF. It was also integrated into the master-slave robotic system to detect rupture events occurred during needle insertion. The experiment results demonstrated that the RWSTUKF outperforms RLS, UKF and RAUKF for soft tissue characterization

The effect of a progesterone receptor modulator on the endometrium and breast in premenopausal women

Background The levonorgestrel intrauterine system, LNG-IUS 52 mg, is a highly effective and costeffective contraceptive, entailing minimal patient effort. Irregular bleeding patterns are common during the first months of use and constitutes one of the main reasons for discontinuation. Up to date, no standard treatment approach has been proven to resolve this problem. Mifepristone is a synthetic steroid hormone, acting mainly as an inhibitor of the progesterone receptor (PR) thereby preventing the effect of progesterone. Administration of mifepristone has been proven beneficial in numerous fields in reproductive medicine and exerts various effects depending on the dosage and stage of the menstrual cycle at treatment. Administration of low daily doses of mifepristone results in anovulation and endometrial suppression with subsequent amenorrhea. Continuous treatment with PRMs cause endometrial alterations previously thought to be similar to unopposed estrogen exposure, given the PR antagonistic effects of PRMs. These alterations are today recognized as progesterone receptor modulator associated changes (PAEC). They are considered to be benign and dissolves with the cessation of treatment. The molecular alterations resulting in their development are still unknown. The mechanism of action of steroidal hormones on breast tissue remains largely unidentified. Epidemiological studies show a positive correlation between number of menstrual cycle exposure and hormone therapy to the risk of breast cancer. While this increased risk has been believed to be mainly caused by estrogen, a growing body of literature suggest progesterone and progestins to play a central role. PRMs can be used as a tool to study the effects of progesterone and holds potential to prevent breast epithelial cell proliferation. Aim The overall aim of this thesis is to explore the effects of the PRM mifepristone on the endometrium and on human breast tissue in premenopausal women. The specific objectives were to assess whether inducing amenorrhea with mifepristone, prior to placement of the LNG-IUS, could reduce the bleeding irregularities during the first months of use. Another objective was to evaluate the endometrial morphology after continuous treatment with mifepristone following insertion of the LNG-IUS, without prior endometrial shedding. Furthermore, we sought to explore how mifepristone alters the transcriptomic landscape in human beast in vivo and the epigenetic alterations observed in the breast tissue following PRM treatment. Materials, methods and results Study I was a prospective, randomized, placebo controlled, double-blind trial including healthy women with regular menstrual cycles opting for the LNG-IUS 52 mg for contraceptive purposes. Fifty-eight women were randomized whereof 29 to the mifepristone and 29 to the comparator group. Study participants received mifepristone, 50 mg every other day or a comparator. The pretreatment period with mifepristone was 2 months, followed by the LNG-IUS insertion. Women kept bleeding diaries as per instruction for the pretreatment period and until 6 months after placement of the device. After removing drop outs and exclusions, 19 women in the mifepristone and 19 in the comparator arm contributed to the final analysis. Bleeding diary data were analyzed as rates of bleeding and spotting days (B/S%) per treatment cycle. The results showed a significant reduction of B/S% during the pretreatment period in the mifepristone arm compared to placebo. Following insertion of the device, no statistical difference could be seen between the two groups. Women in Study II originated from Study I. Endometrial biopsies were retrieved at baseline, prior to the pretreatment period with mifepristone or the comparator. A second biopsy was retrieved at 3 months following LNG-IUS placement, with the IUS in situ. Nine paired biopsies from the mifepristone and 8 from the comparator group, contributed to the final analysis. The specimens were analyzed by an expert pathologist who was blinded to the treatment. All baseline biopsies where benign. The second biopsies were all benign and showed, as expected, changes due to progestin effect on the endometrium. There was no presence of PAEC. Participants in Study III originated from Study I. Core needle breast biopsies were collected at baseline and after 2 months treatment with mifepristone or the comparator. Paired biopsies from 16 women in the mifepristone group contributed to the analysis. The changes on mRNA expression level at baseline compared to after mifepristone treatment were screened using RNA sequencing. Functional annotation and pathway enrichment analysis of the differentially expressed genes (DEGs) revealed genes mainly involved in extracellular matrix (ECM) remodeling. In Study IV, patient cohorts and databases were used to generate and validate a breast tissue specific epigenetic index. That index was subsequently used to assess breast tissue samples from three clinical trials, including Study I. Based on the results from this specific epigenetic index, PRM treatment could exhibit favorable results in the mammary gland from healthy women as well as women with increased risk for developing breast cancer. Conclusion The applied mifepristone treatment regimen could not demonstrate any significant improvement in bleeding disturbances following placement of the LNG-IUS compared to placebo. Continuous treatment with mifepristone and subsequent LNG-IUS insertion without prior endometrial shedding, could represent a safe alternative regarding PAEC endometrial safety. Transcriptomic alterations in the breast after treatment with mifepristone revealed pathways mainly involved in ECM remodeling. Furthermore, epigenetic and genetic alterations in the breast following PRM treatment seem promising and suggestive of further investigations regarding the potential beneficial effects of these compounds in the prevention of breast cancer

Tissue classification from electric impedance spectroscopy for haptic feedback in minimally invasive surgery

Haptic feedback is missing in teleoperated surgical robots creating a sensory disconnect from the surgeon and their patient. This thesis proposes using the electric impedance of tissues, instead of the traditionally used mechanical impedance, to develop haptic feedback for surgical robots. Electric impedance spectroscopy (EIS) and a modified surgical needle were successfully able to measure the electric impedance for gel-based phantoms, ex-vivo tissue, and freshly excised organs. Processes for fitting the electric impedance of these tissues to the double-dispersion Cole model were developed including stochastic and deterministic approaches. The tissues were classified with least square error, k-Nearest Neighbour and Na??ve Bayes using the measured electric impedance and the extracted model parameter values. The thesis culminates in applications of using EIS as part of implementing vibrotactile and force feedback applications involving sets of user trials to validate its effectiveness in identifying the tissue through haptic feedback

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

Systems Engineering: Availability and Reliability

Current trends in Industry 4.0 are largely related to issues of reliability and availability. As a result of these trends and the complexity of engineering systems, research and development in this area needs to focus on new solutions in the integration of intelligent machines or systems, with an emphasis on changes in production processes aimed at increasing production efficiency or equipment reliability. The emergence of innovative technologies and new business models based on innovation, cooperation networks, and the enhancement of endogenous resources is assumed to be a strong contribution to the development of competitive economies all around the world. Innovation and engineering, focused on sustainability, reliability, and availability of resources, have a key role in this context. The scope of this Special Issue is closely associated to that of the ICIE’2020 conference. This conference and journal’s Special Issue is to present current innovations and engineering achievements of top world scientists and industrial practitioners in the thematic areas related to reliability and risk assessment, innovations in maintenance strategies, production process scheduling, management and maintenance or systems analysis, simulation, design and modelling

Navigation system based in motion tracking sensor for percutaneous renal access

Tese de Doutoramento em Engenharia BiomédicaMinimally-invasive kidney interventions are daily performed to diagnose and treat several renal diseases. Percutaneous renal access (PRA) is an essential but challenging stage for most of these procedures, since its outcome is directly linked to the physician’s ability to precisely visualize and reach the anatomical target. Nowadays, PRA is always guided with medical imaging assistance, most frequently using X-ray based imaging (e.g. fluoroscopy). Thus, radiation on the surgical theater represents a major risk to the medical team, where its exclusion from PRA has a direct impact diminishing the dose exposure on both patients and physicians. To solve the referred problems this thesis aims to develop a new hardware/software framework to intuitively and safely guide the surgeon during PRA planning and puncturing. In terms of surgical planning, a set of methodologies were developed to increase the certainty of reaching a specific target inside the kidney. The most relevant abdominal structures for PRA were automatically clustered into different 3D volumes. For that, primitive volumes were merged as a local optimization problem using the minimum description length principle and image statistical properties. A multi-volume Ray Cast method was then used to highlight each segmented volume. Results show that it is possible to detect all abdominal structures surrounding the kidney, with the ability to correctly estimate a virtual trajectory. Concerning the percutaneous puncturing stage, either an electromagnetic or optical solution were developed and tested in multiple in vitro, in vivo and ex vivo trials. The optical tracking solution aids in establishing the desired puncture site and choosing the best virtual puncture trajectory. However, this system required a line of sight to different optical markers placed at the needle base, limiting the accuracy when tracking inside the human body. Results show that the needle tip can deflect from its initial straight line trajectory with an error higher than 3 mm. Moreover, a complex registration procedure and initial setup is needed. On the other hand, a real-time electromagnetic tracking was developed. Hereto, a catheter was inserted trans-urethrally towards the renal target. This catheter has a position and orientation electromagnetic sensor on its tip that function as a real-time target locator. Then, a needle integrating a similar sensor is used. From the data provided by both sensors, one computes a virtual puncture trajectory, which is displayed in a 3D visualization software. In vivo tests showed a median renal and ureteral puncture times of 19 and 51 seconds, respectively (range 14 to 45 and 45 to 67 seconds). Such results represent a puncture time improvement between 75% and 85% when comparing to state of the art methods. 3D sound and vibrotactile feedback were also developed to provide additional information about the needle orientation. By using these kind of feedback, it was verified that the surgeon tends to follow a virtual puncture trajectory with a reduced amount of deviations from the ideal trajectory, being able to anticipate any movement even without looking to a monitor. Best results show that 3D sound sources were correctly identified 79.2 ± 8.1% of times with an average angulation error of 10.4º degrees. Vibration sources were accurately identified 91.1 ± 3.6% of times with an average angulation error of 8.0º degrees. Additionally to the EMT framework, three circular ultrasound transducers were built with a needle working channel. One explored different manufacture fabrication setups in terms of the piezoelectric materials, transducer construction, single vs. multi array configurations, backing and matching material design. The A-scan signals retrieved from each transducer were filtered and processed to automatically detect reflected echoes and to alert the surgeon when undesirable anatomical structures are in between the puncture path. The transducers were mapped in a water tank and tested in a study involving 45 phantoms. Results showed that the beam cross-sectional area oscillates around the ceramics radius and it was possible to automatically detect echo signals in phantoms with length higher than 80 mm. Hereupon, it is expected that the introduction of the proposed system on the PRA procedure, will allow to guide the surgeon through the optimal path towards the precise kidney target, increasing surgeon’s confidence and reducing complications (e.g. organ perforation) during PRA. Moreover, the developed framework has the potential to make the PRA free of radiation for both patient and surgeon and to broad the use of PRA to less specialized surgeons.Intervenções renais minimamente invasivas são realizadas diariamente para o tratamento e diagnóstico de várias doenças renais. O acesso renal percutâneo (ARP) é uma etapa essencial e desafiante na maior parte destes procedimentos. O seu resultado encontra-se diretamente relacionado com a capacidade do cirurgião visualizar e atingir com precisão o alvo anatómico. Hoje em dia, o ARP é sempre guiado com recurso a sistemas imagiológicos, na maior parte das vezes baseados em raios-X (p.e. a fluoroscopia). A radiação destes sistemas nas salas cirúrgicas representa um grande risco para a equipa médica, aonde a sua remoção levará a um impacto direto na diminuição da dose exposta aos pacientes e cirurgiões. De modo a resolver os problemas existentes, esta tese tem como objetivo o desenvolvimento de uma framework de hardware/software que permita, de forma intuitiva e segura, guiar o cirurgião durante o planeamento e punção do ARP. Em termos de planeamento, foi desenvolvido um conjunto de metodologias de modo a aumentar a eficácia com que o alvo anatómico é alcançado. As estruturas abdominais mais relevantes para o procedimento de ARP, foram automaticamente agrupadas em volumes 3D, através de um problema de optimização global com base no princípio de “minimum description length” e propriedades estatísticas da imagem. Por fim, um procedimento de Ray Cast, com múltiplas funções de transferência, foi utilizado para enfatizar as estruturas segmentadas. Os resultados mostram que é possível detetar todas as estruturas abdominais envolventes ao rim, com a capacidade para estimar corretamente uma trajetória virtual. No que diz respeito à fase de punção percutânea, foram testadas duas soluções de deteção de movimento (ótica e eletromagnética) em múltiplos ensaios in vitro, in vivo e ex vivo. A solução baseada em sensores óticos ajudou no cálculo do melhor ponto de punção e na definição da melhor trajetória a seguir. Contudo, este sistema necessita de uma linha de visão com diferentes marcadores óticos acoplados à base da agulha, limitando a precisão com que a agulha é detetada no interior do corpo humano. Os resultados indicam que a agulha pode sofrer deflexões à medida que vai sendo inserida, com erros superiores a 3 mm. Por outro lado, foi desenvolvida e testada uma solução com base em sensores eletromagnéticos. Para tal, um cateter que integra um sensor de posição e orientação na sua ponta, foi colocado por via trans-uretral junto do alvo renal. De seguida, uma agulha, integrando um sensor semelhante, é utilizada para a punção percutânea. A partir da diferença espacial de ambos os sensores, é possível gerar uma trajetória de punção virtual. A mediana do tempo necessário para puncionar o rim e ureter, segundo esta trajetória, foi de 19 e 51 segundos, respetivamente (variações de 14 a 45 e 45 a 67 segundos). Estes resultados representam uma melhoria do tempo de punção entre 75% e 85%, quando comparados com o estado da arte dos métodos atuais. Além do feedback visual, som 3D e feedback vibratório foram explorados de modo a fornecer informações complementares da posição da agulha. Verificou-se que com este tipo de feedback, o cirurgião tende a seguir uma trajetória de punção com desvios mínimos, sendo igualmente capaz de antecipar qualquer movimento, mesmo sem olhar para o monitor. Fontes de som e vibração podem ser corretamente detetadas em 79,2 ± 8,1% e 91,1 ± 3,6%, com erros médios de angulação de 10.4º e 8.0 graus, respetivamente. Adicionalmente ao sistema de navegação, foram também produzidos três transdutores de ultrassom circulares com um canal de trabalho para a agulha. Para tal, foram exploradas diferentes configurações de fabricação em termos de materiais piezoelétricos, transdutores multi-array ou singulares e espessura/material de layers de suporte. Os sinais originados em cada transdutor foram filtrados e processados de modo a detetar de forma automática os ecos refletidos, e assim, alertar o cirurgião quando existem variações anatómicas ao longo do caminho de punção. Os transdutores foram mapeados num tanque de água e testados em 45 phantoms. Os resultados mostraram que o feixe de área em corte transversal oscila em torno do raio de cerâmica, e que os ecos refletidos são detetados em phantoms com comprimentos superiores a 80 mm. Desta forma, é expectável que a introdução deste novo sistema a nível do ARP permitirá conduzir o cirurgião ao longo do caminho de punção ideal, aumentado a confiança do cirurgião e reduzindo possíveis complicações (p.e. a perfuração dos órgãos). Além disso, de realçar que este sistema apresenta o potencial de tornar o ARP livre de radiação e alarga-lo a cirurgiões menos especializados.The present work was only possible thanks to the support by the Portuguese Science and Technology Foundation through the PhD grant with reference SFRH/BD/74276/2010 funded by FCT/MEC (PIDDAC) and by Fundo Europeu de Desenvolvimento Regional (FEDER), Programa COMPETE - Programa Operacional Factores de Competitividade (POFC) do QREN

Using Parametric CAD and FDM to Produce High Fidelity Anatomical Structures for Thoracentesis Training

Currently available thoracentesis medical training simulators lack tactile realism and do not represent the physiological variations in patient characteristics, impeding optimal experiential learning. By systematically implementing advanced computer-aided design (CAD) techniques and additive manufacturing (AM) tools, with a flexible design methodology, thoracic wall representations for a 2-year-old male, an 18-year-old female, and a 30-year-old male, with complete skeletal structures necessary for palpation sequencing were modelled. Models for the 2-year-old male and 18-year-old female were fabricated, complete with realistic tissues that accurately represent the various discrete tissue layers of the human thoracic cross section. Clavicular growth rates were used to develop factors with which to scale the skeletal models to represent a range of patient demographics. Parametrically modelled mould sets enable the modification of tissue thickness to account for varying thoracic wall thicknesses observed in the thoracentesis demographic. Through the implementation of scaling factors based on skeletal growth rates from the literature to represent different patient groups, clavicle sizing accuracy ranging from 0.4%-1.3% was achieved, and intercostal space measurement accuracy of 0.7%-2.8% was achieved as compared to target values from the literature. Improvements to simulated tissue were observed, with a 28.54% improvement in terms of peak force, 20.17% for impulse, and 36.31% for pulse width, when compared to the THM-30, a currently available popular model

Vision-based and marker-less surgical tool detection and tracking: a review of the literature

In recent years, tremendous progress has been made in surgical practice for example with Minimally Invasive Surgery (MIS). To overcome challenges coming from deported eye-to-hand manipulation, robotic and computer-assisted systems have been developed. Having real-time knowledge of the pose of surgical tools with respect to the surgical camera and underlying anatomy is a key ingredient for such systems. In this paper, we present a review of the literature dealing with vision-based and marker-less surgical tool detection. This paper includes three primary contributions: (1) identification and analysis of data-sets used for developing and testing detection algorithms, (2) in-depth comparison of surgical tool detection methods from the feature extraction process to the model learning strategy and highlight existing shortcomings, and (3) analysis of validation techniques employed to obtain detection performance results and establish comparison between surgical tool detectors. The papers included in the review were selected through PubMed and Google Scholar searches using the keywords: “surgical tool detection”, “surgical tool tracking”, “surgical instrument detection” and “surgical instrument tracking” limiting results to the year range 2000 2015. Our study shows that despite significant progress over the years, the lack of established surgical tool data-sets, and reference format for performance assessment and method ranking is preventing faster improvement