Surgical Subtask Automation for Intraluminal Procedures using Deep Reinforcement Learning

Intraluminal procedures have opened up a new sub-field of minimally invasive surgery that use flexible instruments to navigate through complex luminal structures of the body, resulting in reduced invasiveness and improved patient benefits. One of the major challenges in this field is the accurate and precise control of the instrument inside the human body. Robotics has emerged as a promising solution to this problem. However, to achieve successful robotic intraluminal interventions, the control of the instrument needs to be automated to a large extent. The thesis first examines the state-of-the-art in intraluminal surgical robotics and identifies the key challenges in this field, which include the need for safe and effective tool manipulation, and the ability to adapt to unexpected changes in the luminal environment. To address these challenges, the thesis proposes several levels of autonomy that enable the robotic system to perform individual subtasks autonomously, while still allowing the surgeon to retain overall control of the procedure. The approach facilitates the development of specialized algorithms such as Deep Reinforcement Learning (DRL) for subtasks like navigation and tissue manipulation to produce robust surgical gestures. Additionally, the thesis proposes a safety framework that provides formal guarantees to prevent risky actions. The presented approaches are evaluated through a series of experiments using simulation and robotic platforms. The experiments demonstrate that subtask automation can improve the accuracy and efficiency of tool positioning and tissue manipulation, while also reducing the cognitive load on the surgeon. The results of this research have the potential to improve the reliability and safety of intraluminal surgical interventions, ultimately leading to better outcomes for patients and surgeons

Towards Robot Autonomy in Medical Procedures Via Visual Localization and Motion Planning

Robots performing medical procedures with autonomous capabilities have the potential to positively effect patient care and healthcare system efficiency. These benefits can be realized by autonomous robots facilitating novel procedures, increasing operative efficiency, standardizing intra- and inter-physician performance, democratizing specialized care, and focusing the physician’s time on subtasks that best leverage their expertise. However, enabling medical robots to act autonomously in a procedural environment is extremely challenging. The deforming and unstructured nature of the environment, the lack of features in the anatomy, and sensor size constraints coupled with the millimeter level accuracy required for safe medical procedures introduce a host of challenges not faced by robots operating in structured environments such as factories or warehouses. Robot motion planning and localization are two fundamental abilities for enabling robot autonomy. Motion planning methods compute a sequence of safe and feasible motions for a robot to accomplish a specified task, where safe and feasible are defined by constraints with respect to the robot and its environment. Localization methods estimate the position and orientation of a robot in its environment. Developing such methods for medical robots that overcome the unique challenges in procedural environments is critical for enabling medical robot autonomy. In this dissertation, I developed and evaluated motion planning and localization algorithms towards robot autonomy in medical procedures. A majority of my work was done in the context of an autonomous medical robot built for enhanced lung nodule biopsy. First, I developed a dataset of medical environments spanning various organs and procedures to foster future research into medical robots and automation. I used this data in my own work described throughout this dissertation. Next, I used motion planning to characterize the capabilities of the lung nodule biopsy robot compared to existing clinical tools and I highlighted trade-offs in robot design considerations. Then, I conducted a study to experimentally demonstrate the benefits of the autonomous lung robot in accessing otherwise hard-to-reach lung nodules. I showed that the robot enables access to lung regions beyond the reach of existing clinical tools with millimeter-level accuracy sufficient for accessing the smallest clinically operable nodules. Next, I developed a localization method to estimate the bronchoscope’s position and orientation in the airways with respect to a preoperatively planned needle insertion pose. The method can be used by robotic bronchoscopy systems and by traditional manually navigated bronchoscopes. The method is designed to overcome challenges with tissue motion and visual homogeneity in the airways. I demonstrated the success of this method in simulated lungs undergoing respiratory motion and showed the method’s ability to generalize across patients.Doctor of Philosoph

BronchoX : bronchoscopy exploration software for biopsy intervention planning

Altres: ACCIO Tecniospring TECSPR17-1-0045Virtual bronchoscopy (VB) is a non-invasive exploration tool for intervention planning and navigation of possible pulmonary lesions (PLs). A VB software involves the location of a PL and the calculation of a route, starting from the trachea, to reach it. The selection of a VB software might be a complex process, and there is no consensus in the community of medical software developers in which is the best-suited system to use or framework to choose. The authors present Bronchoscopy Exploration (BronchoX), a VB software to plan biopsy interventions that generate physician-readable instructions to reach the PLs. The authors' solution is open source, multiplatform, and extensible for future functionalities, designed by their multidisciplinary research and development group. BronchoX is a compound of different algorithms for segmentation, visualisation, and navigation of the respiratory tract. Performed results are a focus on the test the effectiveness of their proposal as an exploration software, also to measure its accuracy as a guiding system to reach PLs. Then, 40 different virtual planning paths were created to guide physicians until distal bronchioles. These results provide a functional software for BronchoX and demonstrate how following simple instructions is possible to reach distal lesions from the trachea

Segmentation and Deformable Modelling Techniques for a Virtual Reality Surgical Simulator in Hepatic Oncology

Liver surgical resection is one of the most frequently used curative therapies. However, resectability is problematic. There is a need for a computer-assisted surgical planning and simulation system which can accurately and efficiently simulate the liver, vessels and tumours in actual patients. The present project describes the development of these core segmentation and deformable modelling techniques. For precise detection of irregularly shaped areas with indistinct boundaries, the segmentation incorporated active contours - gradient vector flow (GVF) snakes and level sets. To improve efficiency, a chessboard distance transform was used to replace part of the GVF effort. To automatically initialize the liver volume detection process, a rotating template was introduced to locate the starting slice. For shape maintenance during the segmentation process, a simplified object shape learning step was introduced to avoid occasional significant errors. Skeletonization with fuzzy connectedness was used for vessel segmentation. To achieve real-time interactivity, the deformation regime of this system was based on a single-organ mass-spring system (MSS), which introduced an on-the-fly local mesh refinement to raise the deformation accuracy and the mesh control quality. This method was now extended to a multiple soft-tissue constraint system, by supplementing it with an adaptive constraint mesh generation. A mesh quality measure was tailored based on a wide comparison of classic measures. Adjustable feature and parameter settings were thus provided, to make tissues of interest distinct from adjacent structures, keeping the mesh suitable for on-line topological transformation and deformation. More than 20 actual patient CT and 2 magnetic resonance imaging (MRI) liver datasets were tested to evaluate the performance of the segmentation method. Instrument manipulations of probing, grasping, and simple cutting were successfully simulated on deformable constraint liver tissue models. This project was implemented in conjunction with the Division of Surgery, Hammersmith Hospital, London; the preliminary reality effect was judged satisfactory by the consultant hepatic surgeon

Separator fluid volume requirements in multi-infusion settings

INTRODUCTION. Intravenous (IV) therapy is a widely used method for the administration of medication in hospitals worldwide. ICU and surgical patients in particular often require multiple IV catheters due to incompatibility of certain drugs and the high complexity of medical therapy. This increases discomfort by painful invasive procedures, the risk of infections and costs of medication and disposable considerably. When different drugs are administered through the same lumen, it is common ICU practice to flush with a neutral fluid between the administration of two incompatible drugs in order to optimally use infusion lumens. An important constraint for delivering multiple incompatible drugs is the volume of separator fluid that is sufficient to safely separate them. OBJECTIVES. In this pilot study we investigated whether the choice of separator fluid, solvent, or administration rate affects the separator volume required in a typical ICU infusion setting. METHODS. A standard ICU IV line (2m, 2ml, 1mm internal diameter) was filled with methylene blue (40 mg/l) solution and flushed using an infusion pump with separator fluid. Independent variables were solvent for methylene blue (NaCl 0.9% vs. glucose 5%), separator fluid (NaCl 0.9% vs. glucose 5%), and administration rate (50, 100, or 200 ml/h). Samples were collected using a fraction collector until <2% of the original drug concentration remained and were analyzed using spectrophotometry. RESULTS. We did not find a significant effect of administration rate on separator fluid volume. However, NaCl/G5% (solvent/separator fluid) required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). Also, G5%/G5% required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). The significant decrease in required flushing volume might be due to differences in the viscosity of the solutions. However, mean differences were small and were most likely caused by human interactions with the fluid collection setup. The average required flushing volume is 3.7 ml. CONCLUSIONS. The choice of separator fluid, solvent or administration rate had no impact on the required flushing volume in the experiment. Future research should take IV line length, diameter, volume and also drug solution volumes into account in order to provide a full account of variables affecting the required separator fluid volume

The conditioning of medical gases with hot water humidifiers

During invasive mechanical ventilation due to the dryness of medical gases is necessary to provide an adequate level of conditioning. The hot water humidifiers (HWH) heat the water, thus allowing the water vapor to heat and humidify the medical gases. In the common HWH there is a contact between the medical gases and the sterile water, thus increasing the risk of patient’s colonization and infection. Recently to avoid the condensation in the inspiratory limb of the ventilator circuit, new heated ventilator circuits have been developed. In this in vitro study we evaluated the efficiency (absolute/relative humidity) of three HWH: (1) a common HWH without a heated ventilator circuit (MR 730, Fisher&amp;Paykel, New Zeland), (2) the same HWH with a heated ventilator circuit (Mallinckrodt Dar, Italy) and (3) a new HWH (DAR HC 2000, Mallinkckrodt Dar, Italy) with a heated ventilator circuit in which the water vapor reaches the medical gases through a gorotex membrane, avoiding any direct contact between the water and gases. At a temperature of 35°C and 37°C the HWH and heated tube were evaluated. The absolute humidity (AH) and relative humidity (RH) were measured by a psychometric method. The minute ventilation, tidal volume respiratory rate and oxygen fraction were: 5.8 ± 0.1 l/min, 740 ± 258 ml, 7.5 ± 2.6 bpm and 100%, respectively. Ventilator P2 Use of a bougie during percutaneous tracheostom