A Virtual-Based Haptic Endoscopic Sinus Surgery (ESS) Training System: from Development to Validation

Simulated training platforms offer a suitable avenue for surgical students and professionals to build and improve upon their skills, without the hassle of traditional training methods. To enhance the degree of realistic interaction paradigms of training simulators, great work has been done to both model simulated anatomy in more realistic fashion, as well as providing appropriate haptic feedback to the trainee. As such, this chapter seeks to discuss the ongoing research being conducted on haptic feedback-incorporated simulators specifically for Endoscopic Sinus Surgery (ESS). This chapter offers a brief comparative analysis of some EES simulators, in addition to a deeper quantitative and qualitative look into our approach to designing and prototyping a complete virtual-based haptic EES training platform

The Role of Simulation in Endoscopic Sinus Surgery Training

Surgical simulation is an effective tool used to teach many of the fundamental skills required to be a surgeon. Simulation‐based education with directed practice in surgical training allows repeated practice in an environment to learn surgical skills, which do not cause harm to patients. There are several simulators developed for endoscopic sinus surgery training. Some simulators have undergone validation studies with regard to developing skills necessary to perform endoscopic sinus surgery. This book chapter will review the currently available sinus surgery simulators that have undergone validation and evaluate their potential role in surgical training

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery

Virtual and Augmented Reality in Medical Education

Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models that are currently upgrading medical education. VR provides a 3D and dynamic view of structures and the ability of the user to interact with them. The recent technological advances in haptics, display systems, and motion detection allow the user to have a realistic and interactive experience, enabling VR to be ideal for training in hands-on procedures. Consequently, surgical and other interventional procedures are the main fields of application of VR. AR provides the ability of projecting virtual information and structures over physical objects, thus enhancing or altering the real environment. The integration of AR applications in the understanding of anatomical structures and physiological mechanisms seems to be beneficial. Studies have tried to demonstrate the validity and educational effect of many VR and AR applications, in many different areas, employed via various hardware platforms. Some of them even propose a curriculum that integrates these methods. This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented

Surgical Tool Segmentation with Pose-Informed Morphological Polar Transform of Endoscopic Images

This paper presents a tool-pose-informed variable center morphological polar transform to enhance segmentation of endoscopic images. The representation, while not loss-less, transforms rigid tool shapes into morphologies consistently more rectangular that may be more amenable to image segmentation networks. The proposed method was evaluated using the U-Net convolutional neural network, and the input images from endoscopy were represented in one of the four different coordinate formats (1) the original rectangular image representation, (2) the morphological polar coordinate transform, (3) the proposed variable center transform about the tool-tip pixel and (4) the proposed variable center transform about the tool vanishing point pixel. Previous work relied on the observations that endoscopic images typically exhibit unused border regions with content in the shape of a circle (since the image sensor is designed to be larger than the image circle to maximize available visual information in the constrained environment) and that the region of interest (ROI) was most ideally near the endoscopic image center. That work sought an intelligent method for, given an input image, carefully selecting between methods (1) and (2) for best image segmentation prediction. In this extension, the image center reference constraint for polar transformation in method (2) is relaxed via the development of a variable center morphological transformation. Transform center selection leads to different spatial distributions of image loss, and the transform-center location can be informed by robot kinematic model and endoscopic image data. In particular, this work is examined using the tool-tip and tool vanishing point on the image plane as candidate centers. The experiments were conducted for each of the four image representations using a data set of 8360 endoscopic images from real sinus surgery. The segmentation performance was evaluated with standard metrics, and some insight about loss and tool location effects on performance are provided. Overall, the results are promising, showing that selecting a transform center based on tool shape features using the proposed method can improve segmentation performance

A comprehensive evaluation of work and simulation based assessment in otolaryngology training

Introduction: The otolaryngology curriculum requires trainees to show evidence of operative competence before completion of training. The General Medical Council recommended that structured assessment be used throughout training to monitor and guide trainee progression. Despite the reduction in operative exposure and the variation in trainee performance, a ‘one size fits all’ approach continues to be applied. The number of procedures performed remains the main indicator of competence. Objectives: To analyse the utilisation, reliability and validity of workplace-based assessments in otolaryngology training. To identify, develop and validate a series of simulation platforms suitable for incorporation into the otolaryngology curriculum. To develop a model of interchangeable workplace- and simulation-based assessment that reflects trainee’s trajectory, audit the delivery of training and set milestones for modular learning. Methods: A detailed review of the literature identified a list of procedure-specific assessment tools as well as simulators suitable to be used as assessment platforms. A simulation-integrated training programme was piloted and models were tested for feasibility, face, content and construct validity before being incorporated into the North London training programme. The outcomes of workplace- and simulation-based assessments of all core and specialty otolaryngology trainees were collated and analysed. Results: The outcomes of 6535 workplace-based assessments were analysed. The strengths and weaknesses of 4 different assessment tools are highlighted. Validated platforms utilising cadavers, animal tissue, synthetic material and virtual reality simulators were incorporated into the curriculum. 60 trainees and 40 consultants participated in the process and found it of great educational value. Conclusion: Assessment with structured feedback is integral to surgical training. Assessment using validated simulation modules can complement that undertaken in the workplace. The outcomes of structures assessments can be used to monitor and guide trainee trajectory at individual and regional level. The derived learning curves can shape and audit future otolaryngological training.Open Acces

Investigation of 3DP technology for fabrication of surgical simulation phantoms

The demand for affordable and realistic phantoms for training, in particular for functional endoscopic sinus surgery (FESS), has continuously increased in recent years. Conventional training methods, such as current physical models, virtual simulators and cadavers may have restrictions, including fidelity, accessibility, cost and ethics. In this investigation, the potential of three-dimensional printing for the manufacture of biologically representative simulation materials for surgery training phantoms has been investigated. A characterisation of sinus anatomical elements was performed through CT and micro-CT scanning of a cadaveric sinus portion. In particular, the relevant constituent tissues of each sinus region have been determined. Secondly, feedback force values experienced during surgical cutting have been quantified with an actual surgical instrument, specifically modified for this purpose. Force values from multiple post-mortem subjects and different areas of the paranasal sinuses have been gathered and used as a benchmark for the optimisation of 3D-printing materials. The research has explored the wide range of properties achievable in 3DP through post-processing methods and variation of printing parameters. For this latter element, a machine-vision system has been developed to monitor the 3DP in real time. The combination of different infiltrants allowed the reproduction of force values comparable to those registered from cadaveric human tissue. The internal characteristics of 3D printed samples were shown to influence their fracture behaviour under resection. Realistic appearance under endoscopic conditions has also been confirmed. The utilisation of some of the research has also been demonstrated in another medical (non-surgical) training application. This investigation highlights a number of capabilities, and also limitations, of 3DP for the manufacturing of representative materials for application in surgical training phantoms

Virtual Reality Simulator for Training in Myringotomy with Tube Placement

Myringotomy refers to a surgical incision in the eardrum, and it is often followed by ventilation tube placement to treat middle-ear infections. The procedure is difficult to learn; hence, the objectives of this work were to develop a virtual-reality training simulator, assess its face and content validity, and implement quantitative performance metrics and assess construct validity. A commercial digital gaming engine (Unity3D) was used to implement the simulator with support for 3D visualization of digital ear models and support for major surgical tasks. A haptic arm co-located with the stereo scene was used to manipulate virtual surgical tools and to provide force feedback. A questionnaire was developed with 14 face validity questions focusing on realism and 6 content validity questions focusing on training potential. Twelve participants from the Department of Otolaryngology were recruited for the study. Responses to 12 of the 14 face validity questions were positive. One concern was with contact modeling related to tube insertion into the eardrum, and the second was with movement of the blade and forceps. The former could be resolved by using a higher resolution digital model for the eardrum to improve contact localization. The latter could be resolved by using a higher fidelity haptic device. With regard to content validity, 64% of the responses were positive, 21% were neutral, and 15% were negative. In the final phase of this work, automated performance metrics were programmed and a construct validity study was conducted with 11 participants: 4 senior Otolaryngology consultants and 7 junior Otolaryngology residents. Each participant performed 10 procedures on the simulator and metrics were automatically collected. Senior Otolaryngologists took significantly less time to completion compared to junior residents. Junior residents had 2.8 times more errors as compared to experienced surgeons. The senior surgeons also had significantly longer incision lengths, more accurate incision angles, and lower magnification keeping both the umbo and annulus in view. All metrics were able to discriminate senior Otolaryngologists from junior residents with a significance of p \u3c 0.002. The simulator has sufficient realism, training potential and performance discrimination ability to warrant a more resource intensive skills transference study

Metrics for Evaluating Surgical Microscope Usage During Myringotomy

Abstract Although teaching and learning surgical microscope manoeuvring is a fundamental step in middle ear surgical training, currently there is no objective method to teach or assess this skill. This thesis presents an experimental study designed to implement and test sets of metrics capable of numerically evaluating microscope manoeuvrability and qualitatively assessing surgical expertise of a subject during a middle ear surgery called myringotomy. The experiment involved performing a myringotomy on a fixed cadaveric ear. As participants, experienced ear-nose-throat (ENT) surgeons and ENT surgical residents were invited. While performing the procedure, their microscope manoeuvring motions were captured as translational and angular coordinates using an optical tracker. These data were analyzed in terms of motion path length, velocity, acceleration, jitter, manoeuvring volume, smoothness, rotation and time. Participants’ hand motion, body posture and microscopic view were also video recorded to qualitatively assess their surgical expertise. Several metrics were statistically identified as discriminatory. These metrics will be incorporated into a myringotomy surgical simulator to train ENT residents

A design tool for use in simulation and training of sinus surgery

The traditional approaches to training surgeons are becoming increasingly difficult to apply to modern surgical procedures. The development of Minimally Invasive Surgery (MIS) techniques demands new and complex psychomotor skills, and means that the apprentice-based system described by “see one, do one, teach one” can no longer be expected to fully prepare surgeons for operations on real patients, placing patient safety at risk. The use of cadavers and animals in surgical training raises issues of ethics, cost and anatomical similarity to live humans. Endoscopic sinus surgery involves further risk to the patient due to the proximity of vital structures such as the brain, eyes, optic nerve and internal carotid artery. In recent years, simulation has been used to overcome these problems, exposing surgeons to complex procedures in a safe environment, similarly to its use in aviation. However, the cases simulated in this manner may not be customised by training staff to present desired pathology. This thesis describes the design and development of a new tool for the creation of customised cases for the training of sinus surgery. Users who are inexperienced and non-skilled in the use of three-dimensional (3D) Computer Aided Design (CAD) modelling software may use the tool to implement pathology to the virtual sinus model, which was constructed from real CT data. Swelling is applied in five directions (four horizontal, one vertical) to the cavity lining of the frontal and sphenoid sinuses. Tumours are individually customised and positioned in the frontal, sphenoid and ethmoid sinuses. The customised CAD model may then be latterly manufactured using Three-Dimensional Printing (3DP) to produce the complex anatomy of the sinuses in a full colour physical part for the realistic simulation of surgical procedures. An investigation into the colouring of the physical model is also described, involving the study of endoscopic videos to ascertain realistic shades. The program was evaluated by a group of medical professionals from a range of fields, and their feedback was taken into account in subsequent redevelopment of the program, and to suggest further work