A. Training Simulators for Gastrointestinal Endoscopy: Current and Future Perspectives

Over the last decades, visual endoscopy has become a gold standard for the detection and treatment of gastrointestinal cancers. However, mastering endoscopic procedures is complex and requires long hours of practice. In this context, simulation-based training represents a valuable opportunity for acquiring technical and cognitive skills, suiting the different trainees’ learning pace and limiting the risks for the patients. In this regard, the present contribution aims to present a critical and comprehensive review of the current technology for gastrointestinal (GI) endoscopy training, including both commercial products and platforms at a research stage. Not limited to it, the recent revolution played by the technological advancements in the fields of robotics, artificial intelligence, virtual/augmented reality, and computational tools on simulation-based learning is documented and discussed. Finally, considerations on the future trend of this application field are drawn, highlighting the impact of the most recent pandemic and the current demographic trends

Prevalence of haptic feedback in robot-mediated surgery : a systematic review of literature

© 2017 Springer-Verlag. This is a post-peer-review, pre-copyedit version of an article published in Journal of Robotic Surgery. The final authenticated version is available online at: https://doi.org/10.1007/s11701-017-0763-4With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.Peer reviewe

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

Software toolkit for modeling, simulation and control of soft robots

International audienceThe technological differences between traditional robotics and soft robotics have an impact on all of the modeling tools generally in use, including direct kinematics and inverse models, Jacobians, and dynamics. Due to the lack of precise modeling and control methods for soft robots, the promising concepts of using such design for complex applications (medicine, assistance, domestic robotics...) cannot be practically implemented. This paper presents a first unified software framework dedicated to modeling, simulation and control of soft robots. The framework relies on continuum mechanics for modeling the robotic parts and boundary conditions like actuators or contacts using a unified representation based on Lagrange multipliers. It enables the digital robot to be simulated in its environment using a direct model. The model can also be inverted online using an optimization-based method which allows to control the physical robots in the task space. To demonstrate the effectiveness of the approach, we present various soft robots scenarios including ones where the robot is interacting with its environment. The software has been built on top of SOFA, an open-source framework for deformable online simulation and is available at https://project.inria.fr/softrobot

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

FAST PHYSICS-BASED SIMULATION OF VASCULAR SURGERY

Ph.DDOCTOR OF PHILOSOPH

Modelling and simulation of flexible instruments for minimally invasive surgical training in virtual reality

Improvements in quality and safety standards in surgical training, reduction in training hours and constant technological advances have challenged the traditional apprenticeship model to create a competent surgeon in a patient-safe way. As a result, pressure on training outside the operating room has increased. Interactive, computer based Virtual Reality (VR) simulators offer a safe, cost-effective, controllable and configurable training environment free from ethical and patient safety issues. Two prototype, yet fully-functional VR simulator systems for minimally invasive procedures relying on flexible instruments were developed and validated. NOViSE is the first force-feedback enabled VR simulator for Natural Orifice Transluminal Endoscopic Surgery (NOTES) training supporting a flexible endoscope. VCSim3 is a VR simulator for cardiovascular interventions using catheters and guidewires. The underlying mathematical model of flexible instruments in both simulator prototypes is based on an established theoretical framework – the Cosserat Theory of Elastic Rods. The efficient implementation of the Cosserat Rod model allows for an accurate, real-time simulation of instruments at haptic-interactive rates on an off-the-shelf computer. The behaviour of the virtual tools and its computational performance was evaluated using quantitative and qualitative measures. The instruments exhibited near sub-millimetre accuracy compared to their real counterparts. The proposed GPU implementation further accelerated their simulation performance by approximately an order of magnitude. The realism of the simulators was assessed by face, content and, in the case of NOViSE, construct validity studies. The results indicate good overall face and content validity of both simulators and of virtual instruments. NOViSE also demonstrated early signs of construct validity. VR simulation of flexible instruments in NOViSE and VCSim3 can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. Moreover, in the context of an innovative and experimental technique such as NOTES, NOViSE could potentially facilitate its development and contribute to its popularization by keeping practitioners up to date with this new minimally invasive technique.Open Acces