Autonomous Tissue Retraction in Robotic Assisted Minimally Invasive Surgery – A Feasibility Study

In this letter, we describe a novel framework for planning and executing semi-autonomous tissue retraction in minimally invasive robotic surgery. The approach is aimed at removing tissue flaps or connective tissue from the surgical area autonomously, thus exposing the underlying anatomical structures. First, a deep neural network is used to analyse the endoscopic image and detect candidate tissue flaps obstructing the surgical field. A procedural algorithm for planning and executing the retraction gesture is then developed from extended discussions with clinicians. Experimental validation, carried out on a DaVinci Research Kit, shows an average 25% increase of the visible background after retraction. Another significant contribution of this letter is a dataset containing 1,080 labelled surgical stereo images and the associated depth maps, representing tissue flaps in different scenarios. The work described in this letter is a fundamental step towards the autonomous execution of tissue retraction, and the first example of simultaneous use of deep learning and procedural algorithms. The same framework could be applied to a wide range of autonomous tasks, such as debridement and placement of laparoscopic clips

Psychological and occupational impact of the COVID-19 pandemic on UK surgeons: a qualitative investigation

Background The COVID-19 pandemic represents the greatest biopsychosocial emergency the world has faced for a century. The pandemic has changed how individuals live and work, and in particular, frontline healthcare professionals have been exposed to alarming levels of stress. Objective The aim of this study was to understand the professional and personal effects of COVID-19 pandemic on surgeons working in the UK National Health Service (NHS). Setting Surgical departments in the NHS. Design Between May and July 2020, as part of an ongoing study, we asked surgeons two open-ended questions: ‘What challenges are the COVID-19 crisis currently presenting to you in your work and home life?’ and ‘How is this stress affecting you personally?’ Thematic analysis was used for the qualitative data. Responses to the second question were also categorised into four groups reflecting valence: positive, neutral, mildly negative and strongly negative. Results A total of 141 surgeons responded to the survey and the results indicated that 85.8% reported that they were generally negatively affected by the COVID-19 pandemic, of which 7.8% were strongly affected in a negative way. Qualitative thematic analysis identified four key themes from responses relating to the impact of the pandemic: (1) changing and challenging work environment as a result of COVID-19; (2) challenges to professional life and development; (3) management of change and loss in the respondents’ personal lives; (4) emotional and psychological impacts. Conclusion The results highlighted the substantial emotional and psychological effects of the COVID-19 pandemic on surgeons’ mental health, particularly in relation to fear and anxiety, loss of motivation, low mood, stress and burnout. There is an urgent need for workplace support and mental health interventions to help surgeons cope with the difficulties they face during the ongoing COVID-19 pandemic

How UK surgeons experience burnout and the link between burnout and patient care: A qualitative investigation

Background and Aims Poor well-being affects the performance of all kinds of workers, including surgeons. This study aimed to answer two questions: (1) how does burnout affect surgeons personally, and what is their burnout experience like? (2) How does burnout affect the care that surgeons provide in the United Kingdom (UK)? Method This study conducted thematic analysis of semi-structured interviews with 14 surgeons recruited from the UK National Health Service (NHS). Result The study found three themes in surgeons’ experiences of burnout: first, burnout is common but frequently not recognised nor understood; second, burnout is a personal crisis; and third, burnout creates vulnerability at work. The study also revealed four themes related to burnout's effect on patient care: first, burnout reduces the quality of surgeon-patient relationships; second, burnout affects patient safety; third, burnout impairs staff relationships; and fourth, burnout makes surgeons less motivated to improve. Conclusion Burnout is common but not well recognised in surgeons. Improving understanding and treatment of burnout could have benefits for both surgeons themselves and the care they provide to patients

Burnout and patient safety perceptions among surgeons in the United Kingdom during the early phases of the coronavirus disease 2019 pandemic: A two-wave survey

Background Surgeons in the UK report high burnout levels. Burnout has been found to be associated with adverse patient outcomes but there are few studies that have examined this association in surgeons and even fewer which have examined this relationship over time. Purpose The main aim was to examine the relationships between surgeon burnout and surgeons’ perceptions of patient safety cross-sectionally and longitudinally. The secondary aim was to test whether surgeons’ burnout levels varied over the first six months of the coronavirus disease 2019 pandemic. Methods This paper reports data from a two-wave survey (first wave from 5 May and 30 June 2020, the second wave 5 January to 30 February 2021). The dataset was divided into a longitudinal group (for surgeons who responded at both the time points) and two cross-sectional groups (for surgeons who responded at a one-time point, but not the other). Results The first key finding was that burnout was associated with patient safety outcomes measured at the same time point (Group 1 = 108, r = 0.309, p < 0.05 and Group 2 = 84, r = 0.238, p < 0.05). Second, burnout predicted poor patients’ safety perceptions over time, and poor patient safety predicted burnout over time (Group 3 = 39, p < 0.05). Third, burnout increased between the first and second surveys (t = -4.034, p < 0.05). Conclusion Burnout in surgeons may have serious implications for patient safety. Interventions to support surgeons should be prioritised, and healthcare organisations, surgeons and psychological specialists should collaborate on their development

Towards Autonomous Robotic Minimally Invasive Ultrasound Scanning and Vessel Reconstruction on Non-Planar Surfaces

Autonomous robotic Ultrasound (US) scanning has been the subject of research for more than 2 decades. However, little work has been done to apply this concept into a minimally invasive setting, in which accurate force sensing is generally not available and robot kinematics are unreliable due to the tendon-driven, compliant robot structure. As a result, the adequate orientation of the probe towards the tissue surface remains unknown and the anatomy reconstructed from scan may become highly inaccurate. In this work we present solutions to both of these challenges: an attitude sensor fusion scheme for improved kinematic sensing and a visual, deep learning based algorithm to establish and maintain contact between the organ surface and the US probe. We further introduce a novel scheme to estimate and orient the probe perpendicular to the center line of a vascular structure. Our approach enables, for the first time, to autonomously scan across a non-planar surface and navigate along an anatomical structure with a robotically guided minimally invasive US probe. Our experiments on a vessel phantom with a convex surface confirm a significant improvement of the reconstructed curved vessel geometry, with our approach strongly reducing the mean positional error and variance. In the future, our approach could help identify vascular structures more effectively and help pave the way towards semi-autonomous assistance during partial hepatectomy and the potential to reduce procedure length and complication rates

Burnout in Surgical Trainees: a Narrative Review of Trends, Contributors, Consequences and Possible Interventions

Surgical disciplines are popular and training places are competitive to obtain, but trainees report higher levels of burnout than either their non-surgical peers or attending or consultant surgeons. In this review, we critically summarise evidence on trends and changes in burnout over the past decade, contributors to surgical trainee burnout, the personal and professional consequences of burnout and consider the evidence for interventions. There is no evidence for a linear increase in burnout levels in surgeons over the past decade but the impact of the COVID-19 pandemic has yet to be established and is likely to be significant. Working long hours and experiencing stressful interpersonal interactions at work are associated with higher burnout in trainees but feeling more supported by training programmes and receiving workplace supervision are associated with reduced burnout. Burnout is associated with poorer overall mental and physical well-being in surgical trainees and has also been linked with the delivery of less safe patient care in this group. Useful interventions could include mentorship and improving work conditions, but there is a need for more and higher quality studies

A Comparative Study of Spatio-Temporal U-Nets for Tissue Segmentation in Surgical Robotics

In surgical robotics, the ability to achieve high levels of autonomy is often limited by the complexity of the surgical scene. Autonomous interaction with soft tissues requires machines able to examine and understand the endoscopic video streams in real-time and identify the features of interest. In this work, we show the first example of spatio-temporal neural networks, based on the U-Net, aimed at segmenting soft tissues in endoscopic images. The networks, equipped with Long Short-Term Memory and Attention Gate cells, can extract the correlation between consecutive frames in an endoscopic video stream, thus enhancing the segmentation’s accuracy with respect to the standard U-Net. Initially, three configurations of the spatiotemporal layers are compared to select the best architecture. Afterwards, the parameters of the network are optimised and finally the results are compared with the standard U-Net. An accuracy of 83:77%±2:18% and a precision of 78:42%±7:38% are achieved by implementing both Long Short Term Memory (LSTM) convolutional layers and Attention Gate blocks. The results, although originated in the context of surgical tissue retraction, could benefit many autonomous tasks such as ablation, suturing and debridement

Infrared vibrational spectroscopy: a rapid and novel diagnostic and monitoring tool for cystinuria

Cystinuria is the commonest inherited cause of nephrolithiasis (~1% in adults; ~6% in children) and is the result of impaired cystine reabsorption in the renal proximal tubule. Cystine is poorly soluble in urine with a solubility of ~1 mM and can readily form microcrystals that lead to cystine stone formation, especially at low urine pH. Diagnosis of cystinuria is made typically by ion-exchange chromatography (IEC) detection and quantitation, which is slow, laboursome and costly. More rapid and frequent monitoring of urinary cystine concentration would significantly improve the diagnosis and clinical management of cystinuria. We used attenuated total reflection - Fourier transform infrared spectroscopy (ATR-FTIR) to detect and quantitate insoluble cystine in 22 cystinuric and 5 healthy control urine samples. Creatinine concentration was also determined by ATR-FTIR to adjust for urinary concentration/dilution. Urine was centrifuged, the insoluble fraction re-suspended in 5 μL water and dried on the ATR prism. Cystine was quantitated using its 1296 cm−1 absorption band and levels matched with parallel measurements made using IEC. ATR-FTIR afforded a rapid and inexpensive method of detecting and quantitating insoluble urinary cystine. This proof-of-concept study provides a basis for developing a high-throughput, cost-effective diagnostic method for cystinuria, and for point-of-care clinical monitoring

Factors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic. Results from the MIMIC Study (A Multi-centre cohort study evaluating the role of Inflammatory Markers in patients presenting with acute ureteric Colic)

Objectives There is conflicting data on the role of white blood cell count (WBC) and other inflammatory markers in spontaneous stone passage in patients with acute ureteric colic. The aim of the study was to assess the relationship of WBC and other routinely collected inflammatory and clinical markers including stone size, stone position and Medically Expulsive Therapy use (MET) with spontaneous stone passage (SSP) in a large contemporary cohort of patients with acute ureteric colic. Subjects and Methods Multi‐centre retrospective cohort study coordinated by the British Urology Researchers in Surgical Training (BURST) Research Collaborative at 71 secondary care hospitals across 4 countries (United Kingdom, Republic of Ireland, Australia and New Zealand). 4170 patients presented with acute ureteric colic and a computer tomography confirmed single ureteric stone. Our primary outcome measure was SSP as defined by the absence of need for intervention to assist stone passage. Multivariable mixed effects logistic regression was used to explore the relationship between key patient factors and SSP. Results 2518 patients were discharged with conservative management and had further follow up with a SSP rate of 74% (n = 1874/2518). Sepsis after discharge with conservative management was reported in 0.6% (n = 16/2518). On multivariable analysis neither WBC, Neutrophils or CRP were seen to predict SSP, with an adjusted OR of 0.97 [95% CI 0.91 to 1.04, p = 0.38], 1.06 [95% CI 0.99 to 1.13, p = 0.1] and 1.00 [95% CI 0.99 to 1.00, p = 0.17], respectively. Medical expulsive therapy (MET) also did not predict SSP [adjusted OR 1.11 [95% CI 0.76 to 1.61]). However, stone size and stone position were significant predictors. SSP for stones 7mm. For stones in the upper ureter the SSP rate was 52% [95% CI 48 to 56], middle ureter was 70% [95% CI 64 to 76], and lower ureter was 83% [95% CI 81 to 85]. Conclusion In contrast to the previously published literature, we found that in patients with acute ureteric colic who are discharged with initial conservative management, neither WBC, Neutrophil count or CRP help determine the likelihood of spontaneous stone passage. We also found no overall benefit from the use of MET. Stone size and position are important predictors and our findings represent the most comprehensive stone passage rates for each mm increase in stone size from a large contemporary cohort adjusting for key potential confounders. We anticipate that these data will aid clinicians managing patients with acute ureteric colic and help guide management decisions and the need for intervention