Daniel A. Hashimoto

Lena Maier-Hein, Annika Reinke, Patrick Godau et al. · utoronto

Increasing evidence shows that flaws in machine learning (ML) algorithm validation are an underestimated global problem. Particularly in automatic biomedical image analysis, chosen performance metrics often do not reflect the domain interest, thus failing to adequately measure scientific progress and hindering translation of ML techniques into practice. To overcome this, our large international expert consortium created Metrics Reloaded, a comprehensive framework guiding researchers in the problem-aware selection of metrics. Following the convergence of ML methodology across application domains, Metrics Reloaded fosters the convergence of validation methodology. The framework was developed in a multi-stage Delphi process and is based on the novel concept of a problem fingerprint - a structured representation of the given problem that captures all aspects that are relevant for metric selection, from the domain interest to the properties of the target structure(s), data set and algorithm output. Based on the problem fingerprint, users are guided through the process of choosing and applying appropriate validation metrics while being made aware of potential pitfalls. Metrics Reloaded targets image analysis problems that can be interpreted as a classification task at image, object or pixel level, namely image-level classification, object detection, semantic segmentation, and instance segmentation tasks. To improve the user experience, we implemented the framework in the Metrics Reloaded online tool, which also provides a point of access to explore weaknesses, strengths and specific recommendations for the most common validation metrics. The broad applicability of our framework across domains is demonstrated by an instantiation for various biological and medical image analysis use cases.

Annika Reinke, Minu D. Tizabi, Michael Baumgartner et al.

Validation metrics are key for the reliable tracking of scientific progress and for bridging the current chasm between artificial intelligence (AI) research and its translation into practice. However, increasing evidence shows that particularly in image analysis, metrics are often chosen inadequately in relation to the underlying research problem. This could be attributed to a lack of accessibility of metric-related knowledge: While taking into account the individual strengths, weaknesses, and limitations of validation metrics is a critical prerequisite to making educated choices, the relevant knowledge is currently scattered and poorly accessible to individual researchers. Based on a multi-stage Delphi process conducted by a multidisciplinary expert consortium as well as extensive community feedback, the present work provides the first reliable and comprehensive common point of access to information on pitfalls related to validation metrics in image analysis. Focusing on biomedical image analysis but with the potential of transfer to other fields, the addressed pitfalls generalize across application domains and are categorized according to a newly created, domain-agnostic taxonomy. To facilitate comprehension, illustrations and specific examples accompany each pitfall. As a structured body of information accessible to researchers of all levels of expertise, this work enhances global comprehension of a key topic in image analysis validation.

Weiqiu You, Cassandra Goldberg, Amin Madani et al.

Purpose: Accurate assessment of the Critical View of Safety (CVS) during laparoscopic cholecystectomy is essential to prevent bile duct injury, a complication associated with significant morbidity and mortality. While large vision-language models (LVLMs) offer flexible reasoning, their predictions remain difficult to audit and unreliable on safety-critical surgical tasks. Methods: We introduce Sum-of-Checks, a framework that decomposes each CVS criterion into expert-defined reasoning checks reflecting clinically relevant visual evidence. Given a laparoscopic frame, an LVLM evaluates each check, producing a binary judgment and justification. Criterion-level scores are computed via fixed, weighted aggregation of check outcomes. We evaluate on the Endoscapes2023 benchmark using three frontier LVLMs, comparing against direct prompting, chain-of-thought, and sub-question decomposition, each with and without few-shot examples. Results: Sum-of-Checks improves average frame-level mean average precision by 12--14% relative to the best baseline across all three models and criteria. Analysis of individual checks reveals that LVLMs are reliable on observational checks (e.g., visibility, tool obstruction) but show substantial variability on decision-critical anatomical evidence. Conclusion: Structuring surgical reasoning into expert-aligned verification checks improves both accuracy and transparency of LVLM-based CVS assessment, demonstrating that explicitly separating evidence elicitation from decision-making is critical for reliable and auditable surgical AI systems. Code is available at https://github.com/BrachioLab/SumOfChecks.

Guiqiu Liao, Matjaz Jogan, Sai Koushik et al.

Weakly supervised video object segmentation (WSVOS) enables the identification of segmentation maps without requiring an extensive training dataset of object masks, relying instead on coarse video labels indicating object presence. Current state-of-the-art methods either require multiple independent stages of processing that employ motion cues or, in the case of end-to-end trainable networks, lack in segmentation accuracy, in part due to the difficulty of learning segmentation maps from videos with transient object presence. This limits the application of WSVOS for semantic annotation of surgical videos where multiple surgical tools frequently move in and out of the field of view, a problem that is more difficult than typically encountered in WSVOS. This paper introduces Video Spatio-Temporal Disentanglement Networks (VDST-Net), a framework to disentangle spatiotemporal information using semi-decoupled knowledge distillation to predict high-quality class activation maps (CAMs). A teacher network designed to resolve temporal conflicts when specifics about object location and timing in the video are not provided works with a student network that integrates information over time by leveraging temporal dependencies. We demonstrate the efficacy of our framework on a public reference dataset and on a more challenging surgical video dataset where objects are, on average, present in less than 60\% of annotated frames. Our method outperforms state-of-the-art techniques and generates superior segmentation masks under video-level weak supervision.

Guiqiu Liao, Matjaž Jogan, Daniel A. Hashimoto

Dense prediction tasks in surgical computer vision, such as segmentation and surgical zone prediction, can provide valuable guidance for laparoscopic and robotic surgery. However, these models often suffer from distribution shifts, as training datasets rarely cover the variability encountered during deployment, leading to poor generalization. We propose DenseTRF, a self-supervised representation adaptation framework based on texture-centric attention. Our method leverages slot attention to learn texture-aware representations that capture invariant visual structures. By adapting these representations to the target distribution without supervision, DenseTRF significantly improves robustness to domain shifts. The framework is implemented through conditioning dense prediction on slot attention and model merging strategies. Experiments across multiple surgical procedures demonstrate improved cross-distribution generalization in comparison to state-of-the-art segmentation models and test-distribution adaptation methods for dense prediction tasks.

Lorenzo Arboit, Dennis N. Schneider, Toby Collins et al.

Artificial Intelligence (AI) is transforming medicine, with generative AI models like ChatGPT reshaping perceptions of its potential. This study examines surgeons' awareness, expectations, and involvement with AI in surgery through comparative surveys conducted in 2021 and 2024. Two cross-sectional surveys were distributed globally in 2021 and 2024, the first before an IRCAD webinar and the second during the annual EAES meeting. The surveys assessed demographics, AI awareness, expectations, involvement, and ethics (2024 only). The surveys collected a total of 671 responses from 98 countries, 522 in 2021 and 149 in 2024. Awareness of AI courses rose from 14.5% in 2021 to 44.6% in 2024, while course attendance increased from 12.9% to 23%. Despite this, familiarity with foundational AI concepts remained limited. Expectations for AI's role shifted in 2024, with hospital management gaining relevance. Ethical concerns gained prominence, with 87.2% of 2024 participants emphasizing accountability and transparency. Infrastructure limitations remained the primary obstacle to implementation. Interdisciplinary collaboration and structured training were identified as critical for successful AI adoption. Optimism about AI's transformative potential remained high, with 79.9% of respondents believing AI would positively impact surgery and 96.6% willing to integrate AI into their clinical practice. Surgeons' perceptions of AI are evolving, driven by the rise of generative AI and advancements in surgical data science. While enthusiasm for integration is strong, knowledge gaps and infrastructural challenges persist. Addressing these through education, ethical frameworks, and infrastructure development is essential.

Guiqiu Liao, Matjaz Jogan, Marcel Hussing et al.

Object-centric slot attention is an emerging paradigm for unsupervised learning of structured, interpretable object-centric representations (slots). This enables effective reasoning about objects and events at a low computational cost and is thus applicable to critical healthcare applications, such as real-time interpretation of surgical video. The heterogeneous scenes in real-world applications like surgery are, however, difficult to parse into a meaningful set of slots. Current approaches with an adaptive slot count perform well on images, but their performance on surgical videos is low. To address this challenge, we propose a dynamic temporal slot transformer (DTST) module that is trained both for temporal reasoning and for predicting the optimal future slot initialization. The model achieves state-of-the-art performance on multiple surgical databases, demonstrating that unsupervised object-centric methods can be applied to real-world data and become part of the common arsenal in healthcare applications.

Guiqiu Liao, Matjaz Jogan, Marcel Hussing et al.

Object-centric slot attention is a powerful framework for unsupervised learning of structured and explainable representations that can support reasoning about objects and actions, including in surgical videos. While conventional object-centric methods for videos leverage recurrent processing to achieve efficiency, they often struggle with maintaining long-range temporal coherence required for long videos in surgical applications. On the other hand, fully parallel processing of entire videos enhances temporal consistency but introduces significant computational overhead, making it impractical for implementation on hardware in medical facilities. We present Slot-BERT, a bidirectional long-range model that learns object-centric representations in a latent space while ensuring robust temporal coherence. Slot-BERT scales object discovery seamlessly to long videos of unconstrained lengths. A novel slot contrastive loss further reduces redundancy and improves the representation disentanglement by enhancing slot orthogonality. We evaluate Slot-BERT on real-world surgical video datasets from abdominal, cholecystectomy, and thoracic procedures. Our method surpasses state-of-the-art object-centric approaches under unsupervised training achieving superior performance across diverse domains. We also demonstrate efficient zero-shot domain adaptation to data from diverse surgical specialties and databases.

Guiqiu Liao, Matjaz Jogan, Eric Eaton et al.

Learning efficient visual representations across heterogeneous unlabeled datasets remains a central challenge in federated learning. Effective federated representations require features that are jointly informative across clients while disentangling domain-specific factors without supervision. We introduce FORLA, a novel framework for federated object-centric representation learning and feature adaptation across clients using unsupervised slot attention. At the core of our method is a shared feature adapter, trained collaboratively across clients to adapt features from foundation models, and a shared slot attention module that learns to reconstruct the adapted features. To optimize this adapter, we design a two-branch student-teacher architecture. In each client, a student decoder learns to reconstruct full features from foundation models, while a teacher decoder reconstructs their adapted, low-dimensional counterpart. The shared slot attention module bridges cross-domain learning by aligning object-level representations across clients. Experiments in multiple real-world datasets show that our framework not only outperforms centralized baselines on object discovery but also learns a compact, universal representation that generalizes well across domains. This work highlights federated slot attention as an effective tool for scalable, unsupervised visual representation learning from cross-domain data with distributed concepts.

Deepak Alapatt, Jennifer Eckhoff, Zhiliang Lyu et al.

Advances in artificial intelligence (AI) for surgical quality assessment promise to democratize access to expertise, with applications in training, guidance, and accreditation. This study presents the SAGES Critical View of Safety (CVS) Challenge, the first AI competition organized by a surgical society, using the CVS in laparoscopic cholecystectomy, a universally recommended yet inconsistently performed safety step, as an exemplar of surgical quality assessment. A global collaboration across 54 institutions in 24 countries engaged hundreds of clinicians and engineers to curate 1,000 videos annotated by 20 surgical experts according to a consensus-validated protocol. The challenge addressed key barriers to real-world deployment in surgery, including achieving high performance, capturing uncertainty in subjective assessment, and ensuring robustness to clinical variability. To enable this scale of effort, we developed EndoGlacier, a framework for managing large, heterogeneous surgical video and multi-annotator workflows. Thirteen international teams participated, achieving up to a 17\% relative gain in assessment performance, over 80\% reduction in calibration error, and a 17\% relative improvement in robustness over the state-of-the-art. Analysis of results highlighted methodological trends linked to model performance, providing guidance for future research toward robust, clinically deployable AI for surgical quality assessment.

Yutong Ban, Jennifer A. Eckhoff, Thomas M. Ward et al.

We constantly integrate our knowledge and understanding of the world to enhance our interpretation of what we see. This ability is crucial in application domains which entail reasoning about multiple entities and concepts, such as AI-augmented surgery. In this paper, we propose a novel way of integrating conceptual knowledge into temporal analysis tasks via temporal concept graph networks. In the proposed networks, a global knowledge graph is incorporated into the temporal analysis of surgical instances, learning the meaning of concepts and relations as they apply to the data. We demonstrate our results in surgical video data for tasks such as verification of critical view of safety, as well as estimation of Parkland grading scale. The results show that our method improves the recognition and detection of complex benchmarks as well as enables other analytic applications of interest.

Yutong Ban, Guy Rosman, Jennifer A. Eckhoff et al.

Comprehension of surgical workflow is the foundation upon which artificial intelligence (AI) and machine learning (ML) holds the potential to assist intraoperative decision-making and risk mitigation. In this work, we move beyond mere identification of past surgical phases, into the prediction of future surgical steps and specification of the transitions between them. We use a novel Generative Adversarial Network (GAN) formulation to sample future surgical phases trajectories conditioned on past video frames from laparoscopic cholecystectomy (LC) videos and compare it to state-of-the-art approaches for surgical video analysis and alternative prediction methods. We demonstrate the GAN formulation's effectiveness through inferring and predicting the progress of LC videos. We quantify the horizon-accuracy trade-off and explored average performance, as well as the performance on the more challenging, and clinically relevant transitions between phases. Furthermore, we conduct a survey, asking 16 surgeons of different specialties and educational levels to qualitatively evaluate predicted surgery phases.

Annika Reinke, Minu D. Tizabi, Carole H. Sudre et al.

While the importance of automatic image analysis is continuously increasing, recent meta-research revealed major flaws with respect to algorithm validation. Performance metrics are particularly key for meaningful, objective, and transparent performance assessment and validation of the used automatic algorithms, but relatively little attention has been given to the practical pitfalls when using specific metrics for a given image analysis task. These are typically related to (1) the disregard of inherent metric properties, such as the behaviour in the presence of class imbalance or small target structures, (2) the disregard of inherent data set properties, such as the non-independence of the test cases, and (3) the disregard of the actual biomedical domain interest that the metrics should reflect. This living dynamically document has the purpose to illustrate important limitations of performance metrics commonly applied in the field of image analysis. In this context, it focuses on biomedical image analysis problems that can be phrased as image-level classification, semantic segmentation, instance segmentation, or object detection task. The current version is based on a Delphi process on metrics conducted by an international consortium of image analysis experts from more than 60 institutions worldwide.

Lena Maier-Hein, Matthias Eisenmann, Duygu Sarikaya et al.

Recent developments in data science in general and machine learning in particular have transformed the way experts envision the future of surgery. Surgical Data Science (SDS) is a new research field that aims to improve the quality of interventional healthcare through the capture, organization, analysis and modeling of data. While an increasing number of data-driven approaches and clinical applications have been studied in the fields of radiological and clinical data science, translational success stories are still lacking in surgery. In this publication, we shed light on the underlying reasons and provide a roadmap for future advances in the field. Based on an international workshop involving leading researchers in the field of SDS, we review current practice, key achievements and initiatives as well as available standards and tools for a number of topics relevant to the field, namely (1) infrastructure for data acquisition, storage and access in the presence of regulatory constraints, (2) data annotation and sharing and (3) data analytics. We further complement this technical perspective with (4) a review of currently available SDS products and the translational progress from academia and (5) a roadmap for faster clinical translation and exploitation of the full potential of SDS, based on an international multi-round Delphi process.