Imanol Luengo

Chinedu Innocent Nwoye, Deepak Alapatt, Tong Yu et al.

Context-aware decision support in the operating room can foster surgical safety and efficiency by leveraging real-time feedback from surgical workflow analysis. Most existing works recognize surgical activities at a coarse-grained level, such as phases, steps or events, leaving out fine-grained interaction details about the surgical activity; yet those are needed for more helpful AI assistance in the operating room. Recognizing surgical actions as triplets of <instrument, verb, target> combination delivers comprehensive details about the activities taking place in surgical videos. This paper presents CholecTriplet2021: an endoscopic vision challenge organized at MICCAI 2021 for the recognition of surgical action triplets in laparoscopic videos. The challenge granted private access to the large-scale CholecT50 dataset, which is annotated with action triplet information. In this paper, we present the challenge setup and assessment of the state-of-the-art deep learning methods proposed by the participants during the challenge. A total of 4 baseline methods from the challenge organizers and 19 new deep learning algorithms by competing teams are presented to recognize surgical action triplets directly from surgical videos, achieving mean average precision (mAP) ranging from 4.2% to 38.1%. This study also analyzes the significance of the results obtained by the presented approaches, performs a thorough methodological comparison between them, in-depth result analysis, and proposes a novel ensemble method for enhanced recognition. Our analysis shows that surgical workflow analysis is not yet solved, and also highlights interesting directions for future research on fine-grained surgical activity recognition which is of utmost importance for the development of AI in surgery.

Maria Grammatikopoulou, Ricardo Sanchez-Matilla, Felix Bragman et al.

Semantic segmentation in surgical videos has applications in intra-operative guidance, post-operative analytics and surgical education. Segmentation models need to provide accurate and consistent predictions since temporally inconsistent identification of anatomical structures can impair usability and hinder patient safety. Video information can alleviate these challenges leading to reliable models suitable for clinical use. We propose a novel architecture for modelling temporal relationships in videos. The proposed model includes a spatio-temporal decoder to enable video semantic segmentation by improving temporal consistency across frames. The encoder processes individual frames whilst the decoder processes a temporal batch of adjacent frames. The proposed decoder can be used on top of any segmentation encoder to improve temporal consistency. Model performance was evaluated on the CholecSeg8k dataset and a private dataset of robotic Partial Nephrectomy procedures. Segmentation performance was improved when the temporal decoder was applied across both datasets. The proposed model also displayed improvements in temporal consistency.

Jinglu Zhang, Santiago Barbarisi, Abdolrahim Kadkhodamohammadi et al.

Purpose: Advances in surgical phase recognition are generally led by training deeper networks. Rather than going further with a more complex solution, we believe that current models can be exploited better. We propose a self-knowledge distillation framework that can be integrated into current state-of-the-art (SOTA) models without requiring any extra complexity to the models or annotations. Methods: Knowledge distillation is a framework for network regularization where knowledge is distilled from a teacher network to a student network. In self-knowledge distillation, the student model becomes the teacher such that the network learns from itself. Most phase recognition models follow an encoder-decoder framework. Our framework utilizes self-knowledge distillation in both stages. The teacher model guides the training process of the student model to extract enhanced feature representations from the encoder and build a more robust temporal decoder to tackle the over-segmentation problem. Results: We validate our proposed framework on the public dataset Cholec80. Our framework is embedded on top of four popular SOTA approaches and consistently improves their performance. Specifically, our best GRU model boosts performance by +3.33% accuracy and +3.95% F1-score over the same baseline model. Conclusion: We embed a self-knowledge distillation framework for the first time in the surgical phase recognition training pipeline. Experimental results demonstrate that our simple yet powerful framework can improve performance of existing phase recognition models. Moreover, our extensive experiments show that even with 75% of the training set we still achieve performance on par with the same baseline model trained on the full set.

Dimitrios Anastasiou, Santiago Barbarisi, Lucy Culshaw et al.

Purpose: Accurate assessment of surgical complexity is essential in Laparoscopic Cholecystectomy (LC), where severe inflammation is associated with longer operative times and increased risk of postoperative complications. The Parkland Grading Scale (PGS) provides a clinically validated framework for stratifying inflammation severity; however, its automation in surgical videos remains largely unexplored, particularly in realistic scenarios where complete videos must be analyzed without prior manual curation. Methods: In this work, we introduce STC-Net, a novel framework for SingleTimestamp-based Complexity estimation in LC via the PGS, designed to operate under weak temporal supervision. Unlike prior methods limited to static images or manually trimmed clips, STC-Net operates directly on full videos. It jointly performs temporal localization and grading through a localization, window proposal, and grading module. We introduce a novel loss formulation combining hard and soft localization objectives and background-aware grading supervision. Results: Evaluated on a private dataset of 1,859 LC videos, STC-Net achieves an accuracy of 62.11% and an F1-score of 61.42%, outperforming non-localized baselines by over 10% in both metrics and highlighting the effectiveness of weak supervision for surgical complexity assessment. Conclusion: STC-Net demonstrates a scalable and effective approach for automated PGS-based surgical complexity estimation from full LC videos, making it promising for post-operative analysis and surgical training.

Nicolas Toussaint, Emanuele Colleoni, Ricardo Sanchez-Matilla et al.

Monocular relative and metric depth estimation has seen a tremendous boost in the last few years due to the sharp advancements in foundation models and in particular transformer based networks. As we start to see applications to the domain of endoscopic images, there is still a lack of robust benchmarks and high-quality datasets in that area. This paper addresses these limitations by presenting a comprehensive benchmark of state-of-the-art (metric and relative) depth estimation models evaluated on real, unseen endoscopic images, providing critical insights into their generalisation and performance in clinical scenarios. Additionally, we introduce and publish a novel synthetic dataset (EndoSynth) of endoscopic surgical instruments paired with ground truth metric depth and segmentation masks, designed to bridge the gap between synthetic and real-world data. We demonstrate that fine-tuning depth foundation models using our synthetic dataset boosts accuracy on most unseen real data by a significant margin. By providing both a benchmark and a synthetic dataset, this work advances the field of depth estimation for endoscopic images and serves as an important resource for future research. Project page, EndoSynth dataset and trained weights are available at https://github.com/TouchSurgery/EndoSynth.

Ka-Wai Yung, Felix J. S. Bragman, Jialang Xu et al.

Vision Transformers have substantially advanced the capabilities of segmentation models across both image and video domains. Among them, the Swin Transformer stands out for its ability to capture hierarchical, multi-scale representations, making it a popular backbone for segmentation in videos. However, despite its window-attention scheme, it still incurs a high computational cost, especially in larger variants commonly used for dense prediction in videos. This remains a major bottleneck for real-time, resource-constrained applications. Whilst token reduction methods have been proposed to alleviate this, the window-based attention mechanism of Swin requires a fixed number of tokens per window, limiting the applicability of conventional pruning techniques. Meanwhile, training-free token clustering approaches have shown promise in image segmentation while maintaining window consistency. Nevertheless, they fail to exploit temporal redundancy, missing a key opportunity to further optimize video segmentation performance. We introduce Temporal Cluster Assignment (TCA), a lightweight and effective, fine-tuning-free strategy that enhances token clustering by leveraging temporal coherence across frames. Instead of indiscriminately dropping redundant tokens, TCA refines token clusters using temporal correlations, thereby retaining fine-grained details while significantly reducing computation. Extensive evaluations on YouTube-VIS 2019, YouTube-VIS 2021, OVIS, and a private surgical video dataset show that TCA consistently boosts the accuracy-speed trade-off of existing clustering-based methods. Our results demonstrate that TCA generalizes competently across both natural and domain-specific videos.

Tobias Rueckert, David Rauber, Raphaela Maerkl et al.

Reliable recognition and localization of surgical instruments in endoscopic video recordings are foundational for a wide range of applications in computer- and robot-assisted minimally invasive surgery (RAMIS), including surgical training, skill assessment, and autonomous assistance. However, robust performance under real-world conditions remains a significant challenge. Incorporating surgical context - such as the current procedural phase - has emerged as a promising strategy to improve robustness and interpretability. To address these challenges, we organized the Surgical Procedure Phase, Keypoint, and Instrument Recognition (PhaKIR) sub-challenge as part of the Endoscopic Vision (EndoVis) challenge at MICCAI 2024. We introduced a novel, multi-center dataset comprising thirteen full-length laparoscopic cholecystectomy videos collected from three distinct medical institutions, with unified annotations for three interrelated tasks: surgical phase recognition, instrument keypoint estimation, and instrument instance segmentation. Unlike existing datasets, ours enables joint investigation of instrument localization and procedural context within the same data while supporting the integration of temporal information across entire procedures. We report results and findings in accordance with the BIAS guidelines for biomedical image analysis challenges. The PhaKIR sub-challenge advances the field by providing a unique benchmark for developing temporally aware, context-driven methods in RAMIS and offers a high-quality resource to support future research in surgical scene understanding.

Imanol Luengo, Maria Grammatikopoulou, Rahim Mohammadi et al.

Surgical scene segmentation is essential for anatomy and instrument localization which can be further used to assess tissue-instrument interactions during a surgical procedure. In 2017, the Challenge on Automatic Tool Annotation for cataRACT Surgery (CATARACTS) released 50 cataract surgery videos accompanied by instrument usage annotations. These annotations included frame-level instrument presence information. In 2020, we released pixel-wise semantic annotations for anatomy and instruments for 4670 images sampled from 25 videos of the CATARACTS training set. The 2020 CATARACTS Semantic Segmentation Challenge, which was a sub-challenge of the 2020 MICCAI Endoscopic Vision (EndoVis) Challenge, presented three sub-tasks to assess participating solutions on anatomical structure and instrument segmentation. Their performance was assessed on a hidden test set of 531 images from 10 videos of the CATARACTS test set.

Max Allan, Satoshi Kondo, Sebastian Bodenstedt et al.

In 2015 we began a sub-challenge at the EndoVis workshop at MICCAI in Munich using endoscope images of ex-vivo tissue with automatically generated annotations from robot forward kinematics and instrument CAD models. However, the limited background variation and simple motion rendered the dataset uninformative in learning about which techniques would be suitable for segmentation in real surgery. In 2017, at the same workshop in Quebec we introduced the robotic instrument segmentation dataset with 10 teams participating in the challenge to perform binary, articulating parts and type segmentation of da Vinci instruments. This challenge included realistic instrument motion and more complex porcine tissue as background and was widely addressed with modifications on U-Nets and other popular CNN architectures. In 2018 we added to the complexity by introducing a set of anatomical objects and medical devices to the segmented classes. To avoid over-complicating the challenge, we continued with porcine data which is dramatically simpler than human tissue due to the lack of fatty tissue occluding many organs.

Maria Grammatikopoulou, Evangello Flouty, Abdolrahim Kadkhodamohammadi et al.

Video feedback provides a wealth of information about surgical procedures and is the main sensory cue for surgeons. Scene understanding is crucial to computer assisted interventions (CAI) and to post-operative analysis of the surgical procedure. A fundamental building block of such capabilities is the identification and localization of surgical instruments and anatomical structures through semantic segmentation. Deep learning has advanced semantic segmentation techniques in the recent years but is inherently reliant on the availability of labelled datasets for model training. This paper introduces a dataset for semantic segmentation of cataract surgery videos complementing the publicly available CATARACTS challenge dataset. In addition, we benchmark the performance of several state-of-the-art deep learning models for semantic segmentation on the presented dataset. The dataset is publicly available at https://cataracts-semantic-segmentation2020.grand-challenge.org/.

Imanol Luengo, Evangello Flouty, Petros Giataganas et al.

Surgical simulation is an increasingly important element of surgical education. Using simulation can be a means to address some of the significant challenges in developing surgical skills with limited time and resources. The photo-realistic fidelity of simulations is a key feature that can improve the experience and transfer ratio of trainees. In this paper, we demonstrate how we can enhance the visual fidelity of existing surgical simulation by performing style transfer of multi-class labels from real surgical video onto synthetic content. We demonstrate our approach on simulations of cataract surgery using real data labels from an existing public dataset. Our results highlight the feasibility of the approach and also the powerful possibility to extend this technique to incorporate additional temporal constraints and to different applications.

Odysseas Zisimopoulos, Evangello Flouty, Imanol Luengo et al.

Automated surgical workflow analysis and understanding can assist surgeons to standardize procedures and enhance post-surgical assessment and indexing, as well as, interventional monitoring. Computer-assisted interventional (CAI) systems based on video can perform workflow estimation through surgical instruments' recognition while linking them to an ontology of procedural phases. In this work, we adopt a deep learning paradigm to detect surgical instruments in cataract surgery videos which in turn feed a surgical phase inference recurrent network that encodes temporal aspects of phase steps within the phase classification. Our models present comparable to state-of-the-art results for surgical tool detection and phase recognition with accuracies of 99 and 78% respectively.

Imanol Luengo, Mark Basham, Andrew P. French

Recent applications in computer vision have come to heavily rely on superpixel over-segmentation as a pre-processing step for higher level vision tasks, such as object recognition, image labelling or image segmentation. Here we present a new superpixel algorithm called Hierarchical Piecewise-Constant Super-regions (HPCS), which not only obtains superpixels comparable to the state-of-the-art, but can also be applied hierarchically to form what we call n-th order super-regions. In essence, a Markov Random Field (MRF)-based anisotropic denoising formulation over the quantized feature space is adopted to form piecewise-constant image regions, which are then combined with a graph-based split & merge post-processing step to form superpixels. The graph and quantized feature based formulation of the problem allows us to generalize it hierarchically to preserve boundary adherence with fewer superpixels. Experimental results show that, despite the simplicity of our framework, it is able to provide high quality superpixels, and to hierarchically apply them to form layers of over-segmentation, each with a decreasing number of superpixels, while maintaining the same desired properties (such as adherence to strong image edges). The algorithm is also memory efficient and has a low computational cost.