Masaru Ishii

Jan Emily Mangulabnan, Roger D. Soberanis-Mukul, Timo Teufel et al.

Generating accurate 3D reconstructions from endoscopic video is a promising avenue for longitudinal radiation-free analysis of sinus anatomy and surgical outcomes. Several methods for monocular reconstruction have been proposed, yielding visually pleasant 3D anatomical structures by retrieving relative camera poses with structure-from-motion-type algorithms and fusion of monocular depth estimates. However, due to the complex properties of the underlying algorithms and endoscopic scenes, the reconstruction pipeline may perform poorly or fail unexpectedly. Further, acquiring medical data conveys additional challenges, presenting difficulties in quantitatively benchmarking these models, understanding failure cases, and identifying critical components that contribute to their precision. In this work, we perform a quantitative analysis of a self-supervised approach for sinus reconstruction using endoscopic sequences paired with optical tracking and high-resolution computed tomography acquired from nine ex-vivo specimens. Our results show that the generated reconstructions are in high agreement with the anatomy, yielding an average point-to-mesh error of 0.91 mm between reconstructions and CT segmentations. However, in a point-to-point matching scenario, relevant for endoscope tracking and navigation, we found average target registration errors of 6.58 mm. We identified that pose and depth estimation inaccuracies contribute equally to this error and that locally consistent sequences with shorter trajectories generate more accurate reconstructions. These results suggest that achieving global consistency between relative camera poses and estimated depths with the anatomy is essential. In doing so, we can ensure proper synergy between all components of the pipeline for improved reconstructions that will facilitate clinical application of this innovative technology.

Han Zhang, Yiqing Shen, Roger D. Soberanis-Mukul et al.

Developing embodied AI for intelligent surgical systems requires safe, controllable environments for continual learning and evaluation. However, safety regulations and operational constraints in operating rooms (ORs) limit embodied agents from freely perceiving and interacting in realistic settings. Digital twins provide high-fidelity, risk-free environments for exploration and training. How we may create photorealistic and dynamic digital representations of ORs that capture relevant spatial, visual, and behavioral complexity remains unclear. We introduce TwinOR, a framework for constructing photorealistic, dynamic digital twins of ORs for embodied AI research. The system reconstructs static geometry from pre-scan videos and continuously models human and equipment motion through multi-view perception of OR activities. The static and dynamic components are fused into an immersive 3D environment that supports controllable simulation and embodied exploration. The proposed framework reconstructs complete OR geometry with centimeter level accuracy while preserving dynamic interaction across surgical workflows, enabling realistic renderings and a virtual playground for embodied AI systems. In our experiments, TwinOR simulates stereo and monocular sensor streams for geometry understanding and visual localization tasks. Models such as FoundationStereo and ORB-SLAM3 on TwinOR-synthesized data achieve performance within their reported accuracy on real indoor datasets, demonstrating that TwinOR provides sensor-level realism sufficient for perception and localization challenges. By establishing a real-to-sim pipeline for constructing dynamic, photorealistic digital twins of OR environments, TwinOR enables the safe, scalable, and data-efficient development and benchmarking of embodied AI, ultimately accelerating the deployment of embodied AI from sim-to-real.

Jan Emily Mangulabnan, Akshat Chauhan, Laura Fleig et al.

In endoscopic surgery, surgeons continuously locate the endoscopic view relative to the anatomy by interpreting the evolving visual appearance of the intraoperative scene in the context of their prior knowledge. Vision-based navigation systems seek to replicate this capability by recovering camera pose directly from endoscopic video, but most approaches do not embody the same principles of reasoning about new frames that makes surgeons successful. Instead, they remain grounded in feature matching and geometric optimization over keyframes, an approach that has been shown to degrade under the challenging conditions of endoscopic imaging like low texture and rapid illumination changes. Here, we pursue an alternative approach and investigate a policy-based formulation of endoscopic camera pose recovery that seeks to imitate experts in estimating trajectories conditioned on the previous camera state. Our approach directly predicts short-horizon relative motions without maintaining an explicit geometric representation at inference time. It thus addresses, by design, some of the notorious challenges of geometry-based approaches, such as brittle correspondence matching, instability in texture-sparse regions, and limited pose coverage due to reconstruction failure. We evaluate the proposed formulation on cadaveric sinus endoscopy. Under oracle state conditioning, we compare short-horizon motion prediction quality to geometric baselines achieving lowest mean translation error and competitive rotational accuracy. We analyze robustness by grouping prediction windows according to texture richness and illumination change indicating reduced sensitivity to low-texture conditions. These findings suggest that a learned motion policy offers a viable alternative formulation for endoscopic camera pose recovery.

Dominik Schneider, Lalithkumar Seenivasan, Sampath Rapuri et al.

Purpose: Curating large-scale datasets of operating room (OR) workflow, encompassing rare, safety-critical, or atypical events, remains operationally and ethically challenging. This data bottleneck complicates the development of ambient intelligence for detecting, understanding, and mitigating rare or safety-critical events in the OR. Methods: This work presents an OR video diffusion framework that enables controlled synthesis of rare and safety-critical events. The framework integrates a geometric abstraction module, a conditioning module, and a fine-tuned diffusion model to first transform OR scenes into abstract geometric representations, then condition the synthesis process, and finally generate realistic OR event videos. Using this framework, we also curate a synthetic dataset to train and validate AI models for detecting near-misses of sterile-field violations. Results: In synthesizing routine OR events, our method outperforms off-the-shelf video diffusion baselines, achieving lower FVD/LPIPS and higher SSIM/PSNR in both in- and out-of-domain datasets. Through qualitative results, we illustrate its ability for controlled video synthesis of counterfactual events. An AI model trained and validated on the generated synthetic data achieved a RECALL of 70.13% in detecting near safety-critical events. Finally, we conduct an ablation study to quantify performance gains from key design choices. Conclusion: Our solution enables controlled synthesis of routine and rare OR events from abstract geometric representations. Beyond demonstrating its capability to generate rare and safety-critical scenarios, we show its potential to support the development of ambient intelligence models.

Xingtong Liu, Zhaoshuo Li, Masaru Ishii et al.

In endoscopy, many applications (e.g., surgical navigation) would benefit from a real-time method that can simultaneously track the endoscope and reconstruct the dense 3D geometry of the observed anatomy from a monocular endoscopic video. To this end, we develop a Simultaneous Localization and Mapping system by combining the learning-based appearance and optimizable geometry priors and factor graph optimization. The appearance and geometry priors are explicitly learned in an end-to-end differentiable training pipeline to master the task of pair-wise image alignment, one of the core components of the SLAM system. In our experiments, the proposed SLAM system is shown to robustly handle the challenges of texture scarceness and illumination variation that are commonly seen in endoscopy. The system generalizes well to unseen endoscopes and subjects and performs favorably compared with a state-of-the-art feature-based SLAM system. The code repository is available at https://github.com/lppllppl920/SAGE-SLAM.git.

David Z. Li, Masaru Ishii, Russell H. Taylor et al.

In this work, we explore whether it is possible to learn representations of endoscopic video frames to perform tasks such as identifying surgical tool presence without supervision. We use a maximum mean discrepancy (MMD) variational autoencoder (VAE) to learn low-dimensional latent representations of endoscopic videos and manipulate these representations to distinguish frames containing tools from those without tools. We use three different methods to manipulate these latent representations in order to predict tool presence in each frame. Our fully unsupervised methods can identify whether endoscopic video frames contain tools with average precision of 71.56, 73.93, and 76.18, respectively, comparable to supervised methods. Our code is available at https://github.com/zdavidli/tool-presence/

Xingtong Liu, Maia Stiber, Jindan Huang et al.

Reconstructing accurate 3D surface models of sinus anatomy directly from an endoscopic video is a promising avenue for cross-sectional and longitudinal analysis to better understand the relationship between sinus anatomy and surgical outcomes. We present a patient-specific, learning-based method for 3D reconstruction of sinus surface anatomy directly and only from endoscopic videos. We demonstrate the effectiveness and accuracy of our method on in and ex vivo data where we compare to sparse reconstructions from Structure from Motion, dense reconstruction from COLMAP, and ground truth anatomy from CT. Our textured reconstructions are watertight and enable measurement of clinically relevant parameters in good agreement with CT. The source code is available at https://github.com/lppllppl920/DenseReconstruction-Pytorch.

Xingtong Liu, Yiping Zheng, Benjamin Killeen et al.

High-quality 3D reconstructions from endoscopy video play an important role in many clinical applications, including surgical navigation where they enable direct video-CT registration. While many methods exist for general multi-view 3D reconstruction, these methods often fail to deliver satisfactory performance on endoscopic video. Part of the reason is that local descriptors that establish pair-wise point correspondences, and thus drive reconstruction, struggle when confronted with the texture-scarce surface of anatomy. Learning-based dense descriptors usually have larger receptive fields enabling the encoding of global information, which can be used to disambiguate matches. In this work, we present an effective self-supervised training scheme and novel loss design for dense descriptor learning. In direct comparison to recent local and dense descriptors on an in-house sinus endoscopy dataset, we demonstrate that our proposed dense descriptor can generalize to unseen patients and scopes, thereby largely improving the performance of Structure from Motion (SfM) in terms of model density and completeness. We also evaluate our method on a public dense optical flow dataset and a small-scale SfM public dataset to further demonstrate the effectiveness and generality of our method. The source code is available at https://github.com/lppllppl920/DenseDescriptorLearning-Pytorch.

Xingtong Liu, Ayushi Sinha, Masaru Ishii et al.

We present a self-supervised approach to training convolutional neural networks for dense depth estimation from monocular endoscopy data without a priori modeling of anatomy or shading. Our method only requires monocular endoscopic videos and a multi-view stereo method, e.g., structure from motion, to supervise learning in a sparse manner. Consequently, our method requires neither manual labeling nor patient computed tomography (CT) scan in the training and application phases. In a cross-patient experiment using CT scans as groundtruth, the proposed method achieved submillimeter mean residual error. In a comparison study to recent self-supervised depth estimation methods designed for natural video on in vivo sinus endoscopy data, we demonstrate that the proposed approach outperforms the previous methods by a large margin. The source code for this work is publicly available online at https://github.com/lppllppl920/EndoscopyDepthEstimation-Pytorch.

Ayushi Sinha, Masaru Ishii, Russell H. Taylor et al.

Registering images from different modalities is an active area of research in computer aided medical interventions. Several registration algorithms have been developed, many of which achieve high accuracy. However, these results are dependent on many factors, including the quality of the extracted features or segmentations being registered as well as the initial alignment. Although several methods have been developed towards improving segmentation algorithms and automating the segmentation process, few automatic initialization algorithms have been explored. In many cases, the initial alignment from which a registration is initiated is performed manually, which interferes with the clinical workflow. Our aim is to use scene classification in endoscopic procedures to achieve coarse alignment of the endoscope and a preoperative image of the anatomy. In this paper, we show using simulated scenes that a neural network can predict the region of anatomy (with respect to a preoperative image) that the endoscope is located in by observing a single endoscopic video frame. With limited training and without any hyperparameter tuning, our method achieves an accuracy of 76.53 (+/-1.19)%. There are several avenues for improvement, making this a promising direction of research. Code is available at https://github.com/AyushiSinha/AutoInitialization.

Jan Emily Mangulabnan, Roger D. Soberanis-Mukul, Timo Teufel et al.

Purpose: Preoperative imaging plays a pivotal role in sinus surgery where CTs offer patient-specific insights of complex anatomy, enabling real-time intraoperative navigation to complement endoscopy imaging. However, surgery elicits anatomical changes not represented in the preoperative model, generating an inaccurate basis for navigation during surgery progression. Methods: We propose a first vision-based approach to update the preoperative 3D anatomical model leveraging intraoperative endoscopic video for navigated sinus surgery where relative camera poses are known. We rely on comparisons of intraoperative monocular depth estimates and preoperative depth renders to identify modified regions. The new depths are integrated in these regions through volumetric fusion in a truncated signed distance function representation to generate an intraoperative 3D model that reflects tissue manipulation. Results: We quantitatively evaluate our approach by sequentially updating models for a five-step surgical progression in an ex vivo specimen. We compute the error between correspondences from the updated model and ground-truth intraoperative CT in the region of anatomical modification. The resulting models show a decrease in error during surgical progression as opposed to increasing when no update is employed. Conclusion: Our findings suggest that preoperative 3D anatomical models can be updated using intraoperative endoscopy video in navigated sinus surgery. Future work will investigate improvements to monocular depth estimation as well as removing the need for external navigation systems. The resulting ability to continuously update the patient model may provide surgeons with a more precise understanding of the current anatomical state and paves the way toward a digital twin paradigm for sinus surgery.

Han Zhang, Lalithkumar Seenivasan, Jose L. Porras et al.

Observing surgical practice has historically relied on fixed vantage points or recollections, leaving the egocentric visual perspectives that guide clinical decisions undocumented. Fixed-camera video can capture surgical workflows at the room-scale, but cannot reconstruct what each team member actually saw. Thus, these videos only provide limited insights into how decisions that affect surgical safety, training, and workflow optimization are made. Here we introduce EgoSurg, the first framework to reconstruct the dynamic, egocentric replays for any operating room (OR) staff directly from wall-mounted fixed-camera video, and thus, without intervention to clinical workflow. EgoSurg couples geometry-driven neural rendering with diffusion-based view enhancement, enabling high-visual fidelity synthesis of arbitrary and egocentric viewpoints at any moment. In evaluation across multi-site surgical cases and controlled studies, EgoSurg reconstructs person-specific visual fields and arbitrary viewpoints with high visual quality and fidelity. By transforming existing OR camera infrastructure into a navigable dynamic 3D record, EgoSurg establishes a new foundation for immersive surgical data science, enabling surgical practice to be visualized, experienced, and analyzed from every angle.

Catalina Gomez, Lalithkumar Seenivasan, Xinrui Zou et al.

Traditional surgical skill acquisition relies heavily on expert feedback, yet direct access is limited by faculty availability and variability in subjective assessments. While trainees can practice independently, the lack of personalized, objective, and quantitative feedback reduces the effectiveness of self-directed learning. Recent advances in computer vision and machine learning have enabled automated surgical skill assessment, demonstrating the feasibility of automatic competency evaluation. However, it is unclear whether such Artificial Intelligence (AI)-driven feedback can contribute to skill acquisition. Here, we examine the effectiveness of explainable AI (XAI)-generated feedback in surgical training through a human-AI study. We create a simulation-based training framework that utilizes XAI to analyze videos and extract surgical skill proxies related to primitive actions. Our intervention provides automated, user-specific feedback by comparing trainee performance to expert benchmarks and highlighting deviations from optimal execution through understandable proxies for actionable guidance. In a prospective user study with medical students, we compare the impact of XAI-guided feedback against traditional video-based coaching on task outcomes, cognitive load, and trainees' perceptions of AI-assisted learning. Results showed improved cognitive load and confidence post-intervention. While no differences emerged between the two feedback types in reducing performance gaps or practice adjustments, trends in the XAI group revealed desirable effects where participants more closely mimicked expert practice. This work encourages the study of explainable AI in surgical education and the development of data-driven, adaptive feedback mechanisms that could transform learning experiences and competency assessment.

Lalithkumar Seenivasan, Jiru Xu, Roger D. Soberanis Mukul et al.

Emerging surgical data science and robotics solutions, especially those designed to provide assistance in situ, require natural human-machine interfaces to fully unlock their potential in providing adaptive and intuitive aid. Contemporary AI-driven solutions remain inherently rigid, offering limited flexibility and restricting natural human-machine interaction in dynamic surgical environments. These solutions rely heavily on extensive task-specific pre-training, fixed object categories, and explicit manual-prompting. This work introduces a novel Perception Agent that leverages speech-integrated prompt-engineered large language models (LLMs), segment anything model (SAM), and any-point tracking foundation models to enable a more natural human-machine interaction in real-time intraoperative surgical assistance. Incorporating a memory repository and two novel mechanisms for segmenting unseen elements, Perception Agent offers the flexibility to segment both known and unseen elements in the surgical scene through intuitive interaction. Incorporating the ability to memorize novel elements for use in future surgeries, this work takes a marked step towards human-machine symbiosis in surgical procedures. Through quantitative analysis on a public dataset, we show that the performance of our agent is on par with considerably more labor-intensive manual-prompting strategies. Qualitatively, we show the flexibility of our agent in segmenting novel elements (instruments, phantom grafts, and gauze) in a custom-curated dataset. By offering natural human-machine interaction and overcoming rigidity, our Perception Agent potentially brings AI-based real-time assistance in dynamic surgical environments closer to reality.

Xingtong Liu, Ayushi Sinha, Masaru Ishii et al.

We present a self-supervised learning-based pipeline for dense 3D reconstruction from full-length monocular endoscopic videos without a priori modeling of anatomy or shading. Our method only relies on unlabeled monocular endoscopic videos and conventional multi-view stereo algorithms, and requires neither manual interaction nor patient CT in both training and application phases. In a cross-patient study using CT scans as groundtruth, we show that our method is able to produce photo-realistic dense 3D reconstructions with submillimeter mean residual errors from endoscopic videos from unseen patients and scopes.

Xingtong Liu, Ayushi Sinha, Mathias Unberath et al.

We present a self-supervised approach to training convolutional neural networks for dense depth estimation from monocular endoscopy data without a priori modeling of anatomy or shading. Our method only requires sequential data from monocular endoscopic videos and a multi-view stereo reconstruction method, e.g. structure from motion, that supervises learning in a sparse but accurate manner. Consequently, our method requires neither manual interaction, such as scaling or labeling, nor patient CT in the training and application phases. We demonstrate the performance of our method on sinus endoscopy data from two patients and validate depth prediction quantitatively using corresponding patient CT scans where we found submillimeter residual errors.

Ayushi Sinha, Xingtong Liu, Austin Reiter et al.

Clinical examinations that involve endoscopic exploration of the nasal cavity and sinuses often do not have a reference image to provide structural context to the clinician. In this paper, we present a system for navigation during clinical endoscopic exploration in the absence of computed tomography (CT) scans by making use of shape statistics from past CT scans. Using a deformable registration algorithm along with dense reconstructions from video, we show that we are able to achieve submillimeter registrations in in-vivo clinical data and are able to assign confidence to these registrations using confidence criteria established using simulated data.

Alexander Binder, Michael Bockmayr, Miriam Hägele et al.

Recent advances in cancer research largely rely on new developments in microscopic or molecular profiling techniques offering high level of detail with respect to either spatial or molecular features, but usually not both. Here, we present a novel machine learning-based computational approach that allows for the identification of morphological tissue features and the prediction of molecular properties from breast cancer imaging data. This integration of microanatomic information of tumors with complex molecular profiling data, including protein or gene expression, copy number variation, gene methylation and somatic mutations, provides a novel means to computationally score molecular markers with respect to their relevance to cancer and their spatial associations within the tumor microenvironment.

Seth D. Billings, Ayushi Sinha, Austin Reiter et al.

Functional endoscopic sinus surgery (FESS) is a surgical procedure used to treat acute cases of sinusitis and other sinus diseases. FESS is fast becoming the preferred choice of treatment due to its minimally invasive nature. However, due to the limited field of view of the endoscope, surgeons rely on navigation systems to guide them within the nasal cavity. State of the art navigation systems report registration accuracy of over 1mm, which is large compared to the size of the nasal airways. We present an anatomically constrained video-CT registration algorithm that incorporates multiple video features. Our algorithm is robust in the presence of outliers. We also test our algorithm on simulated and in-vivo data, and test its accuracy against degrading initializations.

Piyush Poddar, Narges Ahmidi, S. Swaroop Vedula et al.

Previous work on surgical skill assessment using intraoperative tool motion in the operating room (OR) has focused on highly-structured surgical tasks such as cholecystectomy. Further, these methods only considered generic motion metrics such as time and number of movements, which are of limited instructive value. In this paper, we developed and evaluated an automated approach to the surgical skill assessment of nasal septoplasty in the OR. The obstructed field of view and highly unstructured nature of septoplasty precludes trainees from efficiently learning the procedure. We propose a descriptive structure of septoplasty consisting of two types of activity: (1) brushing activity directed away from the septum plane characterizing the consistency of the surgeon's wrist motion and (2) activity along the septal plane characterizing the surgeon's coverage pattern. We derived features related to these two activity types that classify a surgeon's level of training with an average accuracy of about 72%. The features we developed provide surgeons with personalized, actionable feedback regarding their tool motion.