Beat Müller-Stich

Micha Pfeiffer, Hannes Kenngott, Anas Preukschas et al.

Purpose: The data which is available to surgeons before, during and after surgery is steadily increasing in quantity as well as diversity. When planning a patient's treatment, this large amount of information can be difficult to interpret. To aid in processing the information, new methods need to be found to present multi-modal patient data, ideally combining textual, imagery, temporal and 3D data in a holistic and context-aware system. Methods: We present an open-source framework which allows handling of patient data in a virtual reality (VR) environment. By using VR technology, the workspace available to the surgeon is maximized and 3D patient data is rendered in stereo, which increases depth perception. The framework organizes the data into workspaces and contains tools which allow users to control, manipulate and enhance the data. Due to the framework's modular design, it can easily be adapted and extended for various clinical applications. Results: The framework was evaluated by clinical personnel (77 participants). The majority of the group stated that a complex surgical situation is easier to comprehend by using the framework, and that it is very well suited for education. Furthermore, the application to various clinical scenarios - including the simulation of excitation-propagation in the human atrium - demonstrated the framework's adaptability. As a feasibility study, the framework was used during the planning phase of the surgical removal of a large central carcinoma from a patient's liver. Conclusion: The clinical evaluation showed a large potential and high acceptance for the VR environment in a medical context. The various applications confirmed that the framework is easily extended and can be used in real-time simulation as well as for the manipulation of complex anatomical structures.

Sebastian Bodenstedt, Martin Wagner, Lars Mündermann et al.

Purpose The course of surgical procedures is often unpredictable, making it difficult to estimate the duration of procedures beforehand. A context-aware method that analyses the workflow of an intervention online and automatically predicts the remaining duration would alleviate these problems. As basis for such an estimate, information regarding the current state of the intervention is required. Methods Today, the operating room contains a diverse range of sensors. During laparoscopic interventions, the endoscopic video stream is an ideal source of such information. Extracting quantitative information from the video is challenging though, due to its high dimensionality. Other surgical devices (e.g. insufflator, lights, etc.) provide data streams which are, in contrast to the video stream, more compact and easier to quantify. Though whether such streams offer sufficient information for estimating the duration of surgery is uncertain. Here, we propose and compare methods, based on convolutional neural networks, for continuously predicting the duration of laparoscopic interventions based on unlabeled data, such as from endoscopic images and surgical device streams. Results The methods are evaluated on 80 laparoscopic interventions of various types, for which surgical device data and the endoscopic video are available. Here the combined method performs best with an overall average error of 37% and an average halftime error of 28%. Conclusion In this paper, we present, to our knowledge, the first approach for online procedure duration prediction using unlabeled endoscopic video data and surgical device data in a laparoscopic setting. We also show that a method incorporating both vision and device data performs better than methods based only on vision, while methods only based on tool usage and surgical device data perform poorly, showing the importance of the visual channel.

Sebastian Bodenstedt, Dominik Rivoir, Alexander Jenke et al.

For many applications in the field of computer assisted surgery, such as providing the position of a tumor, specifying the most probable tool required next by the surgeon or determining the remaining duration of surgery, methods for surgical workflow analysis are a prerequisite. Often machine learning based approaches serve as basis for surgical workflow analysis. In general machine learning algorithms, such as convolutional neural networks (CNN), require large amounts of labeled data. While data is often available in abundance, many tasks in surgical workflow analysis need data annotated by domain experts, making it difficult to obtain a sufficient amount of annotations. The aim of using active learning to train a machine learning model is to reduce the annotation effort. Active learning methods determine which unlabeled data points would provide the most information according to some metric, such as prediction uncertainty. Experts will then be asked to only annotate these data points. The model is then retrained with the new data and used to select further data for annotation. Recently, active learning has been applied to CNN by means of Deep Bayesian Networks (DBN). These networks make it possible to assign uncertainties to predictions. In this paper, we present a DBN-based active learning approach adapted for image-based surgical workflow analysis task. Furthermore, by using a recurrent architecture, we extend this network to video-based surgical workflow analysis. We evaluate these approaches on the Cholec80 dataset by performing instrument presence detection and surgical phase segmentation. Here we are able to show that using a DBN-based active learning approach for selecting what data points to annotate next outperforms a baseline based on randomly selecting data points.

Sebastian Bodenstedt, Antonia Ohnemus, Darko Katic et al.

During laparoscopic surgery, context-aware assistance systems aim to alleviate some of the difficulties the surgeon faces. To ensure that the right information is provided at the right time, the current phase of the intervention has to be known. Real-time locating and classification the surgical tools currently in use are key components of both an activity-based phase recognition and assistance generation. In this paper, we present an image-based approach that detects and classifies tools during laparoscopic interventions in real-time. First, potential instrument bounding boxes are detected using a pixel-wise random forest segmentation. Each of these bounding boxes is then classified using a cascade of random forest. For this, multiple features, such as histograms over hue and saturation, gradients and SURF feature, are extracted from each detected bounding box. We evaluated our approach on five different videos from two different types of procedures. We distinguished between the four most common classes of instruments (LigaSure, atraumatic grasper, aspirator, clip applier) and background. Our method succesfully located up to 86% of all instruments respectively. On manually provided bounding boxes, we achieve a instrument type recognition rate of up to 58% and on automatically detected bounding boxes up to 49%. To our knowledge, this is the first approach that allows an image-based classification of surgical tools in a laparoscopic setting in real-time.

Sebastian Bodenstedt, Max Allan, Anthony Agustinos et al.

Intraoperative segmentation and tracking of minimally invasive instruments is a prerequisite for computer- and robotic-assisted surgery. Since additional hardware like tracking systems or the robot encoders are cumbersome and lack accuracy, surgical vision is evolving as promising techniques to segment and track the instruments using only the endoscopic images. However, what is missing so far are common image data sets for consistent evaluation and benchmarking of algorithms against each other. The paper presents a comparative validation study of different vision-based methods for instrument segmentation and tracking in the context of robotic as well as conventional laparoscopic surgery. The contribution of the paper is twofold: we introduce a comprehensive validation data set that was provided to the study participants and present the results of the comparative validation study. Based on the results of the validation study, we arrive at the conclusion that modern deep learning approaches outperform other methods in instrument segmentation tasks, but the results are still not perfect. Furthermore, we show that merging results from different methods actually significantly increases accuracy in comparison to the best stand-alone method. On the other hand, the results of the instrument tracking task show that this is still an open challenge, especially during challenging scenarios in conventional laparoscopic surgery.

Sebastian Bodenstedt, Martin Wagner, Darko Katić et al.

Computer-assisted surgery (CAS) aims to provide the surgeon with the right type of assistance at the right moment. Such assistance systems are especially relevant in laparoscopic surgery, where CAS can alleviate some of the drawbacks that surgeons incur. For many assistance functions, e.g. displaying the location of a tumor at the appropriate time or suggesting what instruments to prepare next, analyzing the surgical workflow is a prerequisite. Since laparoscopic interventions are performed via endoscope, the video signal is an obvious sensor modality to rely on for workflow analysis. Image-based workflow analysis tasks in laparoscopy, such as phase recognition, skill assessment, video indexing or automatic annotation, require a temporal distinction between video frames. Generally computer vision based methods that generalize from previously seen data are used. For training such methods, large amounts of annotated data are necessary. Annotating surgical data requires expert knowledge, therefore collecting a sufficient amount of data is difficult, time-consuming and not always feasible. In this paper, we address this problem by presenting an unsupervised method for training a convolutional neural network (CNN) to differentiate between laparoscopic video frames on a temporal basis. We extract video frames at regular intervals from 324 unlabeled laparoscopic interventions, resulting in a dataset of approximately 2.2 million images. From this dataset, we extract image pairs from the same video and train a CNN to determine their temporal order. To solve this problem, the CNN has to extract features that are relevant for comprehending laparoscopic workflow. Furthermore, we demonstrate that such a CNN can be adapted for surgical workflow segmentation. We performed image-based workflow segmentation on a publicly available dataset of 7 cholecystectomies and 9 colorectal interventions.