Yannik Frisch

Yannik Frisch, Moritz Fuchs, Antoine Sanner et al.

Cataract surgery is a frequently performed procedure that demands automation and advanced assistance systems. However, gathering and annotating data for training such systems is resource intensive. The publicly available data also comprises severe imbalances inherent to the surgical process. Motivated by this, we analyse cataract surgery video data for the worst-performing phases of a pre-trained downstream tool classifier. The analysis demonstrates that imbalances deteriorate the classifier's performance on underrepresented cases. To address this challenge, we utilise a conditional generative model based on Denoising Diffusion Implicit Models (DDIM) and Classifier-Free Guidance (CFG). Our model can synthesise diverse, high-quality examples based on complex multi-class multi-label conditions, such as surgical phases and combinations of surgical tools. We affirm that the synthesised samples display tools that the classifier recognises. These samples are hard to differentiate from real images, even for clinical experts with more than five years of experience. Further, our synthetically extended data can improve the data sparsity problem for the downstream task of tool classification. The evaluations demonstrate that the model can generate valuable unseen examples, allowing the tool classifier to improve by up to 10% for rare cases. Overall, our approach can facilitate the development of automated assistance systems for cataract surgery by providing a reliable source of realistic synthetic data, which we make available for everyone.

Marvin Seyfarth, Salman Ul Hassan Dar, Yannik Frisch et al.

Diffusion models have become a leading approach for high-fidelity medical image synthesis. However, most existing methods for 3D medical image generation rely on convolutional U-Net backbones within latent diffusion frameworks. While effective, these architectures impose strong locality biases and limited receptive fields, which may constrain scalability, global context integration, and flexible conditioning. In this work, we introduce VolDiT, the first purely transformer-based 3D Diffusion Transformer for volumetric medical image synthesis. Our approach extends diffusion transformers to native 3D data through volumetric patch embeddings and global self-attention operating directly over 3D tokens. To enable structured control, we propose a timestep-gated control adapter that maps segmentation masks into learnable control tokens that modulate transformer layers during denoising. This token-level conditioning mechanism allows precise spatial guidance while preserving the modeling advantages of transformer architectures. We evaluate our model on high-resolution 3D medical image synthesis tasks and compare it to state-of-the-art 3D latent diffusion models based on U-Nets. Results demonstrate improved global coherence, superior generative fidelity, and enhanced controllability. Our findings suggest that fully transformerbased diffusion models provide a flexible foundation for volumetric medical image synthesis. The code and models trained on public data are available at https://github.com/Cardio-AI/voldit.

Ssharvien Kumar Sivakumar, Akwele Johnson, Anirudh Dhingra et al.

Realistic surgical simulation plays a crucial role in training novice surgeons and in the development of autonomous agents. World models can scale such simulation environments to realistic and diverse procedures by predicting future patient states conditioned on current observations and surgical actions. However, current state-of-the-art approaches often fail to satisfy key criteria required for clinical applicability, including visual realism, physically grounded interactions, and the ability to simulate scenarios beyond the training distribution. Hence, we introduce SWoMo, a neuro-symbolic world model for cataract surgery simulation that decouples motion generation from visual realism. The symbolic component, consisting of a rule-based simulator and scene graph representations, models motion dynamics and tool-tissue interactions, while a diffusion model produces realistic visual appearance, including textures and tissue deformations. We propose an inverse pairing strategy that reconstructs real surgical videos in the simulator to obtain paired simulated and real videos, which are then used to train our video diffusion model for the reverse objective of sim-to-real translation. Our experiments show both qualitative and quantitative improvements over prior work. We demonstrate that our simulator further satisfies the key criteria, including generalisation to unseen interaction geometries, improvements in downstream phase detection, and unsupervised video style transfer. The code, data, and model weights are available at: https://ssharvienkumar.github.io/SWoMo/

Paul Friedrich, Yannik Frisch, Philippe C. Cattin

Deep generative modeling has emerged as a powerful tool for synthesizing realistic medical images, driving advances in medical image analysis, disease diagnosis, and treatment planning. This chapter explores various deep generative models for 3D medical image synthesis, with a focus on Variational Autoencoders (VAEs), Generative Adversarial Networks (GANs), and Denoising Diffusion Models (DDMs). We discuss the fundamental principles, recent advances, as well as strengths and weaknesses of these models and examine their applications in clinically relevant problems, including unconditional and conditional generation tasks like image-to-image translation and image reconstruction. We additionally review commonly used evaluation metrics for assessing image fidelity, diversity, utility, and privacy and provide an overview of current challenges in the field.

John Kalkhof, Arlene Kühn, Yannik Frisch et al.

Despite considerable success, large Denoising Diffusion Models (DDMs) with UNet backbone pose practical challenges, particularly on limited hardware and in processing gigapixel images. To address these limitations, we introduce two Neural Cellular Automata (NCA)-based DDMs: Diff-NCA and FourierDiff-NCA. Capitalizing on the local communication capabilities of NCA, Diff-NCA significantly reduces the parameter counts of NCA-based DDMs. Integrating Fourier-based diffusion enables global communication early in the diffusion process. This feature is particularly valuable in synthesizing complex images with important global features, such as the CelebA dataset. We demonstrate that even a 331k parameter Diff-NCA can generate 512x512 pathology slices, while FourierDiff-NCA (1.1m parameters) reaches a three times lower FID score of 43.86, compared to the four times bigger UNet (3.94m parameters) with a score of 128.2. Additionally, FourierDiff-NCA can perform diverse tasks such as super-resolution, out-of-distribution image synthesis, and inpainting without explicit training.

Ssharvien Kumar Sivakumar, Yannik Frisch, Amin Ranem et al.

Purpose: Foundation models, trained on multitudes of public datasets, often require additional fine-tuning or re-prompting mechanisms to be applied to visually distinct target domains such as surgical videos. Further, without domain knowledge, they cannot model the specific semantics of the target domain. Hence, when applied to surgical video segmentation, they fail to generalise to sections where previously tracked objects leave the scene or new objects enter. Methods: We propose SASVi, a novel re-prompting mechanism based on a frame-wise Mask R-CNN Overseer model, which is trained on a minimal amount of scarcely available annotations for the target domain. This model automatically re-prompts the foundation model SAM2 when the scene constellation changes, allowing for temporally smooth and complete segmentation of full surgical videos. Results: Re-prompting based on our Overseer model significantly improves the temporal consistency of surgical video segmentation compared to similar prompting techniques and especially frame-wise segmentation, which neglects temporal information, by at least 1.5%. Our proposed approach allows us to successfully deploy SAM2 to surgical videos, which we quantitatively and qualitatively demonstrate for three different cholecystectomy and cataract surgery datasets. Conclusion: SASVi can serve as a new baseline for smooth and temporally consistent segmentation of surgical videos with scarcely available annotation data. Our method allows us to leverage scarce annotations and obtain complete annotations for full videos of the large-scale counterpart datasets. We make those annotations publicly available, providing extensive annotation data for the future development of surgical data science models.

Yannik Frisch, Ssharvien Kumar Sivakumar, Çağhan Köksal et al.

Surgical simulation offers a promising addition to conventional surgical training. However, available simulation tools lack photorealism and rely on hardcoded behaviour. Denoising Diffusion Models are a promising alternative for high-fidelity image synthesis, but existing state-of-the-art conditioning methods fall short in providing precise control or interactivity over the generated scenes. We introduce SurGrID, a Scene Graph to Image Diffusion Model, allowing for controllable surgical scene synthesis by leveraging Scene Graphs. These graphs encode a surgical scene's components' spatial and semantic information, which are then translated into an intermediate representation using our novel pre-training step that explicitly captures local and global information. Our proposed method improves the fidelity of generated images and their coherence with the graph input over the state-of-the-art. Further, we demonstrate the simulation's realism and controllability in a user assessment study involving clinical experts. Scene Graphs can be effectively used for precise and interactive conditioning of Denoising Diffusion Models for simulating surgical scenes, enabling high fidelity and interactive control over the generated content.

Ssharvien Kumar Sivakumar, Yannik Frisch, Ghazal Ghazaei et al.

Surgical simulation plays a pivotal role in training novice surgeons, accelerating their learning curve and reducing intra-operative errors. However, conventional simulation tools fall short in providing the necessary photorealism and the variability of human anatomy. In response, current methods are shifting towards generative model-based simulators. Yet, these approaches primarily focus on using increasingly complex conditioning for precise synthesis while neglecting the fine-grained human control aspect. To address this gap, we introduce SG2VID, the first diffusion-based video model that leverages Scene Graphs for both precise video synthesis and fine-grained human control. We demonstrate SG2VID's capabilities across three public datasets featuring cataract and cholecystectomy surgery. While SG2VID outperforms previous methods both qualitatively and quantitatively, it also enables precise synthesis, providing accurate control over tool and anatomy's size and movement, entrance of new tools, as well as the overall scene layout. We qualitatively motivate how SG2VID can be used for generative augmentation and present an experiment demonstrating its ability to improve a downstream phase detection task when the training set is extended with our synthetic videos. Finally, to showcase SG2VID's ability to retain human control, we interact with the Scene Graphs to generate new video samples depicting major yet rare intra-operative irregularities.

Yannik Frisch, Christina Bornberg, Moritz Fuchs et al.

Augmentation by generative modelling yields a promising alternative to the accumulation of surgical data, where ethical, organisational and regulatory aspects must be considered. Yet, the joint synthesis of (image, mask) pairs for segmentation, a major application in surgery, is rather unexplored. We propose to learn semantically comprehensive yet compact latent representations of the (image, mask) space, which we jointly model with a Latent Diffusion Model. We show that our approach can effectively synthesise unseen high-quality paired segmentation data of remarkable semantic coherence. Generative augmentation is typically applied pre-training by synthesising a fixed number of additional training samples to improve downstream task models. To enhance this approach, we further propose Generative Adaptive Uncertainty-guided Diffusion-based Augmentation (GAUDA), leveraging the epistemic uncertainty of a Bayesian downstream model for targeted online synthesis. We condition the generative model on classes with high estimated uncertainty during training to produce additional unseen samples for these classes. By adaptively utilising the generative model online, we can minimise the number of additional training samples and centre them around the currently most uncertain parts of the data distribution. GAUDA effectively improves downstream segmentation results over comparable methods by an average absolute IoU of 1.6% on CaDISv2 and 1.5% on CholecSeg8k, two prominent surgical datasets for semantic segmentation.