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Grounded in communication models of cultural competence, this study reports on the development and testing of the first module in a larger virtual reality (VR) implicit bias training for physicians to help them better: (a) recognize implicit bias and its effects on communication, patients, and patient care; (b) identify their own implicit biases and exercise strategies for managing them; and (c) learn and practice communicating with BIPOC patients in a culture-centered manner that demonstrates respect and builds trust. Led by communication faculty, a large, interdisciplinary team of researchers, clinicians, and engineers developed the first module tested herein focused on training goal (a). Within the module, participants observe five scenes between patient Marilyn Hayes (a Black woman) and Dr. Richard Flynn (her obstetrician, a White man) during a postpartum visit. The interaction contains examples of implicit bias, and participants are asked to both identify and consider how implicit bias impacts communication, the patient, and patient care. The team recruited 30 medical students and resident physicians to participate in a lab-based study that included a pretest, a training experience of the module using a head-mounted VR display, and a posttest. Following the training, participants reported improved attitudes toward implicit bias instruction, greater importance of determining patients' beliefs and perspectives for history-taking, treatment, and providing quality health care; and greater communication efficacy. Participants' agreement with the importance of assessing patients' perspectives, opinions, and psychosocial and cultural contexts did not significantly change. Implications for medical education about cultural competency and implicit bias are discussed.

Although cone-beam computed tomography (CT) is the predominant cross-sectional imaging modality used by interventional radiologists, advancements in hybrid angiography-CT technology have demonstrated a strong potential for increased utilization in the angiography suite. The benefits of increased workflow efficiency, decreased relative cost, multipurpose utility, and most importantly improved patient care may encourage institutions to accept the higher upfront cost of angiography-CT rooms for potential long-term benefits. Hybrid angiography-CT setups are less prone to motion and streak artifacts and may provide superior image quality compared with cone-beam CT. Although angiography-CT technology has been most frequently utilized for oncologic treatments, its use is being expanded across multiple applications. In this review, the authors illustrate 6 nonhepatic cases at 2 tertiary hospitals that each showcase how angiography-CT technology enabled an intervention., (Copyright © 2025 SIR. Published by Elsevier Inc. All rights reserved.)

Competing Interests: None.

Objectives: To evaluate suturing skills of veterinary students using 3 common performance assessments (PAs) and to compare findings to data obtained by an electromyographic armband., Sample: 16 second-year veterinary students., Procedures: Students performed 4 suturing tasks on synthetic tissue models 1, 3, and 5 weeks after a surgical skills course. Digital videos were scored by 4 expert surgeons using 3 PAs (an Objective Structured Clinical Examination [OSCE]- style surgical binary checklist, an Objective Structured Assessment of Technical Skill [OSATS] checklist, and a surgical Global Rating Scale [GRS]). Surface electromyography (sEMG) data collected from the dominant forearm were input to machine learning algorithms. Performance assessment scores were compared between experts and correlated to task completion times and sEMG data. Inter-rater reliability was calculated using the intraclass correlation coefficient (ICC). Inter-rater agreement was calculated using percent agreement with varying levels of tolerance., Results: Reliability was moderate for the OSCE and OSATS checklists and poor for the GRS. Agreement was achieved for the checklists when moderate tolerance was applied but remained poor for the GRS. sEMG signals did not correlate well with checklist scores or task times, but features extracted from signals permitted task differentiation by routine statistical comparison and correct task classification using machine learning algorithms., Clinical Relevance: Reliability and agreement of an OSCE-style checklist, OSATS checklist, and surgical GRS assessment were insufficient to characterize suturing skills of veterinary students. To avoid subjectivity associated with PA by raters, further study of kinematics and EMG data is warranted in the surgical skills evaluation of veterinary students.

Noroviruses (NoVs) cause over 90% of non-bacterial gastroenteritis outbreaks in adults and children in developed countries. Therefore, there is a need for approaches to mitigate the transmission of noroviruses in workplaces to reduce their substantial health burden. We developed and validated a low-cost, autonomous robot called the UVBot to disinfect occupational spaces using ultraviolet (UV) lamps. The total cost of the UVBOT is less than USD 1000, which is much lower than existing commercial robots that cost as much as USD 35,000. The user-friendly desktop application allows users to control the robot remotely, check the disinfection map, and add virtual walls to the map. A 2D LiDAR and a simultaneous localization and mapping (SLAM) algorithm was used to generate a map of the space being disinfected. Tulane virus (TV), a human norovirus surrogate, was used to validate the UVBot's effectiveness. TV was deposited on a painted drywall and exposed to UV radiation at different doses. A 3-log (99.9%) reduction of TV infectivity was achieved at a UV dose of 45 mJ/cm 2 . We further calculated the sanitizing speed as 3.5 cm/s and the efficient sanitizing distance reached up to 40 cm from the UV bulb. The design, software, and environment test data are available to the public so that any organization with minimal engineering capabilities can reproduce the UVBot system.

Stroke is one of the leading causes of mortality and disability worldwide. Several evaluation methods have been used to assess the effects of stroke on the performance of activities of daily living (ADL). However, these methods are qualitative. A first step toward developing a quantitative evaluation method is to classify different ADL tasks based on the hand grasp. In this paper, a dataset is presented that includes data collected by a leap motion controller on the hand grasps of healthy adults performing eight common ADL tasks. Then, a set of features with time and frequency domains is combined with two well-known classifiers, i.e., the support vector machine and convolutional neural network, to classify the tasks, and a classification accuracy of over 99% is achieved.

Background: We seek to characterize the features of iatrogenic spinal ischemia, determine which spinal levels are affected, and evaluate the efficacy of management strategies., Methods: We performed a meta-analysis of case reports and series of spinal ischemia in the past 10 years. 343 full-length case reports and case series were screened against predefined inclusion/exclusion criteria. 89 patients were included for our final meta-analysis using PRISMA guidelines., Results: Mean age of patients was 59.62 years (range: 9 months-88 years). 66% of all cases were male. Endovascular surgery (32.6%) and aortic surgery (36.0%) were most common causes of iatrogenic injury, followed by non-aortic surgery (32.6%), and non-surgical procedures (22.47%). A- and B-level ASIA Impairment was found in 66% of all patients. Rehabilitation was the most common management (49.44% of cases), followed by blood pressure management (40.45%). Non-aortic surgeries had the poorest overall outcomes (OR = 0.28, p  = 0.016), whereas aortic and endovascular surgeries saw significant improvement in outcomes measured at discharge (OR = 2.6, OR = 2.3, respectively, p  < 0.05). Therapeutic surgical infarctions were found to be associated with improved outcomes (OR = 5.33, p  = 0.032). Ischemic injury to T4-T7, and T10 were associated with significantly poorer outcomes. Autonomic impairment was associated with a likelihood of infarction at T10 (OR = 4.54, p  = 0.0183)., Conclusions: In this paper, we compare outcomes following iatrogenic spinal ischemia. We demonstrate the need for more comprehensive randomized controlled trials to test effective treatment strategies., Competing Interests: The authors have no conflicts of interest related to this work to declare., (© 2021 Published by Elsevier Ltd on behalf of North American Spine Society.)

The coronavirus disease (COVID-19) outbreak requires rapid reshaping of rehabilitation services to include patients recovering from severe COVID-19 with post-intensive care syndromes, which results in physical deconditioning and cognitive impairments, patients with comorbid conditions, and other patients requiring physical therapy during the outbreak with no or limited access to hospital and rehabilitation centers. Considering the access barriers to quality rehabilitation settings and services imposed by social distancing and stay-at-home orders, these patients can be benefited from providing access to affordable and good quality care through home-based rehabilitation. The success of such treatment will depend highly on the intensity of the therapy and effort invested by the patient. Monitoring patients' compliance and designing a home-based rehabilitation that can mentally engage them are the critical elements in home-based therapy's success. Hence, we study the state-of-the-art telerehabilitation frameworks and robotic devices, and comment about a hybrid model that can use existing telerehabilitation framework and home-based robotic devices for treatment and simultaneously assess patient's progress remotely. Second, we comment on the patients' social support and engagement, which is critical for the success of telerehabilitation service. As the therapists are not physically present to guide the patients, we also discuss the adaptability requirement of home-based telerehabilitation. Finally, we suggest that the reformed rehabilitation services should consider both home-based solutions for enhancing the activities of daily living and an on-demand ambulatory rehabilitation unit for extensive training where we can monitor both cognitive and motor performance of the patients remotely., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Manjunatha, Pareek, Jujjavarapu, Ghobadi, Kesavadas and Esfahani.)

Currently, most of the high-performance models for frequency recognition of steady-state visual evoked potentials (SSVEPs) are linear. However, SSVEPs collected from different channels can have non-linear relationship among each other. Linearly combining electroencephalogram (EEG) from multiple channels is not the most accurate solution in SSVEPs classification. To further improve the performance of SSVEP-based brain-computer interface (BCI), we propose a convolutional neural network-based non-linear model, i.e. convolutional correlation analysis (Conv-CA). Different from pure deep learning models, Conv-CA use convolutional neural networks (CNNs) at the top of a self-defined correlation layer. The CNNs function on how to transform multiple channel EEGs into a single EEG signal. The correlation layer calculates the correlation coefficients between the transformed single EEG signal and reference signals. The CNNs provide non-linear operations to combine EEGs in different channels and different time. And the correlation layer constrains the fitting space of the deep learning model. A comparison study between the proposed Conv-CA method and the task-related component analysis (TRCA) based methods is conducted. Both methods are validated on a 40-class SSVEP benchmark dataset recorded from 35 subjects. The study verifies that the Conv-CA method significantly outperforms the TRCA-based methods. Moreover, Conv-CA has good explainability since its inputs of the correlation layer can be analyzed for visualizing what the model learnt from the data. Conv-CA is a non-linear extension of spatial filters. Its CNN structures can be further explored and tuned for reaching a better performance. The structure of combining neural networks and unsupervised features has the potential to be applied to the classification of other signals.

Surgeons, while performing manual endovascular procedures with conventional surgical tools (catheters and guidewires), experience forces on the tool outside the patient's body that are proximal to the point of actuation. Currently, most of the robotic systems for endovascular procedures use active catheters to navigate vasculature and to measure the contact forces at the distal end (tool tip). These tools are more expensive than the conventional surgical tools used in endovascular procedures. To avoid dependence on specialized devices like active catheters, we have developed a novel endovascular robotic system (ERS) that uses conventional surgical tools. Our robot can indirectly measure proximal forces and provide haptic feedback to surgeons. This paper discusses the theory, methodology, and calibration of indirect proximal force measurement. This new calibration technique is presented as a nested optimization problem that is solved using bi-level optimization. The results of experimental validation of the new force calibration methodology are also discussed. The results show that unbiasing of the indirect force measurement by means of force calibration will allow the use of conventional tools in robotic endovascular procedures., (© 2019 John Wiley & Sons, Ltd.)

Laparoendoscopic single-site surgery (LESS) has been shown to reduce the invasiveness of surgery by requiring only one incision to access the abdominal cavity. However, single-site surgery integrating with a compact robotic surgical platform remains as a unique challenge. To address this challenge, we have designed a comprehensive robotic surgery platform that consists of three 6-DOF manipulators and a laparoscope camera can all be inserted into the operation field through a single 18 mm cannula holding by one 4 degrees of freedom light-weight supporting frame. Each dexterous manipulator is 5+1 degree-of-freedom (DOF), serially inserted and removable, and remotely driven by 12 actuation tendons and is composed of rigid links joined by hybrid flexure hinges. This paper introduces the compact multiple-tool single port laparoscopic robot platform for the first time. Details of the mechanical design of the trocar and manipulator including joint design and tendon routing are presented. The forward and inverse kinematics of the manipulator are also discussed along with an analysis and simulation of the cooperative workspace of two manipulators. A preliminary dynamic model of the manipulator was also constructed to study the effect of tendon-sheath friction forces at various joint configurations. Future work will illustrate the existing supporting frame mechanism for posing tools and trocar.

This paper describes a new implementation for calculating Jacobian and its time derivative for robot manipulators in real-time. The estimation of Jacobian is the key in the real-time implementation of kinematics and dynamics of complex planar or spatial robots with fixed as well as floating axes in which the Jacobian form changes with the structure. The proposed method is suitable for such implementations. The new method is based on matrix differential calculus. Unlike the conventional methods, which are based on screw theory, the Jacobian calculation in the proposed approach has been reduced to the inner product of two matrices. Use of the new method to derive linear and angular velocity parts of Jacobian and its time derivative is described in detail. We have demonstrated the method using a two-DOF spatial robot and a hyper-redundant spatial robot., Competing Interests: The authors have declared that no competing interests exist.

Objective: Inadequate visual and force feedback while navigating surgical tools elevate the risk of endovascular procedures. It also poses occupational hazard due to repeated exposure to X-rays. A teleoperated robotic system that augments surgeon's actions is a solution., Method: We have designed and developed an endovascular robotic system that augments surgeon's actions using conventional surgical tools, as well as generates feedback in order to ensure safety during the procedure. The reaction force from vasculature is estimated from motor current that drives the surgical tool. Calibration required for force estimation is based on bilevel optimization. Input shaping is used in conjunction with a cascaded controller to avoid large responses due to faster inputs and to track tool position. The design, realization, and testing of our system are presented., Results: The responses of the system in comparison with the dynamics model is similar vis-à-vis the same input commands. Any error in the position tracking is reduced by the cascaded controller. Phase-portrait analysis of the system showed that the system is stable. The reaction force estimation is validated against load cell measurements. The safety mechanism in the events of excessive reaction forces while interacting with vasculature is demonstrated., Conclusion and Significance: Our system is a step toward intelligent robots that can assist surgeons during endovascular procedures by monitoring and alerting the surgeons regarding detrimental parameters. It arrests any unintended excursions of the surgical tools or surgeon's actions. This will also eliminate the need for surgeons to be in radiation environment.

Surgeons typically rely on their past training and experiences as well as visual aids from medical imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) for the planning of surgical processes. Often, due to the anatomical complexity of the surgery site, two dimensional or virtual images are not sufficient to successfully convey the structural details. For such scenarios, a 3D printed model of the patient's anatomy enables personalized preoperative planning. This paper reviews critical aspects of 3D printing for preoperative planning and surgical training, starting with an overview of the process-flow and 3D printing techniques, followed by their applications spanning across multiple organ systems in the human body. State of the art in these technologies are described along with a discussion of current limitations and future opportunities.

We present a new surgical robot hardware-in-the-loop simulator, with 3D surgical field reconstruction in RGB-D sensor range, which allows tool-tissue interactions to be presented as haptic feedback and thus provides the situation awareness of unwanted collision. First, the point cloud of the complete surgical environment is constructed from multiple frames of sensor data to avoid the occlusion issue. Then the user selects a region of interest where the robot's tool must avoid (also called forbidden region). The real-time haptic force rendering algorithm computes the interaction force which is then communicated to a haptic device at 1 kHz, to assist the surgeon to perform safe actions. The robot used is a RAVEN II system, RGB-D sensor is used to scan the environment, and two Omni haptic devices provide the 3-DoF haptic force. A registration pipeline is presented to complete the surgical environment point cloud mapping in preoperative surgery planning phase, which improves quality of haptic rendering in the presence of occlusion. Furthermore, we propose a feasible and fast algorithm which extends the existing work on the proxy-based method for haptic rendering between a Haptic Interaction Point (HIP) and a point cloud. The proposed methodology has the potential of improving the safety of surgical robots.

This work presents a software and hardware framework for a telerobotic surgery safety and motor skill training simulator. The aims are at providing trainees a comprehensive simulator for acquiring essential skills to perform telerobotic surgery. Existing commercial robotic surgery simulators lack features for safety training and optimal motion planning, which are critical factors in ensuring patient safety and efficiency in operation. In this work, we propose a hardware-in-the-loop simulator directly introducing these two features. The proposed simulator is built upon the Raven-II™ open source surgical robot, integrated with a physics engine and a safety hazard injection engine. Also, a Fast Marching Tree-based motion planning algorithm is used to help trainee learn the optimal instrument motion patterns. The main contributions of this work are (1) reproducing safety hazards events, related to da Vinci™ system, reported to the FDA MAUDE database, with a novel haptic feedback strategy to provide feedback to the operator when the underlying dynamics differ from the real robot's states so that the operator will be aware and can mitigate the negative impact of the safety-critical events, and (2) using motion planner to generate semioptimal path in an interactive robotic surgery training environment.

Objective: To validate robot-assisted surgery skills acquisition using an augmented reality (AR)-based module for urethrovesical anastomosis (UVA)., Methods: Participants at three institutions were randomised to a Hands-on Surgical Training (HoST) technology group or a control group. The HoST group was given procedure-based training for UVA within the haptic-enabled AR-based HoST environment. The control group did not receive any training. After completing the task, the control group was offered to cross over to the HoST group (cross-over group). A questionnaire administered after HoST determined the feasibility and acceptability of the technology. Performance of UVA using an inanimate model on the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was assessed using a UVA evaluation score and a Global Evaluative Assessment of Robotic Skills (GEARS) score. Participants completed the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire for cognitive assessment, as outcome measures. A Wilcoxon rank-sum test was used to compare outcomes among the groups (HoST group vs control group and control group vs cross-over group)., Results: A total of 52 individuals participated in the study. UVA evaluation scores showed significant differences in needle driving (3.0 vs 2.3; P = 0.042), needle positioning (3.0 vs 2.4; P = 0.033) and suture placement (3.4 vs 2.6; P = 0.014) in the HoST vs the control group. The HoST group obtained significantly higher scores (14.4 vs 11.9; P 0.012) on the GEARS. The NASA TLX indicated lower temporal demand and effort in the HoST group (5.9 vs 9.3; P = 0.001 and 5.8 vs 11.9; P = 0.035, respectively). In all, 70% of participants found that HoST was similar to the real surgical procedure, and 75% believed that HoST could improve confidence for carrying out the real intervention., Conclusion: Training in UVA in an AR environment improves technical skill acquisition with minimal cognitive demand., (© 2014 The Authors. BJU International © 2014 BJU International.)

Background: Recent incorporation of simulation in surgical training necessitates developing validated platforms for training and assessment. A tool should fulfill the fundamental criteria of validation., Objective: To report the ability of a simulation-based robotic training curriculum-Fundamental Skills of Robotic Surgery (FSRS)-to assess and distinguish between different performance levels of operator experience (construct validity)., Materials and Methods: This is a prospective multicenter observational study. Participants were classified as novice (0 robotic cases performed) and experts (>150 robotic cases performed). All participants were required to complete 4 key tasks in a previously validated FSRS curriculum: ball placement, coordinated tool control, fourth arm control, and needle handling and exchange. Using the metrics available in the simulator software, the performances of each group were compared to evaluate construct validation., Results: A convenience cohort of 61 surgeons participated. Novice group (n = 49) consisted of 41 fellows/residents/medical students and 8 trained open/laparoscopic surgeons, whereas expert group consisted of 12 surgeons. The novice group had no previous robotic console experience, whereas the expert group had >150 prior robotic cases experience. An overall significant difference was observed in favor of the expert group in 4 skill sets (p < 0.05). Time to complete all 4 tasks was significantly shorter in the expert group (p < 0.001). The expert group displayed significantly lesser tool collision (p = 0.002) and reduced tissue damage (p < 0.001). In performing most tasks, the expert group's camera (p < 0.001) and clutch usage (p < 0.001) was significantly greater when compared with the novice group., Conclusion: The components of the FSRS curriculum showed construct validity. This validation would help in effectively implementing this curriculum for robot-assisted surgical training., (© 2014 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.)

Background: A standardized scoring system does not exist in virtual reality-based assessment metrics to describe safe and crucial surgical skills in robot-assisted surgery. This study aims to develop an assessment score along with its construct validation., Materials and Methods: All subjects performed key tasks on previously validated Fundamental Skills of Robotic Surgery curriculum, which were recorded, and metrics were stored. After an expert consensus for the purpose of content validation (Delphi), critical safety determining procedural steps were identified from the Fundamental Skills of Robotic Surgery curriculum and a hierarchical task decomposition of multiple parameters using a variety of metrics was used to develop Robotic Skills Assessment Score (RSA-Score). Robotic Skills Assessment mainly focuses on safety in operative field, critical error, economy, bimanual dexterity, and time. Following, the RSA-Score was further evaluated for construct validation and feasibility. Spearman correlation tests performed between tasks using the RSA-Scores indicate no cross correlation. Wilcoxon rank sum tests were performed between the two groups., Results: The proposed RSA-Score was evaluated on non-robotic surgeons (n = 15) and on expert-robotic surgeons (n = 12). The expert group demonstrated significantly better performance on all four tasks in comparison to the novice group. Validation of the RSA-Score in this study was carried out on the Robotic Surgical Simulator., Conclusion: The RSA-Score is a valid scoring system that could be incorporated in any virtual reality-based surgical simulator to achieve standardized assessment of fundamental surgical tents during robot-assisted surgery., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS)., Methods: FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group., Results: Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively)., Conclusion: FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Stroke treatment often requires analysis of vascular pathology evaluated using computed tomography (CT) angiography. Due to vascular variability and complexity, finding precise relationships between vessel geometries and arterial pathology is difficult. A new convex shape decomposition strategy was developed to understand complex vascular structures and synthesize a weighted approximate convex decomposition (WACD) method for vascular decomposition in computer-aided diagnosis., Materials and Methods: The vascular tree is decomposed into optimal number of components (determined by an expert). The decomposition is based on two primary features of vascular structures: (i) the branching factor that allows structural decomposition and (ii) the concavity over the vessel surface seen primarily at the site of an aneurysm. Such surfaces are decomposed into subcomponents. Vascular sections are reconstructed using CT angiograms. Next the dual graph is constructed, and edge weights for the graph are computed from shape indices. Graph vertices are iteratively clustered by a mesh decimation operator, while minimizing a cost function related to concavity., Results: The method was validated by first comparing results with an approximate convex decomposition (ACD) method and next on vessel sections (n = 177) whose number of clusters (ground truth) was predetermined by an expert. In both cases, WACD produced promising results with 84.7 % of the vessel sections correctly clustered and when compared with ACD produced a more effective decomposition. Next, the algorithm was validated in a longitudinal study data of 4 subjects where volumetric and surface area comparisons were made between expert segmented sections and WACD decomposed sections that contained aneurysms. The results showed a mean error rate of 7.8 % for volumetric comparisons and 10.4 % for surface area comparisons., Conclusion: Decomposition of the cerebral vasculature from CT angiograms into a geometrically optimal set of convex regions may be useful for computer-assisted diagnosis. A new WACD method capable of decomposing complex vessel structures, including bifurcations and aneurysms, was developed and tested with promising results.

Objective: To determine the overall cost effectiveness of surgical skills training on Robotic Surgical Simulator (RoSS)., Methods: This study evaluates the cost analysis of utilizing RoSS for robot-assisted surgical training, at Roswell Park Center for Robotic Surgery. Trainees were queried for time spent on the RoSS console over a period of 1 year, starting from June 2010 to June 2011. Time spent was converted to training time consumed on robotic console, resulting in loss of OR time and revenue. The mechanical durability of the RoSS was also determined., Results: 105 trainees spent 361 h on the RoSS. This duration converted to 73 robot-assisted radical prostatectomy cases, and 72 animal lab sessions. RoSS prevented a potential loss of $600,000, while 72 animal labs would have cost more than $72,000 without including initial robot installation, annual maintenance and personnel expenses. The mechanical durability testing determined breakdown at 180 and 360 h for master control and pinch device, which were repaired under warranty., Conclusion: RoSS is a cost effective surgical simulator for implementation of a simulation-based robot-assisted surgical training program., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the short-term health status of patients after robot-assisted radical cystectomy using the Convalescence and Recovery Evaluation (CARE). Radical cystectomy and urinary diversion in patients with invasive bladder cancer can have a significant effect on patients' quality of life., Methods: A total of 91 patients completed the CARE preoperatively and postoperatively. The CARE scores were calculated from postoperative day 7 to 90. Outcome measures were calculated using the CARE difference index (CDI), defined as the difference between the baseline CARE and postoperative day 7 CARE scores. The primary outcome was the time taken to recover 90% of the CDI., Results: The mean age at robot-assisted radical cystectomy was 69 years (range 42-86). Of the 91 patients, 68 (74%) were men, 38 underwent extracorporeal urinary diversion, 52 underwent intracorporeal urinary diversion, and 1 underwent no diversion. A comparison of the preoperative and postoperative day 7 scores demonstrated a 48% decline in the total CARE score. The decline in specific CARE domains was 14%, 34%, 56%, and 66% against baseline for the cognition, pain, gastrointestinal, and activity domains, respectively. The mean time to recover 90% of the CDI for the total CARE score was 63 days. The mean time to recover 90% of the CDI for the pain, cognition, and activity domains was 33, 57, and 82 days, respectively. Patients did not recover 90% of the CDI for the gastrointestinal domain within the 90-day follow-up period., Conclusion: Patients who underwent robot-assisted radical cystectomy approached preoperative baseline levels within 90 days using the CARE in the total CARE, pain, cognition, and activity domains but not in the gastrointestinal domain., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: • To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System., Patients and Methods: • Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool., Results: • Forty-two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. • Eighty per cent of the entire cohort had an average of 4 years of experience with robot-assisted surgery. • Eleven (26%) novices lacked independent robot-assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160-2200) robot-assisted cases. Experts rated the 'clutch control' virtual simulation task as a good (71%) or excellent (29%) teaching tool. • Seventy-eight per cent rated the 'ball place' task as good or excellent but 22% rated it as poor. • Twenty-seven per cent rated the 'needle removal' task as an excellent teaching tool, 60% rated it good and 13% rated it poor. • Ninety-one per cent rated the 'fourth arm tissue removal' task as good or excellent. • Ninety-four per cent responded that RoSS would be useful for training purposes. • Eighty-eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. • Seventy-nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery., Conclusion: • Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Recent growth of daVinci Robotic Surgical System as a minimally invasive surgery tool has led to a call for better training of future surgeons. In this paper, a new virtual reality simulator, called RoSS is presented. Initial results from two studies - face and content validity, are very encouraging. 90% of the cohort of expert robotic surgeons felt that the simulator was excellent or somewhat close to the touch and feel of the daVinci console. Content validity of the simulator received 90% approval in some cases. These studies demonstrate that RoSS has the potential of becoming an important training tool for the daVinci surgical robot.

Objectives: To assess the face validity of Robotic Surgery Simulator (RoSS), a novel virtual reality training platform for the da Vinci Surgical System (DVSS)., Methods: Urologic surgeons, fellows, and residents attending the 2009 American Urologic Association Annual Meeting in April 2009 were invited to an orientation session with RoSS. Participants completed a questionnaire after orientation and two modules., Results: Thirty participants including 24 surgeons and fellows experienced with robotic surgery and 6 robotic surgery novices participated in the study. Eighty percent participants had at least 4 years of experience with robotic surgery and 77% had performed an average of 340 cases on the DVSS as primary console surgeons. Subjects indicated that RoSS was realistically close to the DVSS console in terms of virtual simulation and instrumentation. Fifty-two percent of subjects rated RoSS somewhat close and 45% rated RoSS very close to the DVSS console. Thirty-seven percent rated RoSS pinch device somewhat close, and 47% very close to the DVSS. With regard to movement of the arms, 43% rated it somewhat close, 40% rated it very close, and 7% felt that it was just like the DVSS. Camera movement and clutch functions were rated not close (11%), somewhat close (57%), and very close (32%) to the DVSS. Data were further analyzed in terms of surgical volume. Thirty-eight percent of subjects had also tried the Mimic dV-Trainer robotic surgery simulator., Conclusions: RoSS provides opportunity for robot-assisted surgical training for future error-free surgery. Further validation will be necessary to assess RoSS and the application of specific modules for robot-assisted surgical training., (Copyright 2010. Published by Elsevier Inc.)

Background: Recently, robotic systems have been introduced as a method for assisting endovascular interventional procedures. A few commercial and research solutions are available. In a survey it was found that none of the current systems satisfied all basic design requirements set forth for a good robot-assisted therapy platform., Methods: A human motion analysis study was performed to identify design specifications for safe motion and force limits for endovascular surgery. Based on design requirements from surveyed systems and motion analysis, a new, teleoperated, haptically enabled system called System for Endovascular Teleoperated Access (SETA) was constructed. SETA is capable of simultaneously manipulating any guidewire and catheter in the range of 0.014-0.13 inches., Results: SETA's slave was evaluated for precision positioning, using in vitro vascular phantoms. It was also evaluated by a cohort of neurovascular surgeons and fellows (n = 8), using the VIST vascular simulator. A qualitative survey of the participants and a quantitative analysis of metrics procedure time and contrast used found that SETA was equivalent to manual intervention on this platform., Conclusions: SETA provided good performance in the in vitro studies, and will soon be evaluated in a series of in vivo animal model studies., ((c) 2010 John Wiley & Sons, Ltd.)

Objective: To assess the utilization of a novel virtual reality robotic surgical simulator (RoSS) in surgical anatomy training and pattern recognition., Study Design: Ten surgical trainees (medical students and residents) were recruited to participate in a study that evaluated the efficacy of a robotic simulator in anatomy training. The subjects were divided into two groups of five individuals each. Each participant received a syllabus consisting of line diagrams and color pictures of the human anatomy. All participants were later tested on identifying the same five anatomical landmarks from photographs from actual laparoscopic procedures. Group I studied the syllabus and took the test. Group II similarly studied the syllabus, but were trained on the RoSS system using cognitive skill sets and then took the same test. Group II were asked to complete a posttest survey., Results: Mean time to complete the test was 142.8 seconds for group I and 118.4 seconds for group II. Mean number of errors committed by the group trained on RoSS was 0.4 out of 5, whereas the group that did not undergo training on RoSS committed 1.7 out of 5. The mean number of correct answers given by group I was 2.9 out of 5, whereas group II answered 4.2 out 5 correctly. All results were statistically significant. The subjects rated the anatomy module helpful, with a mean rating of 3.6 out of 5., Conclusions: RoSS is an effective tool in anatomy training. Further testing is underway to illustrate its important role in medical education and robotic surgical training.

In needle biopsy of the spine, an Augmented Reality (AR) image guidance system can be very effective in ensuring that while targeting the lesion with the biopsy needle, vital organs near the spine are not damaged and that the approach path is accurate. This procedure requires skill that is hard to master on patients. In this paper, we present a low cost AR based training set-up which consists of a software that uses one static single-camera tracking mechanism to locate the biopsy needle in the patient and which then augments the camera feed of the patient with virtual data providing real-time guidance to the surgeon for insertion of the biopsy needle. The setup is implemented using a phantom model consisting of a set of carefully modeled holes to simulate the needle insertion task. The lack of requirement of elaborate infrared tracking systems and high computing power makes this system very effective for educational and training purposes.

Endovascular neurosurgery has gained acceptance as the best method of treatment of vascular abnormalities like cerebral aneurysms. However, the procedure is associated with difficulties in tool/tissue manipulation. Navigation of stent, catheter and, guide wire through complex arteries without any force information often causes stent snagging, plaque dislocations and formation of thrombosis caused by the damage of the arterial wall. Currently, there is no haptic device available which can provide the surgeons with the force information, related to stent placement procedure. The goal of this work is to create a data base for a fast synthetic endovascular force simulator, which will provide the surgeon with force information during tool-artery interaction, based on the various combinations of tool sizes and vessel complexity, [1, 2] to facilitate better preoperative planning, safer interventions, and advanced training of new surgeons.

Realistic trocar insertion simulator requires reliable and reproducible tissue data. This paper looks at using synthetic surrogate tissue to facilitate creation of data covering a wide range of pathological cases. Furthermore, we propose to map the synthetic puncture force data to the puncture force data obtained on animal/human tissue to create a simulation model of the procedure. We have developed an experimental setup to collect data from surrogate synthetic tissue using a bladeless trocar.

Trocar insertion, the first step to most micro surgery procedures is a difficult procedure to learn and practice because procedure is carried out almost entirely without any visual feedback of the organs underlying the tissue being punctured. A majority of injuries is attributed to the excessive use of force by the surgeon. This paper looks at developing a haptic based trocar insertion simulator which will assist in training and skill advancement in carrying out this procedure. Different issues regarding development of force model and and trocar-tissue interaction is studied.

Subsurface modeling of deformable objects, such as soft tissues and organs, involves the use of non-destructive methods of determining the properties of an object encased by a material. Some of the properties that can be determined from subsurface modeling include: shape, hardness, texture and possibly material. The ability to determine these properties is based on the accuracy of the method used and the properties of the surface encasing the object. As computers become more powerful and are able to produce even more realistic graphics, it will be possible to store and re-create precise duplicates of the original for later analysis. This paper will present a method of approximately modeling both the surface and an object below the surface of the skin by a method of palpation and then present this data in an interactive 3-D model.

The kymograph is device for measuring and presenting pressure-based signals, such as human heart beat and artery volume pressure. The Haptic Kymograph is a haptically-enhanced tele-medicine system which is used to acquire human vital signs and then to transform these signs into sensible, scalable and ubiquitous media so that a user can easily comprehend subtle and ambiguous signals in a remote place. In an experiment setup a patient's artery pressure pulse was captured at 200 Hz of sampling rate, transmitted via TCP/IP network, and replicated in a remote place using a PHANToM haptic device coupled with a real-time visual interface. In this paper we report our recent progresses in developing a low-cost input system, network interfaces and haptic replication of the human artery volume pulse signal.

Minimally invasive surgical techniques using catheter is now used in many procedures. Development of surgical training of such procedures requires real-time simulation of tool-organ interaction. In such processes, each subsequent step of interaction would be based on the current configuration of the surgical tool (guidewire in this case), leading to development of techniques to solve and visualize the configuration of tool at every time step. This paper presents a Finite Element (FEM) based approach to simulate the tool-organ interaction.

This paper describes our efforts at creating a system with real time acquisition and geometric processing of the patients vascular anatomy, supplemented by a framework to simulate catheter vasculature interaction. Our system uses biplane angiograms coupled with an algorithm for generation of 3D vascular trees for patient data acquisition. Surface reconstruction and processing of this data is performed to provide novel decision aids to the interventionalist. The processed data can be loaded in a virtual environment to simulate guidance of the catheter through the patient's vasculature. With our combination of techniques, a patient specific visualization and simulation environment can be prepared within the narrow time window available for this procedure.

The aim of computer haptics is to enable the user to touch, feel and maneuver virtual objects using a haptic interface. As the user "feels" the virtual object by applying force through the interface, complex calculations have to be done in real-time to generate a feedback force appropriate to the material properties of the object being "touched". In this paper we propose a method for modeling soft bodies, which incorporate non-linear, viscoelastic, anisotropic behavior that will enable real-time user interaction and still satisfy the high force-feedback frequency requirements. In this paper, we restrict the user interaction with virtual objects to palpation.

Tracheal intubation is performed for urgent airway control in injured patients. Current methods of training include working on cadavers and manikins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time, the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The haptic device along with the real-time performance of the simulator give it both visual and physical realism. The three-dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many endotracheal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

In advancing our capabilities in the realm of virtual reality, the development of haptic technology has been a rate-limiting factor in producing tactile sensations directly onto the human hands. The Living Anatomy Program seeks to obviate the need for such technology by designing physical objects based on anatomic components that feel realistic to the touch. Furthermore, synchronizing motion between physical and related virtual objects infinitely expands visual design options and provides a profound level of immersion into content.

Esophageal intubations are performed for urgent airway control in injured patients. Current methods of training include working on cadavers and mannequins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The two haptic devices along with the real-time performance of the simulator give it both visual and physical realism. The three dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many esophageal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

Modeling human organs and soft tissue or anatomic regions for the purpose of medical training and simulation is a relatively new area. The data presented here is the groundwork for our ongoing development of a real-time haptic virtual environment for abdominal soft tissue palpation. The purpose of modeling the human abdomen is twofold. First, to provide a mathematical description of soft tissue and organs and second, to simulate the behavior of realistic interactions in real-time within a virtual environment. We have developed a, non-invasive, system that will allow us to determine mathematical functions that model the deformation of individual layers of soft tissue within the human abdomen. This system has been tested, experimentally, with a viscoelastic polyester foam model. We have been able to determine the stiffness and force/displacement function of an object beneath two layers of foam having different material characteristics. These experimental results correlate well with known polyester foam material characteristics. In general, the calculated stiffness constants were within 5% of the actual value. The data presented in this study shows that this system may be a viable tool for accurate measurement of human soft tissue properties and behavioral response to palpation.