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Purpose Today’s hospitals are designed as collections of individual departments, with limited communication and collaboration between medical sub-specialties. Patients are constantly being moved between different places, which is detrimental for patient experience, overall efficiency and capacity. Instead, we argue that care should be brought to the patient, not vice versa, and thus propose a novel hospital architecture concept that we refer to as Patient Hub. It envisions a truly patient-centered, department-less facility, in which all critical functions occur in the same building and on the same floor. Methods To demonstrate the feasibility and benefits of our concept, we selected an exemplary patient scenario and used 3D software to simulate resulting workflows for both the Patient Hub and a traditional hospital based on a generic hospital template by Kaiser-Permanente. Results According to our workflow simulations, the Patient Hub model effectively eliminates waiting and transfer times, drastically simplifies wayfinding, reduces overall traveling distances by 54%, reduces elevator runs by 78% and improves access to quality views from 67 to 100% for patient rooms, from 0 to 100% for exam rooms and from 0 to 38% for corridors. In addition, the interaction of related medical fields is improved while maintaining the quality of care and the relationship between patients and caregivers. Conclusion With the Patient Hub concept, we aim at rethinking traditional hospital layouts. We were able to demonstrate, alas on a proof-of-concept basis, that it is indeed feasible to place the patient at the very center of operations, while increasing overall efficiency and capacity at the same time and maintaining the quality of care.

Objectives Due to the coronavirus disease 2019 (Covid-19) pandemic, all scientific conferences in the year 2020 had to be adapted in their form of presence to accommodate for safety regulations, postponed, or canceled entirely. As organizers of the annual Computer Assisted Radiology & Surgery International Conference & Exhibition (CARS)-Conference 2020, we decided to hold a “hybrid” conference, i.e., a virtual conference with partial presence to mitigate the drawbacks of a purely virtual conference. It is the purpose of this paper to describe the results and experience gained by our first hybrid conference. Methods Besides technical necessities like an online conferencing tool, we introduced additional personal namely the technical chairs and communication officers ensuring a smooth flow of presentations. To measure the success of the hybrid conference, we assessed various parameters during the conference (e.g., counting of adverse events, delays, and no-shows) and sent a questionnaire to participants for evaluation after the conference. Results We offered four types of presentation formats, whereas the majority of speakers presented their pre-produced videos including live discussions. Significant delays in sessions occurred during the morning sessions, which could be reduced during lunch breaks. The analysis of the influence of the distribution of the audience’s location/time zone toward the attendance rate showed a high relevance for the American zone and only little influence for the Asian-Pacific region. Based on the questionnaire, 60% of responders considered the hybrid approach as superior and 12% as inferior to purely virtual conferences. Conclusions Most scientific associations in 2020 had to struggle with a dramatic change: Regular, traditional meetings with personal communication and exchange, networking, and creation of new visions became obsolete almost instantly. As an alternative, virtual conferences became increasingly popular, and are offering additional advantages (e.g., reduction of cost for travel, lodging, and time on transit). To overcome the drawbacks of purely virtual conferences, we introduced a hybrid concept for the CARS-Congress. While certainly, those with the privilege to take part personally on-site did benefit most from the hybrid format. Facing upcoming waves of the Covid-19 Pandemic, with ongoing changes to the regulations on meetings and transit, hybrid conferences are a viable option for scientific conferences for the future.

A core principle of modern health care is the compliance of hygienic and aseptic techniques in areas that are sensitive to contamination through bacteria, dust, aerosols, and fallout, primarily in operating theatres or around patients with contagious diseases. Keeping track of potentially contaminated surfaces in an environment is a major concern, especially when protecting from COVID-19. This work proposes a novel concept in using 3D sensing technology to track human movement within an indoor area and identifying high-risk contaminated surfaces in real-time. It combines recent Augmented Reality display technology, which allows keeping track of decontaminated surfaces during the cleaning process using an interactive visualization method. The proposed concept of Clean- AR is implemented in a clinical environment used for observation in COVID-19 scenarios. We discuss key challenges and outline further research direction in effectively reducing the risk of contamination using the proposed concept.

In context of the Corona pandemic, telemedicine acquired a new significance. Whereas previously the aim was to override given barriers, now, in the case of a pandemic, the main idea is to create an intentional distance between patients and healthcare professionals in order to avoid cross-infection. To meet the needs of a fully diagnostic examination, a robotic based system was designed. However, collaborative robotic systems bear new risks, that have to be dealt with. To prepare future physicians for telediagnostics, we developed a training curriculum for the telemedical examinations. It is based upon multiple stages including a skill trainer, healthy volunteers, supervised examinations of real patients and an exam. In a first proof of concept, we demonstrated the existence of a learning curve and significant better performance after the passed curriculum compared to an untrained collective.

Die digitale Transformation des Gesundheitswesens wird unseren Berufszweig wesentlich verandern und schickt sich an, die onkologische Chirurgie zu revolutionieren. Die vorliegende Arbeit ist bemuht, eine neutrale Ubersicht uber die zentral betroffenen Bereiche und die hier bereits umgesetzten und in Zukunft zu erwartenden Veranderungen zu geben. Der Ubersichtsbeitrag berucksichtigt die aktuelle Literatur, Expertendiskussionen und Kongressinhalte. Der Fokus liegt hierbei auf der Indikationsstellung und der operativen Versorgung, wohingegen allgemeine Aspekte nur kurz abgehandelt werden. Digitalisierung bedeutet primar eine umfassende Bereitstellung von Daten, die im Rahmen des Behandlungsprozesses kontinuierlich und strukturiert erganzt werden. Diese erlauben eine fundierte Entscheidungsunterstutzung und die Einbindung assistierender Funktionen. Insbesondere im chirurgischen Operationssaal ergeben sich potente Werkzeuge der Prazisionsmedizin. Die Digitalisierung der onkologischen Chirurgie bietet zahlreiche Ansatze, die Behandlung unserer Patienten zu verbessern. Eine aktive, aber auch kritische Begleitung ist gefordert, der Patient muss hierbei im Fokus der Bemuhungen stehen.

PurposeIn the era of patient-centered medicine, clinical procedures, tools and instruments should be individually adapted to the patient. In this context, the presented 3D-printed Single-Port Overtube Manipulator System follows the aims to provide patient- and task-specific disposable manipulators for minimally invasive surgery. In a first experiment, the robustness of the monolithic flexure hinge structures in use as robotic manipulators will be investigated.MethodsCustomizable monolithic manipulator structures designed by means of an automated design process and manufactured with selective laser sintering were investigated with regard to long-term stability in an endurance test. Therefore, a bare manipulator arm, an arm equipped with a standard instrument and finally loaded with an additional load of 0.5 N were evaluated by continuously following a trajectory within the workspace of the manipulator arms over a period of 90 min.ResultsThe unloaded manipulator as well as the manipulator arm equipped with a standard instrument showed a sufficient reproducibility (deviation of 1.5 mm and 2.5 mm, respectively, on average) with regard to an application as telemanipulated master–slave surgical robotic system. The 3D-printed manipulators showed no damage and maintained integrity after the experiment.ConclusionIt has been shown that 3D-printed manipulators in principle are suitable for use as disposable surgical manipulator systems and offer a long-term stability over at least 90 min. The developed manipulator design shows great potential for the production of patient-, task- and user-specific robot systems. However, the manipulator geometries as well as the control strategies still show room for improvements.

ZUSAMMENFASSUNGDem Operationssaal fällt eine Schlüsselrolle bei der digitalen Entwicklung in der Chirurgie zu. Unter dem Schlagwort „digitaler OP“ ist dabei nicht die zunehmende Technisierung des OP-Equipments zu verstehen, sondern die Entwicklung einer verstehenden und den Chirurgen aktiv unterstützenden OP-Umgebung. Durch den Einsatz von künstlicher Intelligenz (KI) ist der OP in der Lage, OP-Abläufe zu verstehen und das OP-Team durch „Mitdenken“ zu unterstützen.Die Entwicklung des künstlich intelligenten Operationssaals erfordert 2 Voraussetzungen. Zum einen sollten (möglichst) alle technischen Geräte und Systemeinheiten, die in den operativen Workflow eingebunden sind, mit- und untereinander integriert bzw. vernetzt werden (Sensor-Operationssaal). Zum anderen muss der Ablauf des Eingriffs so abgebildet und die Operation so durchgeführt werden, dass eine computerisierte Beschreibung und Analyse des Eingriffs ermöglicht wird (Modellierung).Der Operationsablauf kann dann computerbasiert in Echtzeit abgebildet und die jeweilige OP-Phase automatisiert erkannt werden. Hierdurch ist es möglich, Vorhersagen über den weiteren OP-Verlauf zu treffen (Prädiktion) und das OP-Team (z. B. im Falle einer drohenden Komplikation) kooperativ zu unterstützen.

Purpose Minimally invasive surgery (MIS) has become the standard for many surgical procedures as it minimizes trauma, reduces infection rates and shortens hospitalization. However, the manipulation of objects in the surgical workspace can be difficult due to the unintuitive handling of instruments and limited range of motion. Apart from the advantages of robot-assisted systems such as augmented view or improved dexterity, both robotic and MIS techniques introduce drawbacks such as limited haptic perception and their major reliance on visual perception. Methods In order to address the above-mentioned limitations, a perception study was conducted to investigate whether the transmission of intra-abdominal acoustic signals can potentially improve the perception during MIS. To investigate whether these acoustic signals can be used as a basis for further automated analysis, a large audio data set capturing the application of electrosurgery on different types of porcine tissue was acquired. A sliding window technique was applied to compute log-mel-spectrograms, which were fed to a pre-trained convolutional neural network for feature extraction. A fully connected layer was trained on the intermediate feature representation to classify instrument–tissue interaction. Results The perception study revealed that acoustic feedback has potential to improve the perception during MIS and to serve as a basis for further automated analysis. The proposed classification pipeline yielded excellent performance for four types of instrument–tissue interaction (muscle, fascia, liver and fatty tissue) and achieved top-1 accuracies of up to 89.9%. Moreover, our model is able to distinguish electrosurgical operation modes with an overall classification accuracy of 86.40%. Conclusion Our proof-of-principle indicates great application potential for guidance systems in MIS, such as controlled tissue resection. Supported by a pilot perception study with surgeons, we believe that utilizing audio signals as an additional information channel has great potential to improve the surgical performance and to partly compensate the loss of haptic feedback.

BACKGROUND Digitalization affects almost every aspect of modern daily life, including a growing number of health care services along with telemedicine applications. Fifth-generation (5G) mobile communication technology has the potential to meet the requirements for this digitalized future with high bandwidths (10 GB/s), low latency ( OBJECTIVE The aim of this study is the development and clinical evaluation of a 5G usability test framework enabling preclinical diagnostics with mobile ultrasound using 5G network technology. METHODS A bidirectional audio-video data transmission between the ambulance car and hospital was established, combining both 5G-radio and -core network parts. Besides technical performance evaluations, a medical assessment of transferred ultrasound image quality and transmission latency was examined. RESULTS Telemedical and clinical application properties of the ultrasound probe were rated 1 (very good) to 2 (good; on a 6 -point Likert scale rated by 20 survey participants). The 5G field test revealed an average end-to-end round trip latency of 10 milliseconds. The measured average throughput for the ultrasound image traffic was 4 Mbps and for the video stream 12 Mbps. Traffic saturation revealed a lower video quality and a slower video stream. Without core slicing, the throughput for the video application was reduced to 8 Mbps. The deployment of core network slicing facilitated quality and latency recovery. CONCLUSIONS Bidirectional data transmission between ambulance car and remote hospital site was successfully established through the 5G network, facilitating sending/receiving data and measurements from both applications (ultrasound unit and video streaming). Core slicing was implemented for a better user experience. Clinical evaluation of the telemedical transmission and applicability of the ultrasound probe was consistently positive.

Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery.A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK).All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques' current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions.Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons' levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body's natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions.

Verfahren der kunstlichen Intelligenz werden auch in der Allgemein- und Viszeralchirurgie spezielle Anwendungsfelder finden, die nicht nur auf die eigentliche Tatigkeit im chirurgischen Operationssaal begrenzt sind, sondern sich auch auf alle perioperativen Prozesse, die Edukation und das Training, sowie die wissenschaftliche Weiterentwicklung erstrecken. Besondere Impulse werden fur die Bereiche Entscheidungsunterstutzung, kognitives kollaborierendes Interventionsumfeld und neue Formen der wissenschaftlichen Evidenzgewinnung erwartet. Die praktische Implementierung verlangt nicht nur profunde informationswissenschaftliche Kenntnisse, sondern auch die souverane Beherrschung der chirurgischen Wissensdomane, sodass eine neue Kultur der Kooperation zwischen Chirurgen und Forschern/Entwicklern gefordert werden muss.

Das „magische Dreieck“ in der Chirurgie und anderen Fachern besteht aus der Forderung nach immer schonenderen Therapieformen, gleichzeitiger Kostenreduktion und dem prinzipiellen Primat der Verbesserung der Ergebnisqualitat. Die Digitalisierung der Medizin bietet hierbei, auch im Sinne der „Chirurgie 4.0“, eine aussichtsreiche Chance, dem gerecht zu werden. Ziel ist hier die Schaffung einer kognitiven, kollaborativen Diagnose- und Therapieumgebung zur Unterstutzung des Chirurgen. Die Modellbildung bildet im Sinne eines „Theoriegebaudes“ fur Analyse und Planung den Grundpfeiler einer modernen Therapieplanung. Hier soll vor allem zwischen Patientenmodell und Behandlungsmodell unterschieden werden. Auch der Ablauf der eigentlichen chirurgischen Behandlung kann modelliert werden: Prinzipiell ist es moglich, den Verlauf einer Operation so feingranular zu beschreiben, dass der Operationsablauf bis auf den einzelnen Einsatz einer Pinzette abgebildet und nachvollzogen werden kann. In Grundzugen ist dies bereits jetzt schon verwirklicht. Auch sog. „neuronale Netze“ eroffnen vollig neue Formen des Erkenntnisgewinns, des maschinellen Lernens und der flexiblen Reaktion auf alle fast nur denkbaren Moglichkeiten in hochkomplexen Ablaufen. „Digitalisierung“ stellt eine notwendige Entwicklung in der Chirurgie dar. Sie bietet nicht nur unzahlige Moglichkeiten der Unterstutzung des Chirurgen in seinem Tatigkeitsfeld, sondern auch die Chance der exakteren Datenerfassung im Hinblick auf die akademische Chirurgie. Die Modellbildung ist hierbei unverzichtbarer Bestandteil und muss hierzu stringent durchgefuhrt und weiterentwickelt werden.

Apart from the tremendous increase in the demand for telemedicine during the COVID-19 pandemic, the use of telemedical technology offers many advantages, such as better coverage of rural areas and improved access to specialists. While current telediagnostic possibilities are often limited to a verbal consultation, the field of surgery has already made use of robotics for one of the most challenging areas of medicine: invasive procedures. Since comprehensive diagnostics are a prerequisite for each surgery, we built upon the knowledge gained in telesurgery and developed a telediagnostic system that allows for an extensive perioperative and emergency examination. It is based on a robotic platform consisting of a remote lead robotic arm at the physician’s site and a follower robot at the patient’s site. Mirroring all movements directly and using force-feedback, both parties can precisely interact, enabling tasks such as auscultation, percussion, and palpation without the need for extensive training. Our overall setup also includes the possibility to measure and monitor all relevant vital parameters and can be used to perform ear and nasopharyngeal inspections as well as an automatic swab to screen for COVID or other contagious diseases prior to hospital admission. In this paper, we focus on the potential of this technology for the surgical community by demonstrating the ease of adding an ultrasound probe to our modular setup to perform a high-quality emergency ultrasound examination. While the system is not yet ready for everyday use in a hospital and drawbacks such as a high cost persist, our setup paves the way for the future use of telediagnostics in surgery.

In this paper we introduce OperA, a transformer-based model that accurately predicts surgical phases from long video sequences. A novel attention regularization loss encourages the model to focus on high-quality frames during training. Moreover, the attention weights are utilized to identify characteristic high attention frames for each surgical phase, which could further be used for surgery summarization. OperA is thoroughly evaluated on two datasets of laparoscopic cholecystectomy videos, outperforming various state-of-the-art temporal refinement approaches.

Purpose During the COVID-19 pandemic, a threatening bottleneck of medical staff arose due to a shortage of trained caregivers, who became infected while working with infectious patients. While telemedicine is rapidly evolving in the fields of teleconsultation and telesurgery, proper telediagnostic systems are not yet available, although the demand for contactless patient–doctor interaction is increasing. Methods In this project, the current limitations were addressed by developing a comprehensive telediagnostic system. Therefore, medical examinations have been assessed in collaboration with medical experts. Subsequently, a framework was developed, satisfying the relevant constraints of medical-, technical-, and hygienic- aspects in order to transform in-person examinations into a contactless procedure. Diagnostic steps were classified into three groups: assisted procedures carried out by the patient, teleoperated examination methods, and adoptions of conventional methods. Results The Telemedical Diagnostic Framework was implemented, resulting in a functional proof of concept, where potentially infectious patients could undergo a full medical examination. The system comprises, e.g., a naso-pharyngeal swab, an inspection of the oral cavity, auscultation, percussion, and palpation, based on robotic end-effectors. The physician is thereby connected using a newly developed user-interface and a lead robot, with force feedback control, that enables precise movements with the follower robot on the patient’s side. Conclusion Our concept proves the feasibility of a fully telediagnostic system, that consolidates available technology and new developments to an efficient solution enabling safe patient-doctor interaction. Besides infectious situations, this solution can also be applied to remote areas.

PurposeWhile demand for telemedicine is increasing, patients are currently restricted to tele-consultation for the most part. Fundamental diagnostics like the percussion still require the in person expertize of a physician. To meet today’s challenges, a transformation of the manual percussion into a standardized, digital version, ready for telemedical execution is required.MethodsIn conjunction with a comprehensive telemedical diagnostic system, in which patients can get examined by aremote-physician, a series of three robotic end-effectors for mechanical percussion were developed. Comprising a motor, a magnetic and a pneumatic-based version, the devices strike a pleximeter to perform the percussion. Emitted sounds were captured using a microphone-equipped stethoscope. The 84 recordings were further integrated into a survey in order to classify lung and non-lung samples.ResultsThe study with 21 participants comprised physicians, medical students and non-medical-related raters in equal parts. With 71.4% correctly classified samples, the ventral motorized device prevailed. While the result is significantly better compared to a manual or pneumatic percussion in this very setup, it only has a small edge over the magnetic devices. In addition, for all ventral versions non-lung regions were rather correctly identified than lung regions.ConclusionThe overall setup proves the feasibility of a telemedical percussion. Despite the fact, that produced sounds differ compared to today’s manual technique, the study shows that a standardized mechanical percussion has the potential to improve the gold standard’s accuracy. While further extensive medical evaluation is yet to come, the system paves the way for future uncompromised remote examinations.

A common treatment for malignant hepatic tumors is radiofrequency thermal ablation (RFA); however this procedure is often exhausting and error-prone, when performed only with hand held devices. In this work, we present a new concept for a computer- and mechatronic-arm-assisted treatment of hepatic tumor with RFA. Challenging factors of state-of-the-art RFA procedures are tackled by utilizing a prototype, which combines state-of-the-art ultrasound image guidance with a mechatronic support arm system. Physicians can image and examine the human abdomen using an ultrasound capturing device which is guided by the mechatronic support arm. The mechatronic arm allows to track the ultrasound transducer via joint position encoders, so that the recorded images’ exact positions are acquired and the patient is automatically registered during imaging. Consequently, physicians can use the acquired ultrasound images to navigate in the imaged abdomen area. The established prototype enables preplanning and semi-automatic alignment of trajectories with sufficient accuracy. In addition, the arm system supports the usually lengthy, exhausting and error-prone holding of the needle during the ablation process. Based on the results of accuracy examination and expert assessments by surgeons, the established concept could be proven to be advantageous for the considered use case.

Modern surgical methods are becoming increasingly sophisticated and the number of technical devices that are used during these interventions is increasing. However, the surgical operating room (OR) remains a mere conglomerate of unconnected medical devices. The increase in the complexity of device functionality, in addition to the demands of surgery, pushes human mental capacity to its limit. Hence, an "intelligent" collaborative support system would be more than welcome. We envision a "human-like" intelligent system, which could support the surgical team as a situation-aware consultant. This so-called "active collaborative support system" (ACSS) is based on four main pillars: real-time data inflow, a comprehensive knowledge-base, access to the Internet of Things (surgical devices), and an understanding of human language through natural language processing. Recent advances in the area of AI are bringing this ambitious goal within reach, but there is still a considerable amount of work to be done, including the establishment of a new way of thinking in the collaboration between surgeons and computer scientists/engineers, and possibly one day with intelligent machines-provided that AI systems can be sufficiently trusted.

Introduction: Esophageal motility disorders have a severe impact on patients’ quality of life. While high-resolution manometry (HRM) is the gold standard in the diagnosis of esophageal motility disorders, intermittently occurring muscular deficiencies often remain undiscovered if they do not lead to an intense level of discomfort or cause suffering in patients. Ambulatory long-term HRM allows us to study the circadian (dys)function of the esophagus in a unique way. With the prolonged examination period of 24 h, however, there is an immense increase in data which requires personnel and time for evaluation not available in clinical routine. Artificial intelligence (AI) might contribute here by performing an autonomous analysis. Methods: On the basis of 40 previously performed and manually tagged long-term HRM in patients with suspected temporary esophageal motility disorders, we implemented a supervised machine learning algorithm for automated swallow detection and classification. Results: For a set of 24 h of long-term HRM by means of this algorithm, the evaluation time could be reduced from 3 days to a core evaluation time of 11 min for automated swallow detection and clustering plus an additional 10–20 min of evaluation time, depending on the complexity and diversity of motility disorders in the examined patient. In 12.5% of patients with suggested esophageal motility disorders, AI-enabled long-term HRM was able to reveal new and relevant findings for subsequent therapy. Conclusion: This new approach paves the way to the clinical use of long-term HRM in patients with temporary esophageal motility disorders and might serve as an ideal and clinically relevant application of AI.

Telemedicine has become a valuable asset in emergency responses for assisting paramedics in decision making and first contact treatment. Paramedics in unfamiliar environments or time-critical situations often encounter complications for which they require external advice. Modern ambulance vehicles are equipped with microphones, cameras, and vital sensors, which allow experts to remotely join the local team. However, the visual channels are rarely used since the statically installed cameras only allow broad views at the patient. They neither allow a close-up view nor a dynamic viewpoint controlled by the remote expert. In this paper, we present EyeRobot, a concept which enables dynamic viewpoints for telepresence using the intuitive control of the user’s head motion. In particular, EyeRobot utilizes the 6 degrees of freedom pose estimation capabilities of modern head-mounted displays and applies them in real-time to the pose of a robot arm. A stereo-camera, installed on the end-effector of the robot arm, serves as the eyes of the remote expert at the local site. We put forward an implementation of EyeRobot and present the results of our pilot study which indicates its intuitive control.

Tracking of surgical instruments is an essential step towards the modernization of the surgical workflow by a comprehensive surgical landscape guidance system (COMPASS). Real-time tracking of a laparoscopic camera used in minimally-invasive surgery is required for applications in surgical workflow documentation, machine learning, image-localization, and intra-operative visualization. In our approach, an inertial measurement unit (IMU) assists the tool tracking in situations when no line-of-sight is available for infrared (IR) based tracking of the laparoscopic camera. The novelty of this approach lies in the localization method adjusted for the laparoscopic visceral surgery, particularly when the line-of-sight is lost. It is based on IMU tracking and the positioning of the trocar entry point. The trocar entry point is the remote center of motion (RCM), reducing degrees of freedom. We developed a method to tackle localization and a real-time tool for position and orientation estimation. The main error sources are given and evaluated in a test scenario. It reveals that for small changes in penetration length (e.g., pivoting), the IMU’s accuracy determines the error.

Die Fortschritte in der Digitalisierung und der Informationsverarbeitung nehmen auch Einfluss auf die interventionelle Medizin. Sich dieser Entwicklung anzupassen, wird eine zentrale Herausforderung der modernen (onkologischen) Chirurgie sein, um weiterhin optimierte Therapieverfahren anbieten zu konnen. Im Hinblick auf die technologische Entwicklung innerhalb und auch auserhalb der Medizin schlagen die Autoren eine „Chirurgie 4.0“ vor, die ein besonderes Augenmerk auf die Sammlung, Aufbereitung und Analyse von perioperativen Daten legt, um durch intelligente Assistenzsysteme die Eingriffe effizienter und sicherer zu machen. Hierzu werden – bezogen auf die 3 operativen Phasen Planung, Durchfuhrung und Nachbehandlung – die Bedeutung der Datengenerierung, Analyse und Interpretation und die moglichen Anwendungen fur kontextsensitive mechatronische oder softwarebasierte Unterstutzungssysteme dargestellt.

Minimal-invasive Eingriffe werden immer komplexer – eine entsprechende Weiterentwicklung der menschlichen Geschicklichkeit ist jedoch nicht moglich. Mechatronische Assistenzsysteme haben das Potenzial, die Geschicklichkeit uber naturliche Grenzen hinaus zu erweitern. Die aktuelle Verwendung von universellen Chirurgiesystemen ermoglicht es jedoch noch nicht, auf eingriffs- und patientenspezifische Besonderheiten einzugehen. Ziel ist es daher, die Auslegung mechatronischer Supportsysteme und deren Integration in den chirurgischen Workflow als Teil einer prazisen, praoperativen Therapieplanung einzubeziehen. Es soll erreicht werden, dass nicht mehr der Patient einer Operationsmethode angepasst, sondern vielmehr die Operation individuell an die besonderen Patientenvoraussetzungen adaptiert wird. Nach der Analyse bestehender Robotersysteme in der Chirurgie werden aktuelle Forschungsarbeiten auf diesem Gebiet vorgestellt und in den aktuellen Kontext gesetzt. Moglichkeiten fur zukunftige Anwendungen werden aufgezeigt. Mittels automatisierter Auslegung und additiver Fertigung lassen sich individualisierte Manipulatorsysteme fur minimal-invasive Eingriffe realisieren. In Kombination mit angepassten Softwaremodulen entstehen somit adaptive mechatronische Supportsysteme, die individuell auf Patient, Operateur und Eingriff zugeschnitten sind. Individualisierbare Medizintechnik wird durch neue Technologien immer realistischer. Derzeit erfolgt die erste klinische Evaluierung individuell angepasster Hardwarelosungen. Erste Softwarekonzepte zeigen zudem den Weg hin zu kognitiven Assistenzsystemen und zu deren Integration in ein vernetztes OP-Umfeld auf.

Die laparoskopische Cholezystektomie (CHE) ist heute eine hochstandardisierte, wenig traumatisierende und sichere Behandlungsform der Cholelithiasis. Dessen ungeachtet wurde immer wieder nach neueren interventionellen Optionen gesucht. Der Einsatz von mechatronischen Systemen („Roboter“) wurde fur die Kamerafuhrung und sogar fur die Ausfuhrung aller Operationsschritte untersucht. Kamerafuhrungssysteme der 1. und 2. Generation haben sich nicht durchsetzen konnen. Intelligente Gerate der 3. Generation haben kunftig moglicherweise das Potenzial fur eine deutliche Kostenreduktion. Der Einsatz von Telemanipulationssystemen ist heute weder von den Kosten noch durch irgendwelche Vorteile bei der Durchfuhrung der Operation zu rechtfertigen. Dies konnte sich erst andern, wenn wesentlich preisgunstigere, aber leistungsfahigere „kollaborative“ Systeme den operativen Workflow optimieren und das Sicherheitsniveau heben wurden. Modifikationen der laparoskopischen Technik wurden in Form der Reduced-Port- (Einsparung von 1 oder 2 Trokaren) oder der Monoporttechnik untersucht. Der instrumentelle und zeitliche Aufwand ist ebenso wie bei der sog. „Minilaparoskopie“ deutlich hoher, ohne dass ein echter Vorteil fur den Patienten bisher belegt werden konnte. Eine wirklich disruptive Option schien sich vor etwa 10 Jahren mit dem Konzept der narbenlosen CHE abzuzeichnen. Inzwischen ist klar, dass dieser Ansatz – auch in der Variante als sog. „starre“ CHE im Rahmen einer „natural orifice transluminal endoscopic surgery“ (NOTES) bisher noch keinen Durchbruch erzielen konnte. Die inzwischen aber bereits erreichten Fortschritte bei der technischen Realisierung lassen annehmen, dass bald eine uberzeugende neue Option fur die CHE klinisch verfugbar sein wird.

Background A reliable and sterile access through the intestinal wall to ease flexible endoscopic transluminal interventions is still appealing but lacks a suitable port system. Methods In a granted industry cooperation, we developed the MIEO-Port, a flexible three components overtube system that provides a temporary hermetic sealing of the intestinal wall to allow endoscopic disinfection and manipulation to gain access to the abdominal cavity. The port features an innovative head part which allows for coupling the port to the intestinal wall by vacuum suction and for controlled jetting the isolated intestinal surface with a disinfectant. The device was tested in vivo in 6 pigs for acute and long-term usability. All animal tests were approved by the local ethics committee. Results In the acute experiment, the port system supported sealed endoscopic mucosa resection and transluminal cholecystectomy. In the survival study on 5 animals, the MIEO-Port proved its reliability after transcolonic peritoneoscopy. In one animal, a port dislocation occurred after extensive retroperitoneal preparation, one animal revealed bacterial contamination at necropsy; however, all animals showed a favourable course over ten days and offered no signs of peritonitis or abscedation during post-mortem examination. Discussion To the best of our knowledge, the MIEO-Port system is the first device to provide a reliable and sterile flexible access to the peritoneal cavity that can be used throughout the entire gastrointestinal tract regardless of the access route and which combines hermetic sealing with local sterilization. Further studies are warranted.

The anastomosis of two bowel segments is one of the core competences in visceral surgery. However, postoperative complication rates and intraoperative trauma are still too high despite numerous methods and products available. The aim of this paper is to show the first approach towards the development of a transluminal system to enable micro invasive anastomosing just using natural orifices. In this context a requirements analysis based on expert discussions and literature evaluation focusing on postoperative complications was carried out. A testing model was developed and a pressure test setup was designed to derive optimal compression zone geometry, based on the material behavior of porcine bowel tissue. For the task of transluminal anastomization a highly adaptable and flexible system must be developed. From some initial experimental trials within an abstracted bowel model, we were able to reveal first promising results concerning feasibility of transluminal anastomosis generation. In the following an experimental protocol has to be developed to assess relevant parameters as a basis for an objective comparison of the different implant models.

High resolution manometry (HRM) is the gold standard in the diagnosis of esophageal motility disorders. In clinical practice HRM is only performed for about 30 minutes with a very standardized protocol. Esophageal motility disorders can cause severe discomfort and symptoms even if they only occur spontaneously. Such temporary motility disorders are often not detectable in conventional HRM. Longterm HRM is a unique way to study the circadian behavior of the esophagus and thus will contribute to a more effective treatment of esophageal motility disorders. Prolonging the time of measurement to a full of 24 hours leads to an exponential increase in data and work, which makes longterm HRM not yet feasible in clinical routine. 40 longterm HRM measurements of patients and healthy volunteers were meticulously tagged by hand and used as training and validation data for our machine learning model. As each longterm HRM dataset consists of at least 155 million datapoints at total amount of 6 billon datapoints big data in medicine can no longer be handled without support by artificial intelligence. Therefore, we implemented an automated swallow detection and a first classification system to help medi-cal professionals gain faster and easier insight in circadian (dys) motility of the esophagus. This significantly reduces the time and manpower required for longterm HRM evaluation and paves the way for a broad clinical use in the future in patients with temporary symptoms of esophageal motility disorders but though high levels of distress.