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Background Within surgery, assistive robotic devices (ARD) have reported improved patient outcomes. ARD can offer the surgical team a “third hand” to perform wider tasks and more degrees of motion in comparison with conventional laparoscopy. We test an eye-tracking based robotic scrub nurse (RSN) in a simulated operating room based on a novel real-time framework for theatre-wide 3D gaze localization in a mobile fashion. Methods Surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses (ETG) assisted by distributed RGB-D motion sensors. To select instruments, surgeons (ST) fixed their gaze on a screen, initiating the RSN to pick up and transfer the item. Comparison was made between the task with the assistance of a human scrub nurse (HSNt) versus the task with the assistance of robotic and human scrub nurse (R&HSNt). Task load (NASA-TLX), technology acceptance (Van der Laan’s), metric data on performance and team communication were measured. Results Overall, 10 ST participated. NASA-TLX feedback for ST on HSNt vs R&HSNt usage revealed no significant difference in mental, physical or temporal demands and no change in task performance. ST reported significantly higher frustration score with R&HSNt. Van der Laan’s scores showed positive usefulness and satisfaction scores in using the RSN. No significant difference in operating time was observed. Conclusions We report initial findings of our eye-tracking based RSN. This enables mobile, unrestricted hands-free human–robot interaction intra-operatively. Importantly, this platform is deemed non-inferior to HSNt and accepted by ST and HSN test users.

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation — robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery — and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

Background Interventional endoluminal therapy is rapidly advancing as a minimally invasive surgical technique. The expanding remit of endoscopic therapy necessitates precision control. Eye tracking is an emerging technology which allows intuitive control of devices. This was a feasibility study to establish if a novel eye gaze-controlled endoscopic system could be used to intuitively control an endoscope. Methods An eye gaze-control system consisting of eye tracking glasses, specialist cameras and a joystick was used to control a robotically driven endoscope allowing steering, advancement, withdrawal and retroflexion. Eight experienced and eight non-endoscopists used both the eye gaze system and a conventional endoscope to identify ten targets in two simulated environments: a sphere and an upper gastrointestinal (UGI) model. Completion of tasks was timed. Subjective feedback was collected from each participant on task load (NASA Task Load Index) and acceptance of technology (Van der Laan scale). Results When using gaze-control endoscopy, non-endoscopists were significantly quicker when using gaze-control rather than conventional endoscopy (sphere task 3:54 ± 1:17 vs. 9:05 ± 5:40 min, p = 0.012, and UGI model task 1:59 ± 0:24 vs 3:45 ± 0:53 min, p Non-endoscopists reported significantly higher NASA-TLX workload total scores using conventional endoscopy versus gaze-control (80.6 ± 11.3 vs 22.5 ± 13.8, p p = 0.012). All subjects reported that the gaze-control had positive ‘usefulness’ and ‘satisfaction’ score of 0.56 ± 0.83 and 1.43 ± 0.51 respectively. Conclusions The novel eye gaze-control system was significantly quicker to use and subjectively lower in workload when used by non-endoscopists. Further work is needed to see if this would translate into a shallower learning curve to proficiency versus conventional endoscopy. The eye gaze-control system appears feasible as an intuitive endoscope control system. Hybrid gaze and hand control may prove a beneficial technology to evolving endoscopic platforms.

Introduction Adverse surgical events remain at an unacceptably high level despite multiple global safety initiatives being introduced. As yet, however there is no conclusive evidence to identify whether physiological markers can be used to predict whether a surgeon will make an error Method Surgeons were asked to complete a simulated laparoscopic cholecystectomy task while physiological metrics and gaze behaviour was tracked. LightGBM and CatBoost were used to predict the physiological metric most useful in predicting whether a surgeon was about to make an error. The binary task used a boolean value of “does an error occur in the next 5 seconds” as the dependent variable, while the multiclass task classified the severity of error (0, 1, 2, 3). Results Autocorrelation with lag (eventually calculated with a lag of timestep 2) measured the tendency of this timeseries to correlate with itself. The degree of correlation, or lack of correlation, and sudden changes in correlation over time were gleaned from this feature. Conclusions Skin conductance was most likely to successfully predict impending error. However when gaze features were added, overall model performance improved by 6.4%. The potential for reduction in surgical error rate and improvement in patient safety are important factors to consider.

Introduction Excessive tool-tissue interaction forces in surgery may result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. Method A systematic review of studies exploring tool-tissue forces applied during surgery was performed in accordance with PRISMA guidelines. Results 45 studies discussing tool-tissue forces during surgical procedures or tasks were included. Mean forces per speciality were as follows: ophthalmology (0.04N), vascular (0.7N), neurosurgery (0.68N), cardiothoracic surgery (1.5N), general surgery (4.7N), otorhinolaryngology (8.5N), obstetrics & gynaecology (mean 8.7N), urology (9.8N) and orthopaedic surgery (210N). Senior surgeons applied 25% less force than novice surgeons, and feedback (haptic, visual or audio) reduced force application by 40% - across specialities and tasks. Nervous tissue required the least amount of force to manipulate (0.4N, n = 17), followed by epithelial (3.8N, n = 18), muscle (4.1N, n = 4) and connective tissue (45.8, n = 10). For manoeuvres, retraction-with-grasping recorded the highest forces (3.65N, n = 13), whilst vessel clamping recorded the lowest (0.5N, n = 2). Conclusions The measurement of tool-tissue forces is a novel but rapidly expanding field. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring surgical forces may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

Background Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. Materials & methods A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. Results Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. Conclusions The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this., Highlights • This review explores tool-tissue forces during surgery, a new and expanding field. • Forces were lowest in ophthalmology (0.04N) and highest in orthopaedics (210N). • Forces were lowest during sharp dissection (0.03N) and highest when drilling (14N). • Being an expert (vs. novice) and having feedback mechanisms (e.g. haptic) reduced exerted forces. • Development of force metrics will facilitate training, assessment & novel technology.

This paper introduces a new surgical end-effector probe, which allows to accurately apply a contact force on a tissue, while at the same time allowing for high resolution and highly repeatable probe movement. These are achieved by implementing a cable-driven parallel manipulator arrangement, which is deployed at the distal-end of a robotic instrument. The combination of the offered qualities can be advantageous in several ways, with possible applications including: large area endomicroscopy and multi-spectral imaging, micro-surgery, tissue palpation, safe energy-based and conventional tissue resection. To demonstrate the concept and its adaptability, the probe is integrated with a modified da Vinci robot instrument., Submitted to IPCAI 2018 (The 9th International Conference on Information Processing in Computer-Assisted Interventions), 13 Pages, 12 Figures

Purpose Improved surgical outcome and patient safety in the operating theatre are constant challenges. We hypothesise that a framework that collects and utilises information —especially perceptually enabled ones—from multiple sources, could help to meet the above goals. This paper presents some core functionalities of a wider low-cost framework under development that allows perceptually enabled interaction within the surgical environment. Methods The synergy of wearable eye-tracking and advanced computer vision methodologies, such as SLAM, is exploited. As a demonstration of one of the framework’s possible functionalities, an articulated collaborative robotic arm and laser pointer is integrated and the set-up is used to project the surgeon’s fixation point in 3D space. Results The implementation is evaluated over 60 fixations on predefined targets, with distances between the subject and the targets of 92–212 cm and between the robot and the targets of 42–193 cm. The median overall system error is currently 3.98 cm. Its real-time potential is also highlighted. Conclusions The work presented here represents an introduction and preliminary experimental validation of core functionalities of a larger framework under development. The proposed framework is geared towards a safer and more efficient surgical theatre. Electronic supplementary material The online version of this article (doi:10.1007/s11548-017-1580-y) contains supplementary material, which is available to authorized users.

The field of 'Neuroergonomics' has the potential to improve safety in high-risk operative environments through a better appreciation of the way in which the brain responds during human-tool interactions. This is especially relevant to minimally invasive surgery (MIS). Amongst the many challenges imposed on the surgeon by traditional MIS (laparoscopy), arguably the greatest is the loss of depth perception. Robotic MIS platforms, on the other hand, provide the surgeon with a magnified three-dimensional view of the environment, and as a result may offload a degree of the cognitive burden. The posterior parietal cortex (PPC) plays an integral role in human depth perception. Therefore, it can be hypothesized that differences in PPC activation between monoscopic and stereoscopic vision may be observed. In order to investigate this hypothesis, the current study explores disparities in PPC responses between monoscopic and stereoscopic visual perception to better de-couple the burden imposed by laparoscopy and robotic surgery on the operator's brain. Fourteen participants conducted tasks of depth perception and hand-eye coordination under both monoscopic and stereoscopic visual feedback. Cortical haemodynamic responses were monitored throughout using optical functional neuroimaging. Overall, recruitment of the bilateral superior parietal lobule was observed during both depth perception and hand-eye coordination tasks. This occurred contrary to our hypothesis, regardless of the mode of visual feedback. Operator technical performance was significantly different in two- and three-dimensional visual displays. These differences in technical performance do not appear to be explained by significant differences in parietal lobe processing.

Eye-tracking technology has been shown to improve trainee performance in the aircraft industry, radiology, and surgery. The ability to track the point-of-regard of a supervisor and reflect this onto a subjects’ laparoscopic screen to aid instruction of a simulated task is attractive, in particular when considering the multilingual make up of modern surgical teams and the development of collaborative surgical techniques. We tried to develop a bespoke interface to project a supervisors’ point-of-regard onto a subjects’ laparoscopic screen and to investigate whether using the supervisor’s eye-gaze could be used as a tool to aid the identification of a target during a surgical-simulated task. We developed software to project a supervisors’ point-of-regard onto a subjects’ screen whilst undertaking surgically related laparoscopic tasks. Twenty-eight subjects with varying levels of operative experience and proficiency in English undertook a series of surgically minded laparoscopic tasks. Subjects were instructed with verbal queues (V), a cursor reflecting supervisor’s eye-gaze (E), or both (VE). Performance metrics included time to complete tasks, eye-gaze latency, and number of errors. Completion times and number of errors were significantly reduced when eye-gaze instruction was employed (VE, E). In addition, the time taken for the subject to correctly focus on the target (latency) was significantly reduced. We have successfully demonstrated the effectiveness of a novel framework to enable a supervisor eye-gaze to be projected onto a trainee’s laparoscopic screen. Furthermore, we have shown that utilizing eye-tracking technology to provide visual instruction improves completion times and reduces errors in a simulated environment. Although this technology requires significant development, the potential applications are wide-ranging.

Laparoscopic surgery poses many different constraints for the operating surgeon, resulting in a slow uptake of advanced laparoscopic procedures. Traditional approaches to the assessment of surgical performance rely on prior classification of a cohort of surgeons' technical skills for validation, which may introduce subjective bias to the outcome. In this study, Hidden Markov Models (HMMs) are used to learn surgical maneuvers from 11 subjects with mixed abilities. By using the leave-one-out method, the HMMs are trained without prior clustering of subjects into different skill levels, and the output likelihood indicates the similarity of a particular subject's motion trajectories to those of the group. The results show that after a short period of training, the novices become more similar to the group when compared to the initial pre-training assessment. The study demonstrates the strength of the proposed method in ranking the quality of trajectories of the subjects, highlighting its value in minimizing the subjective bias in skills assessment for minimally invasive surgery.

The effect of growth hormone (GH) and insulin-like growth factor-I (IGF-I) on intestinal mucosal integrity and bacterial translocation after abdominal radiation was studied in rats. Animals were divided into the following groups: I (control), II (radiation), III (radiation plus GH) and IV (radiation plus IGF-I). Radiation (1,100 cGy) was administered on the 1st day to groups II, III and IV. GH [0.25 mg/kg body weight (BW) s.c. once daily] was administered on days 1, 2 and 3 to group III, and IGF-I (0.1 mg/kg BW s.c. twice daily) was given on days 1, 2 and 3 to group IV. On day 4, animals were sacrificed. Cultures of the mesenteric lymph nodes (MLN) and blood cultures from aorta and portal vein were performed. The number of villi per centimeter (V/cm), the villus height (Vh), mitoses per crypt (M/C) and protein and DNA contents of the mucosa were evaluated in samples from the terminal ileum. Radiation increased the number of positive MLN cultures, while treatment with GH and IGF-I reduced them significantly. V/cm, Vh, M/C, protein and DNA contents were significantly increased in all irradiated animals treated with GH and IGF-I. In conclusion both GH and IGF-I are not only capable of improving the mucosal integrity but also to reduce the bacterial translocation that follows intestinal radiation. In small doses IGF-I could reproduce the effects of GH and in some parameters the effects were more pronounced, although not statistically significant. This suggests that the effects of GH on intestine could be mediated through the local and systemic generation of IGF-I.