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Medical visual question answering (VQA) bridges the gap between visual information and clinical decision-making, enabling doctors to extract understanding from clinical images and videos. In particular, surgical VQA can enhance the interpretation of surgical data, aiding in accurate diagnoses, effective education, and clinical interventions. However, the inability of VQA models to visually indicate the regions of interest corresponding to the given questions results in incomplete comprehension of the surgical scene. To tackle this, we propose the surgical visual question localized-answering (VQLA) for precise and context-aware responses to specific queries regarding surgical images. Furthermore, to address the strong demand for safety in surgical scenarios and potential corruptions in image acquisition and transmission, we propose a novel approach called Calibrated Co-Attention Gated Vision-Language (C$^2$G-ViL) embedding to integrate and align multimodal information effectively. Additionally, we leverage the adversarial sample-based contrastive learning strategy to boost our performance and robustness. We also extend our EndoVis-18-VQLA and EndoVis-17-VQLA datasets to broaden the scope and application of our data. Extensive experiments on the aforementioned datasets demonstrate the remarkable performance and robustness of our solution. Our solution can effectively combat real-world image corruption. Thus, our proposed approach can serve as an effective tool for assisting surgical education, patient care, and enhancing surgical outcomes., Comment: Accepted by Information Fusion. Code and data availability: https://github.com/longbai1006/Surgical-VQLAPlus

Accurate segmentation of tools in robot-assisted surgery is critical for machine perception, as it facilitates numerous downstream tasks including augmented reality feedback. While current feed-forward neural network-based methods exhibit excellent segmentation performance under ideal conditions, these models have proven susceptible to even minor corruptions, significantly impairing the model's performance. This vulnerability is especially problematic in surgical settings where predictions might be used to inform high-stakes decisions. To better understand model behavior under non-adversarial corruptions, prior work has explored introducing artificial corruptions, like Gaussian noise or contrast perturbation to test set images, to assess model robustness. However, these corruptions are either not photo-realistic or model/task agnostic. Thus, these investigations provide limited insights into model deterioration under realistic surgical corruptions. To address this limitation, we introduce the SegSTRONG-C challenge that aims to promote the development of algorithms robust to unforeseen but plausible image corruptions of surgery, like smoke, bleeding, and low brightness. We collect and release corruption-free mock endoscopic video sequences for the challenge participants to train their algorithms and benchmark them on video sequences with photo-realistic non-adversarial corruptions for a binary robot tool segmentation task. This new benchmark will allow us to carefully study neural network robustness to non-adversarial corruptions of surgery, thus constituting an important first step towards more robust models for surgical computer vision. In this paper, we describe the data collection and annotation protocol, baseline evaluations of established segmentation models, and data augmentation-based techniques to enhance model robustness.

Despite the availability of computer-aided simulators and recorded videos of surgical procedures, junior residents still heavily rely on experts to answer their queries. However, expert surgeons are often overloaded with clinical and academic workloads and limit their time in answering. For this purpose, we develop a surgical question-answering system to facilitate robot-assisted surgical scene and activity understanding from recorded videos. Most of the existing VQA methods require an object detector and regions based feature extractor to extract visual features and fuse them with the embedded text of the question for answer generation. However, (1) surgical object detection model is scarce due to smaller datasets and lack of bounding box annotation; (2) current fusion strategy of heterogeneous modalities like text and image is naive; (3) the localized answering is missing, which is crucial in complex surgical scenarios. In this paper, we propose Visual Question Localized-Answering in Robotic Surgery (Surgical-VQLA) to localize the specific surgical area during the answer prediction. To deal with the fusion of the heterogeneous modalities, we design gated vision-language embedding (GVLE) to build input patches for the Language Vision Transformer (LViT) to predict the answer. To get localization, we add the detection head in parallel with the prediction head of the LViT. We also integrate GIoU loss to boost localization performance by preserving the accuracy of the question-answering model. We annotate two datasets of VQLA by utilizing publicly available surgical videos from MICCAI challenges EndoVis-17 and 18. Our validation results suggest that Surgical-VQLA can better understand the surgical scene and localize the specific area related to the question-answering. GVLE presents an efficient language-vision embedding technique by showing superior performance over the existing benchmarks., Comment: To appear in IEEE ICRA 2023. Code and data availability: https://github.com/longbai1006/Surgical-VQLA

Advances in GPT-based large language models (LLMs) are revolutionizing natural language processing, exponentially increasing its use across various domains. Incorporating uni-directional attention, these autoregressive LLMs can generate long and coherent paragraphs. However, for visual question answering (VQA) tasks that require both vision and language processing, models with bi-directional attention or models employing fusion techniques are often employed to capture the context of multiple modalities all at once. As GPT does not natively process vision tokens, to exploit the advancements in GPT models for VQA in robotic surgery, we design an end-to-end trainable Language-Vision GPT (LV-GPT) model that expands the GPT2 model to include vision input (image). The proposed LV-GPT incorporates a feature extractor (vision tokenizer) and vision token embedding (token type and pose). Given the limitations of unidirectional attention in GPT models and their ability to generate coherent long paragraphs, we carefully sequence the word tokens before vision tokens, mimicking the human thought process of understanding the question to infer an answer from an image. Quantitatively, we prove that the LV-GPT model outperforms other state-of-the-art VQA models on two publically available surgical-VQA datasets (based on endoscopic vision challenge robotic scene segmentation 2018 and CholecTriplet2021) and on our newly annotated dataset (based on the holistic surgical scene dataset). We further annotate all three datasets to include question-type annotations to allow sub-type analysis. Furthermore, we extensively study and present the effects of token sequencing, token type and pose embedding for vision tokens in the LV-GPT model., Comment: The manuscript is accepted in MICCAI 2023. Code are available at: https://github.com/lalithjets/SurgicalGPT

Purpose: In curriculum learning, the idea is to train on easier samples first and gradually increase the difficulty, while in self-paced learning, a pacing function defines the speed to adapt the training progress. While both methods heavily rely on the ability to score the difficulty of data samples, an optimal scoring function is still under exploration. Methodology: Distillation is a knowledge transfer approach where a teacher network guides a student network by feeding a sequence of random samples. We argue that guiding student networks with an efficient curriculum strategy can improve model generalization and robustness. For this purpose, we design an uncertainty-based paced curriculum learning in self distillation for medical image segmentation. We fuse the prediction uncertainty and annotation boundary uncertainty to develop a novel paced-curriculum distillation (PCD). We utilize the teacher model to obtain prediction uncertainty and spatially varying label smoothing with Gaussian kernel to generate segmentation boundary uncertainty from the annotation. We also investigate the robustness of our method by applying various types and severity of image perturbation and corruption. Results: The proposed technique is validated on two medical datasets of breast ultrasound image segmentation and robotassisted surgical scene segmentation and achieved significantly better performance in terms of segmentation and robustness. Conclusion: P-CD improves the performance and obtains better generalization and robustness over the dataset shift. While curriculum learning requires extensive tuning of hyper-parameters for pacing function, the level of performance improvement suppresses this limitation., Comment: 15 pages

Purpose: Surgery scene understanding with tool-tissue interaction recognition and automatic report generation can play an important role in intra-operative guidance, decision-making and postoperative analysis in robotic surgery. However, domain shifts between different surgeries with inter and intra-patient variation and novel instruments' appearance degrade the performance of model prediction. Moreover, it requires output from multiple models, which can be computationally expensive and affect real-time performance. Methodology: A multi-task learning (MTL) model is proposed for surgical report generation and tool-tissue interaction prediction that deals with domain shift problems. The model forms of shared feature extractor, mesh-transformer branch for captioning and graph attention branch for tool-tissue interaction prediction. The shared feature extractor employs class incremental contrastive learning (CICL) to tackle intensity shift and novel class appearance in the target domain. We design Laplacian of Gaussian (LoG) based curriculum learning into both shared and task-specific branches to enhance model learning. We incorporate a task-aware asynchronous MTL optimization technique to fine-tune the shared weights and converge both tasks optimally. Results: The proposed MTL model trained using task-aware optimization and fine-tuning techniques reported a balanced performance (BLEU score of 0.4049 for scene captioning and accuracy of 0.3508 for interaction detection) for both tasks on the target domain and performed on-par with single-task models in domain adaptation. Conclusion: The proposed multi-task model was able to adapt to domain shifts, incorporate novel instruments in the target domain, and perform tool-tissue interaction detection and report generation on par with single-task models., Comment: Manuscript accepted in the International Journal of Computer Assisted Radiology and Surgery. codes available: https://github.com/lalithjets/Domain-adaptation-in-MTL

Visual question answering (VQA) in surgery is largely unexplored. Expert surgeons are scarce and are often overloaded with clinical and academic workloads. This overload often limits their time answering questionnaires from patients, medical students or junior residents related to surgical procedures. At times, students and junior residents also refrain from asking too many questions during classes to reduce disruption. While computer-aided simulators and recording of past surgical procedures have been made available for them to observe and improve their skills, they still hugely rely on medical experts to answer their questions. Having a Surgical-VQA system as a reliable 'second opinion' could act as a backup and ease the load on the medical experts in answering these questions. The lack of annotated medical data and the presence of domain-specific terms has limited the exploration of VQA for surgical procedures. In this work, we design a Surgical-VQA task that answers questionnaires on surgical procedures based on the surgical scene. Extending the MICCAI endoscopic vision challenge 2018 dataset and workflow recognition dataset further, we introduce two Surgical-VQA datasets with classification and sentence-based answers. To perform Surgical-VQA, we employ vision-text transformers models. We further introduce a residual MLP-based VisualBert encoder model that enforces interaction between visual and text tokens, improving performance in classification-based answering. Furthermore, we study the influence of the number of input image patches and temporal visual features on the model performance in both classification and sentence-based answering., Comment: Code: https://github.com/lalithjets/Surgical_VQA.git

Context-aware decision support in the operating room can foster surgical safety and efficiency by leveraging real-time feedback from surgical workflow analysis. Most existing works recognize surgical activities at a coarse-grained level, such as phases, steps or events, leaving out fine-grained interaction details about the surgical activity; yet those are needed for more helpful AI assistance in the operating room. Recognizing surgical actions as triplets of combination delivers comprehensive details about the activities taking place in surgical videos. This paper presents CholecTriplet2021: an endoscopic vision challenge organized at MICCAI 2021 for the recognition of surgical action triplets in laparoscopic videos. The challenge granted private access to the large-scale CholecT50 dataset, which is annotated with action triplet information. In this paper, we present the challenge setup and assessment of the state-of-the-art deep learning methods proposed by the participants during the challenge. A total of 4 baseline methods from the challenge organizers and 19 new deep learning algorithms by competing teams are presented to recognize surgical action triplets directly from surgical videos, achieving mean average precision (mAP) ranging from 4.2% to 38.1%. This study also analyzes the significance of the results obtained by the presented approaches, performs a thorough methodological comparison between them, in-depth result analysis, and proposes a novel ensemble method for enhanced recognition. Our analysis shows that surgical workflow analysis is not yet solved, and also highlights interesting directions for future research on fine-grained surgical activity recognition which is of utmost importance for the development of AI in surgery., Comment: CholecTriplet2021 challenge report. Paper accepted at Elsevier journal of Medical Image Analysis. 22 pages, 8 figures, 11 tables. Challenge website: https://cholectriplet2021.grand-challenge.org

Global and local relational reasoning enable scene understanding models to perform human-like scene analysis and understanding. Scene understanding enables better semantic segmentation and object-to-object interaction detection. In the medical domain, a robust surgical scene understanding model allows the automation of surgical skill evaluation, real-time monitoring of surgeon's performance and post-surgical analysis. This paper introduces a globally-reasoned multi-task surgical scene understanding model capable of performing instrument segmentation and tool-tissue interaction detection. Here, we incorporate global relational reasoning in the latent interaction space and introduce multi-scale local (neighborhood) reasoning in the coordinate space to improve segmentation. Utilizing the multi-task model setup, the performance of the visual-semantic graph attention network in interaction detection is further enhanced through global reasoning. The global interaction space features from the segmentation module are introduced into the graph network, allowing it to detect interactions based on both node-to-node and global interaction reasoning. Our model reduces the computation cost compared to running two independent single-task models by sharing common modules, which is indispensable for practical applications. Using a sequential optimization technique, the proposed multi-task model outperforms other state-of-the-art single-task models on the MICCAI endoscopic vision challenge 2018 dataset. Additionally, we also observe the performance of the multi-task model when trained using the knowledge distillation technique. The official code implementation is made available in GitHub., Comment: Code available at: https://github.com/lalithjets/Global-reasoned-multi-task-model

Despite impressive accuracy, deep neural networks are often miscalibrated and tend to overly confident predictions. Recent techniques like temperature scaling (TS) and label smoothing (LS) show effectiveness in obtaining a well-calibrated model by smoothing logits and hard labels with scalar factors, respectively. However, the use of uniform TS or LS factor may not be optimal for calibrating models trained on a long-tailed dataset where the model produces overly confident probabilities for high-frequency classes. In this study, we propose class-distribution-aware TS (CDA-TS) and LS (CDA-LS) by incorporating class frequency information in model calibration in the context of long-tailed distribution. In CDA-TS, the scalar temperature value is replaced with the CDA temperature vector encoded with class frequency to compensate for the over-confidence. Similarly, CDA-LS uses a vector smoothing factor and flattens the hard labels according to their corresponding class distribution. We also integrate CDA optimal temperature vector with distillation loss, which reduces miscalibration in self-distillation (SD). We empirically show that class-distribution-aware TS and LS can accommodate the imbalanced data distribution yielding superior performance in both calibration error and predictive accuracy. We also observe that SD with an extremely imbalanced dataset is less effective in terms of calibration performance. Code is available in https://github.com/mobarakol/Class-Distribution-Aware-TS-LS., Comment: Presented at the ICML 2021 Workshop on Uncertainty and Robustness in Deep Learning

Learning to infer graph representations and performing spatial reasoning in a complex surgical environment can play a vital role in surgical scene understanding in robotic surgery. For this purpose, we develop an approach to generate the scene graph and predict surgical interactions between instruments and surgical region of interest (ROI) during robot-assisted surgery. We design an attention link function and integrate with a graph parsing network to recognize the surgical interactions. To embed each node with corresponding neighbouring node features, we further incorporate SageConv into the network. The scene graph generation and active edge classification mostly depend on the embedding or feature extraction of node and edge features from complex image representation. Here, we empirically demonstrate the feature extraction methods by employing label smoothing weighted loss. Smoothing the hard label can avoid the over-confident prediction of the model and enhances the feature representation learned by the penultimate layer. To obtain the graph scene label, we annotate the bounding box and the instrument-ROI interactions on the robotic scene segmentation challenge 2018 dataset with an experienced clinical expert in robotic surgery and employ it to evaluate our propositions., Comment: MICCAI 2020