Human-Centred Automation, Robotics and Monitoring

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• Journal article
  Rodríguez-Luna MR, Keller DS, Guerriero L, Kunda R, Marom G, Rubio-Solis A, Mylonas G, Mintz Y, Perretta Set al., 2024,

  A snapshot audit of global flexible endoscopy practice among European Association of Endoscopic Surgeons (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) surgeons from the EAES Flexible Endoscopy Subcommittee survey.

  , Surg Endosc

  INTRODUCTION: Endoscopy is an essential skill for all surgeons. However, endoscopic competency, training, and practice may vary widely among them. The EAES Flexible Endoscopy Subcommittee is working towards a standardized set of fundamental endoscopic knowledge and skills. To best advise on current practice patterns of flexible endoscopy among surgeons worldwide, a snapshot audit was conducted on the training, use, and limitations of flexible endoscopy in practice. METHODS: An online survey was distributed via email distribution and social media platforms for EAES, SAGES, and WebSurg members. Respondent demographics, training, and practice patterns were assessed. The main outcome measure was the annual endoscopic volume. Multivariate regression and machine learning models analyzed relationships between outcomes and independent variables of age, geographic region, laparoscopic surgery practice, and surgical specialization. RESULTS: A total of 1486 surgeons from 195 countries completed the survey. Respondents were mainly general (n = 894/1486, 60.2%), colorectal (n = 189/1486, 12.7%), bariatric (n = 117/1486, 7.9%), upper gastrointestinal (GI)/foregut (n = 108, 7.3%), hepatobiliopancreatic/HPB (n = 59/1486, 4%), and endocrine surgeons (n = 11/1486, 0.7%) in active practice. Eighty-two percent (n = 1,204) mentioned having used endoscopy in their practice, and 64.7% (n = 961/1486) received formal flexible endoscopy training. Of those performing endoscopy annually, 64.2% (n = 660/1486) performed between 0 and 20 endoscopies, 15.2% (n = 156/1486) performed between 20 and 50 endoscopies, 10.1% (n = 104/1486) performed between 50 and 100 endoscopies, and 10.5% (n = 108/1486) performed over 100 endoscopies. From the regression

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• Journal article
  Das B, Ledesma F, Naik R, Law S, Soleimani-Nouri P, Khan OA, Mylonas G, Pai M, Ashrafian H, Spalding D, Fehervari Met al., 2024,

  Development and validation of a virtual teaching method for minimally invasive surgery skills: a prospective cohort study.

  , Int J Surg

  INTRODUCTION: The COVID-19 pandemic led to a significant reduction in operative exposure for surgical trainees, necessitating alternative training methods to mitigate the impact on surgical education. This study sought to evaluate whether minimally invasive surgery (MIS) skills could be taught remotely using widely available technology with objective assessments of proficiency. METHODS: This was a pilot observational study with comparative assessment of face-to-face (F2F) and virtual training of novice learners in MIS skills. Performance and objective cognitive workload parameters (Surgical Task Load Index (SURG-TLX) score, heart rate and pupil metrics) were evaluated. The assessments were peg transfer (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS)) and suturing (Suturing Training and Testing (SUTT)) tasks performed using box trainers. Virtual teaching was conducted by expert trainers using a web-based streaming platform. RESULTS: Technical challenges of delivering a virtual MIS skills course were addressed after a pilot course. Participants (n = 20) in the final course had similar baseline characteristics and were randomly allocated to F2F (n = 8) and virtual (n = 12) teaching groups. Participants in the online group completed the peg transfer task faster than the F2F group (11.25 minutes vs. 16.88 minutes; P = 0.015). There were no significant differences in all other MISTELS and SUTT performance measures between groups. Cognitive workload parameters (SURG-TLX score, heart rate and pupil metrics) were also similar between groups. CONCLUSION: This study has demonstrated that virtual teaching of MIS skills using a web-based streaming platform is feasible and effective, providing the foundation for low-cost, effective, and scalable MIS skills programs in the future.

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• Journal article
  Sivananthan A, Rubio-Solis A, Darzi A, Mylonas G, Patel Net al., 2024,

  Eye-controlled endoscopy - a benchtop trial of a novel robotic steering platform - iGAZE2.

  , J Robot Surg, Vol: 18

  The endoscopic control system has remained similar in design for many decades The remit of advanced therapeutic endoscopy continues to expand requiring precision control and high cognitive workloads. Robotic systems are emerging, but all still require bimanual control and expensive and large new systems. Eye tracking is an exciting area that can be used as an endoscope control system. This is a study to establish the feasibility of an eye-controlled endoscope and compare its performance and cognitive demand to use of a conventional endoscope. An eye gaze-control system consisting of eye-tracking glasses, customised software and a small motor unit was built and attached to a conventional endoscope. Twelve non-endoscopists used both the eye gaze system and a conventional endoscope to complete a benchtop task in a simulated oesophagus and stomach. Completion of tasks was timed. Subjective feedback was collected from each participant on task load using the NASA Task Load Index. Participants were significantly quicker completing the task using iGAZE2 vs a conventional endoscope (65.02 ± 16.34s vs 104.21 ± 51.31s, p = 0.013) Participants were also significantly quicker completing retroflexion using iGAZE2 vs a conventional endoscope (8.48 ± 3.08 vs 11.38 ± 5.36s, p = 0.036). Participants reported a significantly lower workload (raw NASA-TLX score) when using iGAZE2 vs the conventional endoscope (152.1 ± 63.4 vs 319.6 ± 81.6, p = 0.0001) (Fig. 7). Users found iGAZE2 to have a significantly lower temporal demand, mental demand, effort, mental demand, physical demand, and frustration level. The eye gaze system is an exciting, small, and retrofittable system to any endoscope. The system shows exciting potential as a novel endoscopic control system with a significantly lower workload and better performance in no

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• Journal article
  Almukhtar A, Caddick V, Naik R, Goble M, Mylonas G, Darzi A, Orihuela-Espina F, Leff Det al., 2024,

  Objective assessment of cognitive workload in surgery: a systematic review

  , Annals of Surgery, ISSN: 0003-4932

  Objective: To systematically review technologies that objectively measure CWL in surgery, assessing their psychometric and methodological characteristics.Summary Background Data: Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing cognitive workload (CWL) could enable interventions to alleviate burden and improve patient safety.Methods: Ovid MEDLINE, OVID Embase, the Cochrane Library and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, Cognitive Load Theory (CLT) domain, objective and subjective parameters, statistical analysis and results were extracted. Studies were assessed for a) definition of CWL, b) details of the clinical task paradigm, and c) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics.Results: 10790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (e.g. task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multi-sensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be sub-optimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies cond

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• Journal article
  Yang J, Runciman M, Avery J, Sun Z, Mylonas Get al., 2024,

  A soft inflatable robot driven by hydraulic folded pouch actuators for minimally invasive surgery

  , IEEE Robotics and Automation Letters, Vol: 9, Pages: 4870-4877, ISSN: 2377-3766

  This paper presents a soft, inflatable, cable-driven parallel robot (CDPR) for Minimally Invasive Surgery. The CDPR has 5 degrees of freedom and is driven by 6 cables and 6 hydraulic folded actuators. The actuator utilizes a folded chamber to pull a cable. The robot comprises a soft hexagonal variable-stiffness scaffold with a welded internal triangular support, which increases the stiffness of the robot when pressurized. The fabrication methodology is demonstrated in detail. A test platform is designed to obtain the characteristics of the folding actuator. The relationship between input liquid volume and actuator displacement can be predicted well by a geometry-based method. The displacement output of the actuator can reach 22 mm, which is nearly twice its length in its zero-volume folded state. Robot repeatability tests show mean and root mean square errors below 0.3 mm. The robot is made from plastic laminate sheets of thickness 120 μm and can deploy from 100 mm in length and 14 mm in diameter when folded, into an inflatable hollow hexagonal prism with 29 mm side length and 78 mm edge length. Deployment in a colon phantom is demonstrated and simulated surgery is conducted to validate the robot performance.

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• Journal article
  Zhou Z, Yang J, Runciman M, Avery J, Sun Z, Mylonas Get al., 2024,

  A tension sensor array for cable-driven surgical robots

  , Sensors, Vol: 24, ISSN: 1424-8220

  Tendon–sheath structures are commonly utilized to drive surgical robots due to their compact size, flexibility, and straightforward controllability. However, long-distance cable tension estimation poses a significant challenge due to its frictional characteristics affected by complicated factors. This paper proposes a miniature tension sensor array for an endoscopic cable-driven parallel robot, aiming to integrate sensors into the distal end of long and flexible surgical instruments to sense cable tension and alleviate friction between the tendon and sheath. The sensor array, mounted at the distal end of the robot, boasts the advantages of a small size (16 mm outer diameter) and reduced frictional impact. A force compensation strategy was presented and verified on a platform with a single cable and subsequently implemented on the robot. The robot demonstrated good performance in a series of palpation tests, exhibiting a 0.173 N average error in force estimation and a 0.213 N root-mean-square error. In blind tests, all ten participants were able to differentiate between silicone pads with varying hardness through force feedback provided by a haptic device.

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• Journal article
  Yang J, Li X, Runciman M, Avery J, Zhou Z, Sun Z, Mylonas Get al., 2024,

  A novel, soft, cable-driven parallel robot for minimally invasive surgeries based on folded pouch actuators

  , Applied Sciences, Vol: 14, ISSN: 2076-3417

  This paper introduces a soft, cable-driven parallel robot for minimally invasive surgeries. The robot comprises a pneumatic inflatable scaffold, six hydraulic, folded pouch actuators, and a hollow, cylindrical end-effector offering five degrees of freedom. A key development is the design of the pouch actuators, which are small, low-profile, simple structures, capable of a high stroke of 180° angular displacement. The scaffold, actuators, and plastic cables are economically and rapidly fabricated using laser cutting and welding techniques. Constructed primarily from soft plastic materials, the robot can be compactly folded into a cylinder measuring 110 mm in length and 14 mm in diameter. Upon inflation, the scaffold transforms into a hexagonal prism structure with side lengths of 34 mm and edge lengths of 100 mm. The kinematic model of the robot has been developed for workspace calculation and control purposes. A series of tests have been conducted to evaluate the performance of the actuator and the robot. Repeatability tests demonstrate the robot’s high repeatability, with mean and root mean square errors of 0.3645 mm and 0.4186 mm, respectively. The direct connection between the end-effector and the actuators theoretically eliminates cable friction, resulting in a hysteresis angle of less than 2°, as confirmed by the tracking results. In addition, simulated surgical tasks have been performed to further demonstrate the robot’s performance.

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• Conference paper
  Dong B, Chen J, Wang Z, Deng K, Li Y, Lo B, Mylonas Get al., 2024,

  An Intelligent Robotic Endoscope Control System Based on Fusing Natural Language Processing and Vision Models

  , Pages: 8180-8186, ISSN: 1050-4729

  In recent years, the area of Robot-Assisted Minimally Invasive Surgery (RAMIS) is standing on the the verge of a new wave of innovations. However, autonomy in RAMIS is still in a primitive stage. Therefore, most surgeries still require manual control of the endoscope and the robotic instruments, resulting in surgeons needing to switch attention between performing surgical procedures and moving endoscope camera. Automation may reduce the complexity of surgical operations and consequently reduce the cognitive load on the surgeon while speeding up the surgical process. In this paper, a hybrid robotic endoscope control system based on fusion model of natural language processing (NLP) and modified YOLO-V8 vision model is proposed. This proposed system can analyze the current surgical workflow and generate logs to summarize the procedure for teaching and providing feedback to junior surgeons. The user study of this system indicated a significant reduction of the number of clutching actions and mean task time, which effectively enhanced the surgical training.

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• Journal article
  Alian A, Avery J, Mylonas G, 2024,

  Tissue palpation in endoscopy using EIT and soft actuators.

  , Front Robot AI, Vol: 11

  The integration of soft robots in medical procedures has significantly improved diagnostic and therapeutic interventions, addressing safety concerns and enhancing surgeon dexterity. In conjunction with artificial intelligence, these soft robots hold the potential to expedite autonomous interventions, such as tissue palpation for cancer detection. While cameras are prevalent in surgical instruments, situations with obscured views necessitate palpation. This proof-of-concept study investigates the effectiveness of using a soft robot integrated with Electrical Impedance Tomography (EIT) capabilities for tissue palpation in simulated in vivo inspection of the large intestine. The approach involves classifying tissue samples of varying thickness into healthy and cancerous tissues using the shape changes induced on a hydraulically-driven soft continuum robot during palpation. Shape changes of the robot are mapped using EIT, providing arrays of impedance measurements. Following the fabrication of an in-plane bending soft manipulator, the preliminary tissue phantom design is detailed. The phantom, representing the descending colon wall, considers induced stiffness by surrounding tissues based on a mass-spring model. The shape changes of the manipulator, resulting from interactions with tissues of different stiffness, are measured, and EIT measurements are fed into a Long Short-Term Memory (LSTM) classifier. Train and test datasets are collected as temporal sequences of data from a single training phantom and two test phantoms, namely, A and B, possessing distinctive thickness patterns. The collected dataset from phantom B, which differs in stiffness distribution, remains unseen to the network, thus posing challenges to the classifier. The classifier and proposed method achieve an accuracy of 93 % and 88.1 % on phantom A and B, respectively. Classification results are presented through confusion matrices and heat maps, visualising the accuracy of the algorithm and correspond

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• Journal article
  Robertson D, Sterke F, van Weteringen W, Arezzo A, Mintz Y, Horeman Tet al., 2023,

  Escape of surgical smoke particles, comparing conventional and valveless trocar systems

  , SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, Vol: 37, Pages: 8552-8561, ISSN: 0930-2794
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