Conceptual framework for the design, implementation and validation of psychomotor skills’ assessment systems in minimally invasive surgery

Las técnicas de cirugía de mínima invasión (CMI) se están consolidando hoy en día como alternativa a la cirugía tradicional, debido a sus numerosos beneficios para los pacientes. Este cambio de paradigma implica que los cirujanos deben aprender una serie de habilidades distintas de aquellas requeridas en cirugía abierta. El entrenamiento y evaluación de estas habilidades se ha convertido en una de las mayores preocupaciones en los programas de formación de cirujanos, debido en gran parte a la presión de una sociedad que exige cirujanos bien preparados y una reducción en el número de errores médicos. Por tanto, se está prestando especial atención a la definición de nuevos programas que permitan el entrenamiento y la evaluación de las habilidades psicomotoras en entornos seguros antes de que los nuevos cirujanos puedan operar sobre pacientes reales. Para tal fin, hospitales y centros de formación están gradualmente incorporando instalaciones de entrenamiento donde los residentes puedan practicar y aprender sin riesgos. Es cada vez más común que estos laboratorios dispongan de simuladores virtuales o simuladores físicos capaces de registrar los movimientos del instrumental de cada residente. Estos simuladores ofrecen una gran variedad de tareas de entrenamiento y evaluación, así como la posibilidad de obtener información objetiva de los ejercicios. Los diferentes estudios de validación llevados a cabo dan muestra de su utilidad; pese a todo, los niveles de evidencia presentados son en muchas ocasiones insuficientes. Lo que es más importante, no existe un consenso claro a la hora de definir qué métricas son más útiles para caracterizar la pericia quirúrgica. El objetivo de esta tesis doctoral es diseñar y validar un marco de trabajo conceptual para la definición y validación de entornos para la evaluación de habilidades en CMI, en base a un modelo en tres fases: pedagógica (tareas y métricas a emplear), tecnológica (tecnologías de adquisición de métricas) y analítica (interpretación de la competencia en base a las métricas). Para tal fin, se describe la implementación práctica de un entorno basado en (1) un sistema de seguimiento de instrumental fundamentado en el análisis del vídeo laparoscópico; y (2) la determinación de la pericia en base a métricas de movimiento del instrumental. Para la fase pedagógica se diseñó e implementó un conjunto de tareas para la evaluación de habilidades psicomotoras básicas, así como una serie de métricas de movimiento. La validación de construcción llevada a cabo sobre ellas mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. Adicionalmente, los resultados obtenidos en la validación de apariencia fueron en general positivos en todos los grupos considerados (noveles, residentes, expertos). Para la fase tecnológica, se introdujo el EVA Tracking System, una solución para el seguimiento del instrumental quirúrgico basado en el análisis del vídeo endoscópico. La precisión del sistema se evaluó a 16,33ppRMS para el seguimiento 2D de la herramienta en la imagen; y a 13mmRMS para el seguimiento espacial de la misma. La validación de construcción con una de las tareas de evaluación mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. La validación concurrente con el TrEndo® Tracking System por su parte presentó valores altos de correlación para 8 de las 9 métricas analizadas. Finalmente, para la fase analítica se comparó el comportamiento de tres clasificadores supervisados a la hora de determinar automáticamente la pericia quirúrgica en base a la información de movimiento del instrumental, basados en aproximaciones lineales (análisis lineal discriminante, LDA), no lineales (máquinas de soporte vectorial, SVM) y difusas (sistemas adaptativos de inferencia neurodifusa, ANFIS). Los resultados muestran que en media SVM presenta un comportamiento ligeramente superior: 78,2% frente a los 71% y 71,7% obtenidos por ANFIS y LDA respectivamente. Sin embargo las diferencias estadísticas medidas entre los tres no fueron demostradas significativas. En general, esta tesis doctoral corrobora las hipótesis de investigación postuladas relativas a la definición de sistemas de evaluación de habilidades para cirugía de mínima invasión, a la utilidad del análisis de vídeo como fuente de información y a la importancia de la información de movimiento de instrumental a la hora de caracterizar la pericia quirúrgica. Basándose en estos cimientos, se han de abrir nuevos campos de investigación que contribuyan a la definición de programas de formación estructurados y objetivos, que puedan garantizar la acreditación de cirujanos sobradamente preparados y promocionen la seguridad del paciente en el quirófano. Abstract Minimally invasive surgery (MIS) techniques have become a standard in many surgical sub-specialties, due to their many benefits for patients. However, this shift in paradigm implies that surgeons must acquire a complete different set of skills than those normally attributed to open surgery. Training and assessment of these skills has become a major concern in surgical learning programmes, especially considering the social demand for better-prepared professionals and for the decrease of medical errors. Therefore, much effort is being put in the definition of structured MIS learning programmes, where practice with real patients in the operating room (OR) can be delayed until the resident can attest for a minimum level of psychomotor competence. To this end, skills’ laboratory settings are being introduced in hospitals and training centres where residents may practice and be assessed on their psychomotor skills. Technological advances in the field of tracking technologies and virtual reality (VR) have enabled the creation of new learning systems such as VR simulators or enhanced box trainers. These systems offer a wide range of tasks, as well as the capability of registering objective data on the trainees’ performance. Validation studies give proof of their usefulness; however, levels of evidence reported are in many cases low. More importantly, there is still no clear consensus on topics such as the optimal metrics that must be used to assess competence, the validity of VR simulation, the portability of tracking technologies into real surgeries (for advanced assessment) or the degree to which the skills measured and obtained in laboratory environments transfer to the OR. The purpose of this PhD is to design and validate a conceptual framework for the definition and validation of MIS assessment environments based on a three-pillared model defining three main stages: pedagogical (tasks and metrics to employ), technological (metric acquisition technologies) and analytical (interpretation of competence based on metrics). To this end, a practical implementation of the framework is presented, focused on (1) a video-based tracking system and (2) the determination of surgical competence based on the laparoscopic instruments’ motionrelated data. The pedagogical stage’s results led to the design and implementation of a set of basic tasks for MIS psychomotor skills’ assessment, as well as the definition of motion analysis parameters (MAPs) to measure performance on said tasks. Validation yielded good construct results for parameters such as time, path length, depth, average speed, average acceleration, economy of area and economy of volume. Additionally, face validation results showed positive acceptance on behalf of the experts, residents and novices. For the technological stage the EVA Tracking System is introduced. EVA provides a solution for tracking laparoscopic instruments from the analysis of the monoscopic video image. Accuracy tests for the system are presented, which yielded an average RMSE of 16.33pp for 2D tracking of the instrument on the image and of 13mm for 3D spatial tracking. A validation experiment was conducted using one of the tasks and the most relevant MAPs. Construct validation showed significant differences for time, path length, depth, average speed, average acceleration, economy of area and economy of volume; especially between novices and residents/experts. More importantly, concurrent validation with the TrEndo® Tracking System presented high correlation values (>0.7) for 8 of the 9 MAPs proposed. Finally, the analytical stage allowed comparing the performance of three different supervised classification strategies in the determination of surgical competence based on motion-related information. The three classifiers were based on linear (linear discriminant analysis, LDA), non-linear (support vector machines, SVM) and fuzzy (adaptive neuro fuzzy inference systems, ANFIS) approaches. Results for SVM show slightly better performance than the other two classifiers: on average, accuracy for LDA, SVM and ANFIS was of 71.7%, 78.2% and 71% respectively. However, when confronted, no statistical significance was found between any of the three. Overall, this PhD corroborates the investigated research hypotheses regarding the definition of MIS assessment systems, the use of endoscopic video analysis as the main source of information and the relevance of motion analysis in the determination of surgical competence. New research fields in the training and assessment of MIS surgeons can be proposed based on these foundations, in order to contribute to the definition of structured and objective learning programmes that guarantee the accreditation of well-prepared professionals and the promotion of patient safety in the OR.

Obtaining contradiction measure on intuitionistic fuzzy sets from fuzzy connectives

In a previous paper, we proposed an axiomatic model for measuring self-contradiction in the framework of Atanassov fuzzy sets. This way, contradiction measures that are semicontinuous and completely semicontinuous, from both below and above, were defined. Although some examples were given, the problem of finding families of functions satisfying the different axioms remained open. The purpose of this paper is to construct some families of contradiction measures firstly using continuous t-norms and t-conorms, and secondly by means of strong negations. In both cases, we study the properties that they satisfy. These families are then classified according the different kinds of measures presented in the above paper.

Hybrid incremental modeling based on least squares and fuzzy K-NN for monitoring tool wear in turning processes

There is now an emerging need for an efficient modeling strategy to develop a new generation of monitoring systems. One method of approaching the modeling of complex processes is to obtain a global model. It should be able to capture the basic or general behavior of the system, by means of a linear or quadratic regression, and then superimpose a local model on it that can capture the localized nonlinearities of the system. In this paper, a novel method based on a hybrid incremental modeling approach is designed and applied for tool wear detection in turning processes. It involves a two-step iterative process that combines a global model with a local model to take advantage of their underlying, complementary capacities. Thus, the first step constructs a global model using a least squares regression. A local model using the fuzzy k-nearest-neighbors smoothing algorithm is obtained in the second step. A comparative study then demonstrates that the hybrid incremental model provides better error-based performance indices for detecting tool wear than a transductive neurofuzzy model and an inductive neurofuzzy model.

Tool wear monitoring using neuro-fuzzy techniques: a comparative study in a turning process

Tool wear detection is a key issue for tool condition monitoring. The maximization of useful tool life is frequently related with the optimization of machining processes. This paper presents two model-based approaches for tool wear monitoring on the basis of neuro-fuzzy techniques. The use of a neuro-fuzzy hybridization to design a tool wear monitoring system is aiming at exploiting the synergy of neural networks and fuzzy logic, by combining human reasoning with learning and connectionist structure. The turning process that is a well-known machining process is selected for this case study. A four-input (i.e., time, cutting forces, vibrations and acoustic emissions signals) single-output (tool wear rate) model is designed and implemented on the basis of three neuro-fuzzy approaches (inductive, transductive and evolving neuro-fuzzy systems). The tool wear model is then used for monitoring the turning process. The comparative study demonstrates that the transductive neuro-fuzzy model provides better error-based performance indices for detecting tool wear than the inductive neuro-fuzzy model and than the evolving neuro-fuzzy model.

Comparing fuzzy and intelligent PI controllers in stop-and-go manoeuvres

The aim of this work was twofold: on the one hand, to describe a comparative study of two intelligent control techniques-fuzzy and intelligent proportional-integral (PI) control, and on the other, to try to provide an answer to an as yet unsolved topic in the automotive sector-stop-and-go control in urban environments at very low speeds. Commercial vehicles exhibit nonlinear behavior and therefore constitute an excellent platform on which to check the controllers. This paper describes the design, tuning, and evaluation of the controllers performing actions on the longitudinal control of a car-the throttle and brake pedals-to accomplish stop-and-go manoeuvres. They are tested in two steps. First, a simulation model is used to design and tune the controllers, and second, these controllers are implemented in the commercial vehicle-which has automatic driving capabilities-to check their behavior. A stop-and-go manoeuvre is implemented with the two control techniques using two cooperating vehicles.

Genetic fuzzy-based steering wheel controller using a mass-produced car

Intelligent Transportation Systems (ITS) cover a broad range of methods and technologies that provide answers to many problems of transportation. Unmanned control of the steering wheel is one of the most important challenges facing researchers in this area. This paper presents a method to adjust automatically a fuzzy controller to manage the steering wheel of a mass-produced vehicle to reproduce the steering of a human driver. To this end, information is recorded about the car's state while being driven by human drivers and used to obtain, via genetic algorithms, appropriate fuzzy controllers that can drive the car in the way that humans do. These controllers have satisfy two main objectives: to reproduce the human behavior, and to provide smooth actions to ensure comfortable driving. Finally, the results of automated driving on a test circuit are presented, showing both good route tracking (similar to the performance obtained by persons in the same task) and smooth driving.

A fuzzy MCDA framework for safety assessment in the remediation of a uranium mill tailings site in Ukraine

The Pridneprovsky Chemical Plant was one of the largest uranium processing enterprises in the former USSR, producing a huge amount of uranium residues. The Zapadnoe tailings site contains most of these residues. We propose a theoretical framework based on multicriteria decision analysis and fuzzy logic to analyze different remediation alternatives for the Zapadnoe tailings, which simultaneously accounts for potentially conflicting economic, social and environmental objectives. We build an objective hierarchy that includes all the relevant aspects. Fuzzy rather than precise values are proposed for use to evaluate remediation alternatives against the different criteria and to quantify preferences, such as the weights representing the relative importance of criteria identified in the objective hierarchy. Finally, we suggest that remediation alternatives should be evaluated by means of a fuzzy additive multi-attribute utility function and ranked on the basis of the respective trapezoidal fuzzy number representing their overall utility.

An interactive method of fuzzy probability elicitation in risk analysis

Expert knowledge is used to assign probabilities to events in many risk analysis models. However, experts sometimes find it hard to provide specific values for these probabilities, preferring to express vague or imprecise terms that are mapped using a previously defined fuzzy number scale. The rigidity of these scales generates bias in the probability elicitation process and does not allow experts to adequately express their probabilistic judgments. We present an interactive method for extracting a fuzzy number from experts that represents their probabilistic judgments for a given event, along with a quality measure of the probabilistic judgments, useful in a final information filtering and analysis sensitivity process.

UAS See-and-Avoid Strategy using a Fuzzy Logic Controller Optimized by Cross-Entropy in Scaling Factors and Membership Functions

This work aims to develop a novel Cross-Entropy (CE) optimization-based fuzzy controller for Unmanned Aerial Monocular Vision-IMU System (UAMVIS) to solve the seeand- avoid problem using its accurate autonomous localization information. The function of this fuzzy controller is regulating the heading of this system to avoid the obstacle, e.g. wall. In the Matlab Simulink-based training stages, the Scaling Factor (SF) is adjusted according to the specified task firstly, and then the Membership Function (MF) is tuned based on the optimized Scaling Factor to further improve the collison avoidance performance. After obtained the optimal SF and MF, 64% of rules has been reduced (from 125 rules to 45 rules), and a large number of real flight tests with a quadcopter have been done. The experimental results show that this approach precisely navigates the system to avoid the obstacle. To our best knowledge, this is the first work to present the optimized fuzzy controller for UAMVIS using Cross-Entropy method in Scaling Factors and Membership Functions optimization.

Autonomous Landing of an Unmanned Aerial Vehicle using Image-Based Fuzzy Control

This paper presents a vision based autonomous landing control approach for unmanned aerial vehicles (UAV). The 3D position of an unmanned helicopter is estimated based on the homographies estimated of a known landmark. The translation and altitude estimation of the helicopter against the helipad position are the only information that is used to control the longitudinal, lateral and descend speeds of the vehicle. The control system approach consists in three Fuzzy controllers to manage the speeds of each 3D axis of the aircraft s coordinate system. The 3D position estimation was proven rst, comparing it with the GPS + IMU data with very good results. The robust of the vision algorithm against occlusions was also tested. The excellent behavior of the Fuzzy control approach using the 3D position estimation based in homographies was proved in an outdoors test using a real unmanned helicopter.

On-line learning of a fuzzy controller for a precise vehicle cruise control system

Usually, vehicle applications require the use of artificial intelligent techniques to implement control methods, due to noise provided by sensors or the impossibility of full knowledge about dynamics of the vehicle (engine state, wheel pressure or occupiers weight). This work presents a method to on-line evolve a fuzzy controller for commanding vehicles? pedals at low speeds; in this scenario, the slightest alteration in the vehicle or road conditions can vary controller?s behavior in a non predictable way. The proposal adapts singletons positions in real time, and trapezoids used to codify the input variables are modified according with historical data. Experimentation in both simulated and real vehicles are provided to show how fast and precise the method is, even compared with a human driver or using different vehicles.

Multi-argument fuzzy measures on lattices of fuzzy sets

In this paper, we axiomatically introduce fuzzy multi-measures on bounded lattices. In particular, we make a distinction between four different types of fuzzy set multi-measures on a universe X, considering both the usual or inverse real number ordering of this lattice and increasing or decreasing monotonicity with respect to the number of arguments. We provide results from which we can derive families of measures that hold for the applicable conditions in each case.

UAS See-and-Avoid Strategy using a Fuzzy Logic Controller Optimized by Cross-Entropy in Scaling Factors and Membership Functions.

This work aims to develop a novel Cross-Entropy (CE) optimization-based fuzzy controller for Unmanned Aerial Monocular Vision-IMU System (UAMVIS) to solve the seeand-avoid problem using its accurate autonomous localization information. The function of this fuzzy controller is regulating the heading of this system to avoid the obstacle, e.g. wall. In the Matlab Simulink-based training stages, the Scaling Factor (SF) is adjusted according to the specified task firstly, and then the Membership Function (MF) is tuned based on the optimized Scaling Factor to further improve the collison avoidance performance. After obtained the optimal SF and MF, 64% of rules has been reduced (from 125 rules to 45 rules), and a large number of real flight tests with a quadcopter have been done. The experimental results show that this approach precisely navigates the system to avoid the obstacle. To our best knowledge, this is the first work to present the optimized fuzzy controller for UAMVIS using Cross-Entropy method in Scaling Factors and Membership Functions optimization.