Methods and Tools for Objective Assessment of Psychomotor Skills in Laparoscopic Surgery

Training and assessment paradigms for laparoscopic surgical skills are evolving from traditional mentor–trainee tutorship towards structured, more objective and safer programs. Accreditation of surgeons requires reaching a consensus on metrics and tasks used to assess surgeons’ psychomotor skills. Ongoing development of tracking systems and software solutions has allowed for the expansion of novel training and assessment means in laparoscopy. The current challenge is to adapt and include these systems within training programs, and to exploit their possibilities for evaluation purposes. This paper describes the state of the art in research on measuring and assessing psychomotor laparoscopic skills. It gives an overview on tracking systems as well as on metrics and advanced statistical and machine learning techniques employed for evaluation purposes. The later ones have a potential to be used as an aid in deciding on the surgical competence level, which is an important aspect when accreditation of the surgeons in particular, and patient safety in general, are considered. The prospective of these methods and tools make them complementary means for surgical assessment of motor skills, especially in the early stages of training. Successful examples such as the Fundamentals of Laparoscopic Surgery should help drive a paradigm change to structured curricula based on objective parameters. These may improve the accreditation of new surgeons, as well as optimize their already overloaded training schedules.

Objective Assessment of Olfactory Function Using Functional Magnetic Resonance Imaging=Estudio objetivo del olfato mediante resonancia magnética funcional

Objective: To show the results of a device that generates automated olfactory stimuli suitable for functional magnetic resonance imaging (fMRI) experiments. Material and methods: Te n normal volunteers, 5 women and 5 men, were studied. The system allows the programming of several sequences, providing the capability to synchronise the onset of odour presentation with acquisition by a trigger signal of the MRI scanner. The olfactometer is a device that allows selection of the odour, the event paradigm, the time of stimuli and the odour concentration. The paradigm used during fMRI scanning consisted of 15-s blocks. The odorant event took 2 s with butanol, mint and coffee. Results: We observed olfactory activity in the olfactory bulb, entorhinal cortex (4%), amygdala (2.5%) and temporo-parietal cortex, especially in the areas related to emotional integration. Conclusions: The device has demonstrated its effectiveness in stimulating olfactory areas and its capacity to adapt to fMRI equipment.RESUMEN Objetivo: Mostrar los resultados del olfatómetro capaz de generar tareas olfativas en un equipo de resonancia magnética funcional (fMRI). Material y métodos: Estudiamos 10 sujetos normales: 5 varones y 5 mujeres. El olfatómetro está dise ̃ nado para que el estímulo que produce se sincronice con el equipo de fMRI mediante la se ̃ nal desencadenante que suministra el propio equipo. El olfatómetro es capaz de: selec- cionar el olor, secuenciar los distintos olores, programar la frecuencia y duración de los olores y controlar la intensidad del olor. El paradigma utilizado responde a un dise ̃ no de activación asociada a eventos, en el que la duración del bloque de activación y de reposo es de 15 s. La duración del estímulo olfativo (butanol, menta o café) es de 2 segundos, durante toda la serie que consta de 9 ciclos. Resultados: Se ha observado reactividad (contraste BOLD) en las diferentes áreas cerebrales involucradas en las tareas olfativas: bulbo olfatorio, córtex entorrinal (4%), amigdala (2,5%) y córtex temporoparietal. Las áreas relacionadas con integración de las emociones tienen una reactividad mayor. Conclusiones: El dispositivo propuesto nos permite controlar de forma automática y sincronizada los olores necesarios para estudiar la actividad de las áreas olfatorias cerebrales mediante fMRI.

Face, content, and construct validity of the EndoViS training system for objective assessment of psychomotor skills of laparoscopic surgeons

Background The aim of this study is to present face, content, and constructs validity of the endoscopic orthogonal video system (EndoViS) training system and determines its efficiency as a training and objective assessment tool of the surgeons’ psychomotor skills. Methods Thirty-five surgeons and medical students participated in this study: 11 medical students, 19 residents, and 5 experts. All participants performed four basic skill tasks using conventional laparoscopic instruments and EndoViS training system. Subsequently, participants filled out a questionnaire regarding the design, realism, overall functionality, and its capabilities to train hand–eye coordination and depth perception, rated on a 5-point Likert scale. Motion data of the instruments were obtained by means of two webcams built into a laparoscopic physical trainer. To identify the surgical instruments in the images, colored markers were placed in each instrument. Thirteen motion-related metrics were used to assess laparoscopic performance of the participants. Statistical analysis of performance was made between novice, intermediate, and expert groups. Internal consistency of all metrics was analyzed with Cronbach’s α test. Results Overall scores about features of the EndoViS system were positives. Participants agreed with the usefulness of tasks and the training capacities of EndoViS system (score >4). Results presented significant differences in the execution of three skill tasks performed by participants. Seven metrics showed construct validity for assessment of performance with high consistency levels. Conclusions EndoViS training system has been successfully validated. Results showed that EndoViS was able to differentiate between participants of varying laparoscopic experience. This simulator is a useful and effective tool to objectively assess laparoscopic psychomotor skills of the surgeons.

Systems and technologies for objective evaluation of technical skills in laparoscopic surgery

Minimally invasive surgery is a highly demanding surgical approach regarding technical requirements for the surgeon, who must be trained in order to perform a safe surgical intervention. Traditional surgical education in minimally invasive surgery is commonly based on subjective criteria to quantify and evaluate surgical abilities, which could be potentially unsafe for the patient. Authors, surgeons and associations are increasingly demanding the development of more objective assessment tools that can accredit surgeons as technically competent. This paper describes the state of the art in objective assessment methods of surgical skills. It gives an overview on assessment systems based on structured checklists and rating scales, surgical simulators, and instrument motion analysis. As a future work, an objective and automatic assessment method of surgical skills should be standardized as a means towards proficiency-based curricula for training in laparoscopic surgery and its certification.

Technical evaluation of a third generation optical pose tracker for motion analysis and image-guided surgery

Laparoscopic instrument tracking systems are an essential component in image-guided interventions and offer new possibilities to improve and automate objective assessment methods of surgical skills. In this study we present our system design to apply a third generation optical pose tracker (Micron- Tracker®) to laparoscopic practice. A technical evaluation of this design is performed in order to analyze its accuracy in computing the laparoscopic instrument tip position. Results show a stable fluctuation error over the entire analyzed workspace. The relative position errors are 1.776±1.675 mm, 1.817±1.762 mm, 1.854±1.740 mm, 2.455±2.164 mm, 2.545±2.496 mm, 2.764±2.342 mm, 2.512±2.493 mm for distances of 50, 100, 150, 200, 250, 300, and 350 mm, respectively. The accumulated distance error increases with the measured distance. The instrument inclination covered by the system is high, from 90 to 7.5 degrees. The system reports a low positional accuracy for the instrument tip.

Adaptive neuro-fuzzy inference systems (ANFIS) for supervised classification of competence in MIS based on psychomotor skills

INTRODUCTION: Objective assessment of motor skills has become an important challenge in minimally invasive surgery (MIS) training.Currently, there is no gold standard defining and determining the residents' surgical competence.To aid in the decision process, we analyze the validity of a supervised classifier to determine the degree of MIS competence based on assessment of psychomotor skills METHODOLOGY: The ANFIS is trained to classify performance in a box trainer peg transfer task performed by two groups (expert/non expert). There were 42 participants included in the study: the non-expert group consisted of 16 medical students and 8 residents (< 10 MIS procedures performed), whereas the expert group consisted of 14 residents (> 10 MIS procedures performed) and 4 experienced surgeons. Instrument movements were captured by means of the Endoscopic Video Analysis (EVA) tracking system. Nine motion analysis parameters (MAPs) were analyzed, including time, path length, depth, average speed, average acceleration, economy of area, economy of volume, idle time and motion smoothness. Data reduction was performed by means of principal component analysis, and then used to train the ANFIS net. Performance was measured by leave one out cross validation. RESULTS: The ANFIS presented an accuracy of 80.95%, where 13 experts and 21 non-experts were correctly classified. Total root mean square error was 0.88, while the area under the classifiers' ROC curve (AUC) was measured at 0.81. DISCUSSION: We have shown the usefulness of ANFIS for classification of MIS competence in a simple box trainer exercise. The main advantage of using ANFIS resides in its continuous output, which allows fine discrimination of surgical competence. There are, however, challenges that must be taken into account when considering use of ANFIS (e.g. training time, architecture modeling). Despite this, we have shown discriminative power of ANFIS for a low-difficulty box trainer task, regardless of the individual significances between MAPs. Future studies are required to confirm the findings, inclusion of new tasks, conditions and sample population.

Comparative study of two laparoscopic instrument tracker designs for motion analysis and image-guided surgery: a technical evaluation

Laparoscopic instrument tracking systems are a key element in image-guided interventions, which requires high accuracy to be used in a real surgical scenario. In addition, these systems are a suitable option for objective assessment of laparoscopic technical skills based on instrument motion analysis. This study presents a new approach that improves the accuracy of a previously presented system, which applies an optical pose tracking system to laparoscopic practice. A design enhancement of the artificial markers placed on the laparoscopic instrument as well as an improvement of the calibration process are presented as a means to achieve more accurate results. A technical evaluation has been performed in order to compare the accuracy between the previous design and the new approach. Results show a remarkable improvement in the fluctuation error throughout the measurement platform. Moreover, the accumulated distance error and the inclination error have been improved. The tilt range covered by the system is the same for both approaches, from 90º to 7.5º. The relative position error is better for the new approach mainly at close distances to the camera system

Supervised classification of minimally invasive surgery psychomotor competence based on instruments motion analysis

Background Objective assessment of psychomotor skills has become an important challenge in the training of minimally invasive surgical (MIS) techniques. Currently, no gold standard defining surgical competence exists for classifying residents according to their surgical skills. Supervised classification has been proposed as a means for objectively establishing competence thresholds in psychomotor skills evaluation. This report presents a study comparing three classification methods for establishing their validity in a set of tasks for basic skills’ assessment. Methods Linear discriminant analysis (LDA), support vector machines (SVM), and adaptive neuro-fuzzy inference systems (ANFIS) were used. A total of 42 participants, divided into an experienced group (4 expert surgeons and 14 residents with >10 laparoscopic surgeries performed) and a nonexperienced group (16 students and 8 residents with <10 laparoscopic surgeries performed), performed three box trainer tasks validated for assessment of MIS psychomotor skills. Instrument movements were captured using the TrEndo tracking system, and nine motion analysis parameters (MAPs) were analyzed. The performance of the classifiers was measured by leave-one-out cross-validation using the scores obtained by the participants. Results The mean accuracy performances of the classifiers were 71 % (LDA), 78.2 % (SVM), and 71.7 % (ANFIS). No statistically significant differences in the performance were identified between the classifiers. Conclusions The three proposed classifiers showed good performance in the discrimination of skills, especially when information from all MAPs and tasks combined were considered. A correlation between the surgeons’ previous experience and their execution of the tasks could be ascertained from results. However, misclassifications across all the classifiers could imply the existence of other factors influencing psychomotor competence.

Análisis sistemático de pautas para la accesibilidad TIC para personas con discapacidad cognitiva

Este trabajo de investigación presenta los resultados de una revisión sistemática realizada a partir de la recopilación, lectura y análisis de distintas fuentes bibliográficas dentro de un conjunto heterogéneo consistente de 175 estudios que forman la base bibliográfica actual del documento “Cognitive Accessibility User Research” (W3C, 2015a) del W3C. Esta base bibliográfica está compuesta por publicaciones científicas basadas en libros, artículos, conferencias y sitios Web especializados, en los cuales se potencia como objeto particular de análisis, la indagación en la búsqueda de pautas de accesibilidad en las tecnologías Web que apoyen la integración a personas con discapacidad cognitiva. Como parte de este proceso de investigación se ha recopilado y descrito la situación actual, particularmente, de los retos en la utilización de las tecnologías de la información y la comunicación (TIC) en relación a personas con dificultades de aprendizaje o discapacidades cognitivas, tales como la Dislexia, Afasia, Trastorno de Aprendizaje No verbal, Envejecimiento-Demencia, Trastornos por Déficit de Atención con o sin Hiperactividad, Autismo, Síndrome de Down y Discalculia. Como aporte primordial de este Trabajo Fin de Master (TFM), se intenta trazar una línea de criterios que permitan la evaluación objetiva de este tópico, con miras a ofrecer un enfoque práctico y reciente sobre ésta temática, mostrando de forma esquematizada las pautas existentes y sirviendo de síntesis orientativa para el diseño accesible de las TIC con la finalidad de promover un soporte real a personas con los tipo de discapacidad cognitiva en los que se ha enfocado esta investigación. Logrando obtener como resultado principal de este estudio, 36 pautas generales que agrupan las coincidencias del grupo de discapacidades estudiadas y que han sido distribuidas en categorías: texto, navegación y generales, para su mejor interpretación y manejo de la Accesibilidad en las TIC´S para Personas con Discapacidad Cognitiva.---ABSTRACT---This research presents the results of a systematic review from collecting, reading and analysis of different bibliographic sources within a heterogeneous group consisting of 175 studies that form the basis of current literature document "Accessibility User Cognitive Research" (W3C , 2015th) of the W3C. This bibliographic database is composed of scientific publications based on books, articles, lectures and specialized Web sites, in which is enhanced as a particular object of analysis, the inquiry into the search for accessibility guidelines for Web technologies to support integration of people with cognitive disabilities. As part of this research process, the current situation has been collected and described, particularly the challenges in the use of information and communications technology (ICT) in relation to people with learning disabilities or cognitive disabilities, such as Dyslexia, aphasia, nonverbal learning disorder, aging-Dementia, Attention Deficit Disorders with or without hyperactivity, autism, Down syndrome and dyscalculia. As primary contribution of this Master's Thesis (TFM), it tries to draw a line of criteria to allow an objective assessment of this topic, in order to provide a practical and recent focus on this theme, showing schematically existing guidelines and serving as guidance for accessible design of ICT in order to promote a real support to people with cognitive disabilities where this research has focused on. Managing to obtain the main result of this study, 36 general guidelines that group the set of disabilities studied and have been distributed in categories: text, navigation and general, for better interpretation and management of ICTs for Accessibility people with cognitive disabilities.

Handy or practical student. Objective: to pass or to learn

With the introduction of the European Higher Education Area and the development of the "Bologna" method in learning certain technological subjects, a pilot assessment procedure was launched in the "old" plan to observe, monitor and analyze the acquiring knowledge of senior students in various academic courses. This paper is a reflection on culture and knowledge. Will students accommodate to get a lower score on tests because they know they have a lot of tooltips to achieve their objectives?. Are their skills lower for these reason?.

High definition video quality assessment metric built upon full reference ratios

Métrica de calidad de video de alta definición construida a partir de ratios de referencia completa. La medida de calidad de video, en inglés Visual Quality Assessment (VQA), es uno de los mayores retos por solucionar en el entorno multimedia. La calidad de vídeo tiene un impacto altísimo en la percepción del usuario final (consumidor) de los servicios sustentados en la provisión de contenidos multimedia y, por tanto, factor clave en la valoración del nuevo paradigma denominado Calidad de la Experiencia, en inglés Quality of Experience (QoE). Los modelos de medida de calidad de vídeo se pueden agrupar en varias ramas según la base técnica que sustenta el sistema de medida, destacando en importancia los que emplean modelos psicovisuales orientados a reproducir las características del sistema visual humano, en inglés Human Visual System, del que toman sus siglas HVS, y los que, por el contrario, optan por una aproximación ingenieril en la que el cálculo de calidad está basado en la extracción de parámetros intrínsecos de la imagen y su comparación. A pesar de los avances recogidos en este campo en los últimos años, la investigación en métricas de calidad de vídeo, tanto en presencia de referencia (los modelos denominados de referencia completa), como en presencia de parte de ella (modelos de referencia reducida) e incluso los que trabajan en ausencia de la misma (denominados sin referencia), tiene un amplio camino de mejora y objetivos por alcanzar. Dentro de ellos, la medida de señales de alta definición, especialmente las utilizadas en las primeras etapas de la cadena de valor que son de muy alta calidad, son de especial interés por su influencia en la calidad final del servicio y no existen modelos fiables de medida en la actualidad. Esta tesis doctoral presenta un modelo de medida de calidad de referencia completa que hemos llamado PARMENIA (PArallel Ratios MEtric from iNtrInsic features Analysis), basado en la ponderación de cuatro ratios de calidad calculados a partir de características intrínsecas de la imagen. Son: El Ratio de Fidelidad, calculado mediante el gradiente morfológico o gradiente de Beucher. El Ratio de Similitud Visual, calculado mediante los puntos visualmente significativos de la imagen a través de filtrados locales de contraste. El Ratio de Nitidez, que procede de la extracción del estadístico de textura de Haralick contraste. El Ratio de Complejidad, obtenido de la definición de homogeneidad del conjunto de estadísticos de textura de Haralick PARMENIA presenta como novedad la utilización de la morfología matemática y estadísticos de Haralick como base de una métrica de medida de calidad, pues esas técnicas han estado tradicionalmente más ligadas a la teledetección y la segmentación de objetos. Además, la aproximación de la métrica como un conjunto ponderado de ratios es igualmente novedosa debido a que se alimenta de modelos de similitud estructural y otros más clásicos, basados en la perceptibilidad del error generado por la degradación de la señal asociada a la compresión. PARMENIA presenta resultados con una altísima correlación con las valoraciones MOS procedentes de las pruebas subjetivas a usuarios que se han realizado para la validación de la misma. El corpus de trabajo seleccionado procede de conjuntos de secuencias validados internacionalmente, de modo que los resultados aportados sean de la máxima calidad y el máximo rigor posible. La metodología de trabajo seguida ha consistido en la generación de un conjunto de secuencias de prueba de distintas calidades a través de la codificación con distintos escalones de cuantificación, la obtención de las valoraciones subjetivas de las mismas a través de pruebas subjetivas de calidad (basadas en la recomendación de la Unión Internacional de Telecomunicaciones BT.500), y la validación mediante el cálculo de la correlación de PARMENIA con estos valores subjetivos, cuantificada a través del coeficiente de correlación de Pearson. Una vez realizada la validación de los ratios y optimizada su influencia en la medida final y su alta correlación con la percepción, se ha realizado una segunda revisión sobre secuencias del hdtv test dataset 1 del Grupo de Expertos de Calidad de Vídeo (VQEG, Video Quality Expert Group) mostrando los resultados obtenidos sus claras ventajas. Abstract Visual Quality Assessment has been so far one of the most intriguing challenges on the media environment. Progressive evolution towards higher resolutions while increasing the quality needed (e.g. high definition and better image quality) aims to redefine models for quality measuring. Given the growing interest in multimedia services delivery, perceptual quality measurement has become a very active area of research. First, in this work, a classification of objective video quality metrics based on their underlying methodologies and approaches for measuring video quality has been introduced to sum up the state of the art. Then, this doctoral thesis describes an enhanced solution for full reference objective quality measurement based on mathematical morphology, texture features and visual similarity information that provides a normalized metric that we have called PARMENIA (PArallel Ratios MEtric from iNtrInsic features Analysis), with a high correlated MOS score. The PARMENIA metric is based on the pooling of different quality ratios that are obtained from three different approaches: Beucher’s gradient, local contrast filtering, and contrast and homogeneity Haralick’s texture features. The metric performance is excellent, and improves the current state of the art by providing a wide dynamic range that make easier to discriminate between very close quality coded sequences, especially for very high bit rates whose quality, currently, is transparent for quality metrics. PARMENIA introduces a degree of novelty against other working metrics: on the one hand, exploits the structural information variation to build the metric’s kernel, but complements the measure with texture information and a ratio of visual meaningful points that is closer to typical error sensitivity based approaches. We would like to point out that PARMENIA approach is the only metric built upon full reference ratios, and using mathematical morphology and texture features (typically used in segmentation) for quality assessment. On the other hand, it gets results with a wide dynamic range that allows measuring the quality of high definition sequences from bit rates of hundreds of Megabits (Mbps) down to typical distribution rates (5-6 Mbps), even streaming rates (1- 2 Mbps). Thus, a direct correlation between PARMENIA and MOS scores are easily constructed. PARMENIA may further enhance the number of available choices in objective quality measurement, especially for very high quality HD materials. All this results come from validation that has been achieved through internationally validated datasets on which subjective tests based on ITU-T BT.500 methodology have been carried out. Pearson correlation coefficient has been calculated to verify the accuracy of PARMENIA and its reliability.

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.

An approach to automatic learning assessment based on the computational theory of perceptions

E-learning systems output a huge quantity of data on a learning process. However, it takes a lot of specialist human resources to manually process these data and generate an assessment report. Additionally, for formative assessment, the report should state the attainment level of the learning goals defined by the instructor. This paper describes the use of the granular linguistic model of a phenomenon (GLMP) to model the assessment of the learning process and implement the automated generation of an assessment report. GLMP is based on fuzzy logic and the computational theory of perceptions. This technique is useful for implementing complex assessment criteria using inference systems based on linguistic rules. Apart from the grade, the model also generates a detailed natural language progress report on the achieved proficiency level, based exclusively on the objective data gathered from correct and incorrect responses. This is illustrated by applying the model to the assessment of Dijkstra’s algorithm learning using a visual simulation-based graph algorithm learning environment, called GRAPHs

Regularized model learning in EDAs for continuous and multi-objective optimization

Probabilistic modeling is the de�ning characteristic of estimation of distribution algorithms (EDAs) which determines their behavior and performance in optimization. Regularization is a well-known statistical technique used for obtaining an improved model by reducing the generalization error of estimation, especially in high-dimensional problems. `1-regularization is a type of this technique with the appealing variable selection property which results in sparse model estimations. In this thesis, we study the use of regularization techniques for model learning in EDAs. Several methods for regularized model estimation in continuous domains based on a Gaussian distribution assumption are presented, and analyzed from di�erent aspects when used for optimization in a high-dimensional setting, where the population size of EDA has a logarithmic scale with respect to the number of variables. The optimization results obtained for a number of continuous problems with an increasing number of variables show that the proposed EDA based on regularized model estimation performs a more robust optimization, and is able to achieve signi�cantly better results for larger dimensions than other Gaussian-based EDAs. We also propose a method for learning a marginally factorized Gaussian Markov random �eld model using regularization techniques and a clustering algorithm. The experimental results show notable optimization performance on continuous additively decomposable problems when using this model estimation method. Our study also covers multi-objective optimization and we propose joint probabilistic modeling of variables and objectives in EDAs based on Bayesian networks, speci�cally models inspired from multi-dimensional Bayesian network classi�ers. It is shown that with this approach to modeling, two new types of relationships are encoded in the estimated models in addition to the variable relationships captured in other EDAs: objectivevariable and objective-objective relationships. An extensive experimental study shows the e�ectiveness of this approach for multi- and many-objective optimization. With the proposed joint variable-objective modeling, in addition to the Pareto set approximation, the algorithm is also able to obtain an estimation of the multi-objective problem structure. Finally, the study of multi-objective optimization based on joint probabilistic modeling is extended to noisy domains, where the noise in objective values is represented by intervals. A new version of the Pareto dominance relation for ordering the solutions in these problems, namely �-degree Pareto dominance, is introduced and its properties are analyzed. We show that the ranking methods based on this dominance relation can result in competitive performance of EDAs with respect to the quality of the approximated Pareto sets. This dominance relation is then used together with a method for joint probabilistic modeling based on `1-regularization for multi-objective feature subset selection in classi�cation, where six di�erent measures of accuracy are considered as objectives with interval values. The individual assessment of the proposed joint probabilistic modeling and solution ranking methods on datasets with small-medium dimensionality, when using two di�erent Bayesian classi�ers, shows that comparable or better Pareto sets of feature subsets are approximated in comparison to standard methods.

Quantity and degree assessment in an RDF.based semantic language

This paper introduces a semantic language developed with the objective to be used in a semantic analyzer based on linguistic and world knowledge. Linguistic knowledge is provided by a Combinatorial Dictionary and several sets of rules. Extra-linguistic information is stored in an Ontology. The meaning of the text is represented by means of a series of RDF-type triples of the form predicate (subject, object). Semantic analyzer is one of the options of the multifunctional ETAP-3 linguistic processor. The analyzer can be used for Information Extraction and Question Answering. We describe semantic representation of expressions that provide an assessment of the number of objects involved and/or give a quantitative evaluation of different types of attributes. We focus on the following aspects: 1) parametric and non-parametric attributes; 2) gradable and non-gradable attributes; 3) ontological representation of different classes of attributes; 4) absolute and relative quantitative assessment; 5) punctual and interval quantitative assessment; 6) intervals with precise and fuzzy boundaries