H Feussner’s research while affiliated with Technical University of Munich and other places

Background: The development of assistive technologies will become of increasing importance in the coming years and not only in surgery. The comprehensive perception of the actual situation is the basis of every autonomous action. Different sensor systems can be used for this purpose, of which video-based systems have a special potential. Method: Based on the available literature and on own research projects, central aspects of image-based support systems for surgery are presented. In this context, not only the potential but also the limitations of the methods are explained. Results: An established application is the phase detection of surgical interventions, for which surgical videos are analyzed using neural networks. Through a time-based and transformative analysis the results of the prediction could only recently be significantly improved. Robotic camera guidance systems will also use image data to autonomously navigate laparoscopes in the near future. The reliability of the systems needs to be adapted to the high requirements in surgery by means of additional information. A comparable multimodal approach has already been implemented for navigation and localization during laparoscopic procedures. For this purpose, video data are analyzed using various methods and these data are fused with other sensor modalities. Discussion: Image-based supportive methods are already available for various tasks and will become an important aspect for the surgery of the future; however, in order to be able to be reliably implemented for autonomous functions, they must be embedded in multimodal approaches in the future in order to provide the necessary security.

Purpose Surgical documentation is an important yet time-consuming necessity in clinical routine. Beside its core function to transmit information about a surgery to other medical professionals, the surgical report has gained even more significance in terms of information extraction for scientific, administrative and judicial application. A possible basis for computer aided reporting is phase detection by convolutional neural networks (CNN). In this article we propose a workflow to generate operative notes based on the output of the TeCNO CNN. Methods Video recordings of 15 cholecystectomies were used for inference. The annotation of TeCNO was compared to that of an expert surgeon (HE) and the algorithm based annotation of a scientist (HA). The CNN output then was used to identify aberrance from standard course as basis for the final report. Moreover, we assessed the phenomenon of ‘phase flickering’ as clusters of incorrectly labeled frames and evaluated its usability. Results The accordance of the HE and CNN was 79.7% and that of HA and CNN 87.0%. ‘Phase flickering’ indicated an aberrant course with AUCs of 0.91 and 0.89 in ROC analysis regarding number and extend of concerned frames. Finally, we created operative notes based on a standard text, deviation alerts, and manual completion by the surgeon. Conclusion Computer-aided documentation is a noteworthy use case for phase recognition in standardized surgery. The analysis of phase flickering in a CNN’s annotation has the potential of retrieving more information about the course of a particular procedure to complement an automated report.

Introduction. Dysphagia affects 1 of 6 adults during their lifetime [1]. There are both benign and malignant forms of dysphagia, commonly caused by esophageal, oropharyngeal and neuromuscular diseases. Even in its benign forms, dysphagia can have a significant impact on quality of life. In current practice, a combination of endoscopy, esophageal manometry and fluoroscopic x-ray cinematography has been established for diagnostics. These modalities are applied in sequential order and provide quite different views on the issue. We propose a novel approach for time-synchronizing and visualizing manometric and cinematographic data to provide an intuitive means for diagnosing oropharyngeal dysphagia and to gain an enhanced understanding of the functional processes in the highly dynamic oropharyngoesophageal region. Materials and Methods. We used a state-of-the-art manometric probe with 36 pressure sensors for gathering the manometric data. The cinematography was recorded simultaneously with an x-ray machine. Since both data sets had to be recorded on separate devices (PC and x-ray machine) with individual clocks, we developed a method for determining the time difference between both devices: We placed a stamp mechanism in the radiologic frame that is able to actuate one of the manometry probe“s sensors and thus creates a noticeable stimulus in both manometric and radiologic data. For both data sets, we extracted the timestamps of the exact frame when this stimulus begins and calculated the time difference. This time difference was later used to precisely time-synchronize manometric and radiologic data gathered from the study participant. Within the x-ray frames we detected the sensor positions of the manometric probe and overlayed the manometric data using a well-established color-coded visualization for high-resolution manometry [2]. Results and Discussion. Our sensor detection algorithm yielded robust results for well-exposed radiologic images, though we experienced difficulties in regions where the sensor geometry blends into the background, especially around the mandibular corpus and angelus. By fitting a cubic b-spline through all successfully detected sensors, we were able to effectively bridge gaps in most cases (Fig. 1). We showed the final visualization to experienced examiners as well as novices and received overall positive feedback regarding the intuitiveness of our visualization. According to the participants, this new form of presenting diagnostic data enhances the understanding of disorders and of both anatomy and physiologic motility. It is especially helpful for visualizing pressure changes and probe movement in the highly dynamic oropharyngoesophageal region. Refernces [1] Adkins, Christopher, et al. (2020); DOI: https://doi.org/10.1016/j.cgh.2019.10.029. [2] R. Yadlapati (2017); PMID: 28539845. Fig. 1. Result of sensor detection and spline fitting.

Background The digital transformation of the healthcare system will significantly change our profession and is about to revolutionize surgical oncology.Objective The present work aims to give a neutral overview of central aspects of this process and of changes that have already been made or are to be expected in the near future.Materials and methodsThis review article takes into account the current literature, expert discussions, and congress contents. The focus is laid on the indication process and on operative care, whereas general aspects are only dealt with in an overview.ResultsDigitalization in surgical oncology primarily means the comprehensive provision of data, which is continuously supplemented along the treatment process in a structured manner. The available knowledge will allow for well-founded decision support and the integration of assisting functions in all areas. For the surgical operating theatre in particular, it will provide effective tools for precision medicine.Conclusion The digitalization of oncological surgery offers numerous approaches to improve the treatment of our patients. Active but also critical support is required; the patient must be the focus of efforts.

Background A reliable and sterile access through the intestinal wall to ease flexible endoscopic transluminal interventions is still appealing but lacks a suitable port system. Methods In a granted industry cooperation, we developed the MIEO-Port, a flexible three components overtube system that provides a temporary hermetic sealing of the intestinal wall to allow endoscopic disinfection and manipulation to gain access to the abdominal cavity. The port features an innovative head part which allows for coupling the port to the intestinal wall by vacuum suction and for controlled jetting the isolated intestinal surface with a disinfectant. The device was tested in vivo in 6 pigs for acute and long-term usability. All animal tests were approved by the local ethics committee. Results In the acute experiment, the port system supported sealed endoscopic mucosa resection and transluminal cholecystectomy. In the survival study on 5 animals, the MIEO-Port proved its reliability after transcolonic peritoneoscopy. In one animal, a port dislocation occurred after extensive retroperitoneal preparation, one animal revealed bacterial contamination at necropsy; however, all animals showed a favourable course over ten days and offered no signs of peritonitis or abscedation during post-mortem examination. Discussion To the best of our knowledge, the MIEO-Port system is the first device to provide a reliable and sterile flexible access to the peritoneal cavity that can be used throughout the entire gastrointestinal tract regardless of the access route and which combines hermetic sealing with local sterilization. Further studies are warranted.

Verfahren der künstlichen Intelligenz werden auch in der Allgemein- und Viszeralchirurgie spezielle Anwendungsfelder finden, die nicht nur auf die eigentliche Tätigkeit im chirurgischen Operationssaal begrenzt sind, sondern sich auch auf alle perioperativen Prozesse, die Edukation und das Training, sowie die wissenschaftliche Weiterentwicklung erstrecken. Besondere Impulse werden für die Bereiche Entscheidungsunterstützung, kognitives kollaborierendes Interventionsumfeld und neue Formen der wissenschaftlichen Evidenzgewinnung erwartet. Die praktische Implementierung verlangt nicht nur profunde informationswissenschaftliche Kenntnisse, sondern auch die souveräne Beherrschung der chirurgischen Wissensdomäne, sodass eine neue Kultur der Kooperation zwischen Chirurgen und Forschern/Entwicklern gefördert werden muss.

Background The digitalization process is currently on everyone’s lips and sweeping changes in the field of public health and especially in surgery are to be expected within the next few years. Besides general issues, such as electronic health records and medical information systems, artificial intelligence, robotics and model-based surgery will decisively impact on the daily routine. In order to provide the necessary knowledge base, to point out related risks and chances and also to define fields of action for surgery, the German Society of Surgery commissioned a position paper on digitalization. A first appraisal in form of an online survey is the subject of this article. Methods This article is based on an online survey of the members of the German Society of Surgery and selected members of other related societies. The survey asked for the members’ personal assessment concerning different aspects of the digitalization process and the respective state of knowledge as well as the impact on the field of surgery. Results A total of 296 members contributed to this survey. According to their assessment, digitalization in surgery is currently associated with terms such as electronic health records and medical information systems but they also assume a relevant influence on their own activities and on the fields of interventional medicine and surgery. A relevant need for improvement of the current state of knowledge was highlighted, not only for general aspects of digitalization but also for surgically relevant issues in particular. The vast majority of interviewed members saw digitalization more as a chance for improvement than as a risk factor. Conclusion According to the views of interviewed members of the German Society of Surgery the process of digital transformation will significantly impact the field of surgery. All those involved should feel responsible to contribute to and guide this process in order to maintain the surgically inherent requirements and to protect patient safety. The position paper on digitalization can serve as a basis and should define concrete recommendations for action. In the sense of an academic approach the new possibilities should be critically evaluated with respect to suitability and should be exclusively confined to applications that are beneficial to ourselves and to our patients.