Expert Consensus-based Video-Based Assessment Tool for Workflow Analysis in Minimally Invasive Colorectal Surgery: Development and Validation of ColoWorkflow

Minimally invasive colorectal surgery is characterized by procedural variability, a difficult learning curve, and complications that impact quality and outcomes. Video-based assessment (VBA) offers an opportunity to generate data-driven insights to reduce variability, optimize training, and improve surgical performance. However, existing tools for workflow analysis remain difficult to standardize and implement. This study aims to develop and validate a VBA tool for workflow analysis across minimally invasive colorectal procedures. A Delphi process was conducted to achieve consensus on generalizable workflow descriptors. The resulting framework informed the development of a new VBA tool, ColoWorkflow. Independent raters then applied ColoWorkflow to a multicentre video dataset of laparoscopic and robotic colorectal surgery (CRS). Applicability and inter-rater reliability were evaluated. Consensus was achieved for 10 procedure-agnostic phases and 34 procedure-specific steps describing CRS workflows. ColoWorkflow was developed and applied to 54 colorectal operative videos (left and right hemicolectomies, sigmoid and rectosigmoid resections, and total proctocolectomies) from five centres. The tool demonstrated broad applicability, with all but one label utilized. Inter-rater reliability was moderate, with mean Cohen's K of 0.71 for phases and 0.66 for steps. Most discrepancies arose at phase transitions and step boundary definitions. ColoWorkflow is the first consensus-based, validated VBA tool for comprehensive workflow analysis in minimally invasive CRS. It establishes a reproducible framework for video-based performance assessment, enabling benchmarking across institutions and supporting the development of artificial intelligence-driven workflow recognition. Its adoption may standardize training, accelerate competency acquisition, and advance data-informed surgical quality improvement.

Surgeons Awareness, Expectations, and Involvement with Artificial Intelligence: a Survey Pre and Post the GPT Era

Artificial Intelligence (AI) is transforming medicine, with generative AI models like ChatGPT reshaping perceptions of its potential. This study examines surgeons' awareness, expectations, and involvement with AI in surgery through comparative surveys conducted in 2021 and 2024. Two cross-sectional surveys were distributed globally in 2021 and 2024, the first before an IRCAD webinar and the second during the annual EAES meeting. The surveys assessed demographics, AI awareness, expectations, involvement, and ethics (2024 only). The surveys collected a total of 671 responses from 98 countries, 522 in 2021 and 149 in 2024. Awareness of AI courses rose from 14.5% in 2021 to 44.6% in 2024, while course attendance increased from 12.9% to 23%. Despite this, familiarity with foundational AI concepts remained limited. Expectations for AI's role shifted in 2024, with hospital management gaining relevance. Ethical concerns gained prominence, with 87.2% of 2024 participants emphasizing accountability and transparency. Infrastructure limitations remained the primary obstacle to implementation. Interdisciplinary collaboration and structured training were identified as critical for successful AI adoption. Optimism about AI's transformative potential remained high, with 79.9% of respondents believing AI would positively impact surgery and 96.6% willing to integrate AI into their clinical practice. Surgeons' perceptions of AI are evolving, driven by the rise of generative AI and advancements in surgical data science. While enthusiasm for integration is strong, knowledge gaps and infrastructural challenges persist. Addressing these through education, ethical frameworks, and infrastructure development is essential.

S4M: Segment Anything with 4 Extreme Points

The Segment Anything Model (SAM) has revolutionized open-set interactive image segmentation, inspiring numerous adapters for the medical domain. However, SAM primarily relies on sparse prompts such as point or bounding box, which may be suboptimal for fine-grained instance segmentation, particularly in endoscopic imagery, where precise localization is critical and existing prompts struggle to capture object boundaries effectively. To address this, we introduce S4M (Segment Anything with 4 Extreme Points), which augments SAM by leveraging extreme points -- the top-, bottom-, left-, and right-most points of an instance -- prompts. These points are intuitive to identify and provide a faster, structured alternative to box prompts. However, a na\"ive use of extreme points degrades performance, due to SAM's inability to interpret their semantic roles. To resolve this, we introduce dedicated learnable embeddings, enabling the model to distinguish extreme points from generic free-form points and better reason about their spatial relationships. We further propose an auxiliary training task through the Canvas module, which operates solely on prompts -- without vision input -- to predict a coarse instance mask. This encourages the model to internalize the relationship between extreme points and mask distributions, leading to more robust segmentation. S4M outperforms other SAM-based approaches on three endoscopic surgical datasets, demonstrating its effectiveness in complex scenarios. Finally, we validate our approach through a human annotation study on surgical endoscopic videos, confirming that extreme points are faster to acquire than bounding boxes.

Surgical Text-to-Image Generation

Acquiring surgical data for research and development is significantly hindered by high annotation costs and practical and ethical constraints. Utilizing synthetically generated images could offer a valuable alternative. In this work, we conduct an in-depth analysis on adapting text-to-image generative models for the surgical domain, leveraging the CholecT50 dataset, which provides surgical images annotated with surgical action triplets (instrument, verb, target). We investigate various language models and find T5 to offer more distinct features for differentiating surgical actions based on triplet-based textual inputs. Our analysis demonstrates strong alignment between long and triplet-based captions, supporting the use of triplet-based labels. We address the challenges in training text-to-image models on triplet-based captions without additional input signals by uncovering that triplet text embeddings are instrument-centric in the latent space and then, by designing an instrument-based class balancing technique to counteract the imbalance and skewness in the surgical data, improving training convergence. Extending Imagen, a diffusion-based generative model, we develop Surgical Imagen to generate photorealistic and activity-aligned surgical images from triplet-based textual prompts. We evaluate our model using diverse metrics, including human expert surveys and automated methods like FID and CLIP scores. We assess the model performance on key aspects: quality, alignment, reasoning, knowledge, and robustness, demonstrating the effectiveness of our approach in providing a realistic alternative to real data collection.