The Impact of Machine Learning on 2D/3D Registration for Image-guided Interventions: A Systematic Review and Perspective

Image-based navigation is widely considered the next frontier of minimally invasive surgery. It is believed that image-based navigation will increase the access to reproducible, safe, and high-precision surgery as it may then be performed at acceptable costs and effort. This is because image-based techniques avoid the need of specialized equipment and seamlessly integrate with contemporary workflows. Further, it is expected that image-based navigation will play a major role in enabling mixed reality environments and autonomous, robotic workflows. A critical component of image guidance is 2D/3D registration, a technique to estimate the spatial relationships between 3D structures, e.g., volumetric imagery or tool models, and 2D images thereof, such as fluoroscopy or endoscopy. While image-based 2D/3D registration is a mature technique, its transition from the bench to the bedside has been restrained by well-known challenges, including brittleness of the optimization objective, hyperparameter selection, and initialization, difficulties around inconsistencies or multiple objects, and limited single-view performance. One reason these challenges persist today is that analytical solutions are likely inadequate considering the complexity, variability, and high-dimensionality of generic 2D/3D registration problems. The recent advent of machine learning-based approaches to imaging problems that, rather than specifying the desired functional mapping, approximate it using highly expressive parametric models holds promise for solving some of the notorious challenges in 2D/3D registration. In this manuscript, we review the impact of machine learning on 2D/3D registration to systematically summarize the recent advances made by introduction of this novel technology. Grounded in these insights, we then offer our perspective on the most pressing needs, significant open problems, and possible next steps.

E-DSSR: Efficient Dynamic Surgical Scene Reconstruction with Transformer-based Stereoscopic Depth Perception

Reconstructing the scene of robotic surgery from the stereo endoscopic video is an important and promising topic in surgical data science, which potentially supports many applications such as surgical visual perception, robotic surgery education and intra-operative context awareness. However, current methods are mostly restricted to reconstructing static anatomy assuming no tissue deformation, tool occlusion and de-occlusion, and camera movement. However, these assumptions are not always satisfied in minimal invasive robotic surgeries. In this work, we present an efficient reconstruction pipeline for highly dynamic surgical scenes that runs at 28 fps. Specifically, we design a transformer-based stereoscopic depth perception for efficient depth estimation and a light-weight tool segmentor to handle tool occlusion. After that, a dynamic reconstruction algorithm which can estimate the tissue deformation and camera movement, and aggregate the information over time is proposed for surgical scene reconstruction. We evaluate the proposed pipeline on two datasets, the public Hamlyn Centre Endoscopic Video Dataset and our in-house DaVinci robotic surgery dataset. The results demonstrate that our method can recover the scene obstructed by the surgical tool and handle the movement of camera in realistic surgical scenarios effectively at real-time speed.

An Interpretable Approach to Automated Severity Scoring in Pelvic Trauma

Pelvic ring disruptions result from blunt injury mechanisms and are often found in patients with multi-system trauma. To grade pelvic fracture severity in trauma victims based on whole-body CT, the Tile AO/OTA classification is frequently used. Due to the high volume of whole-body trauma CTs generated in busy trauma centers, an automated approach to Tile classification would provide substantial value, e.,g., to prioritize the reading queue of the attending trauma radiologist. In such scenario, an automated method should perform grading based on a transparent process and based on interpretable features to enable interaction with human readers and lower their workload by offering insights from a first automated read of the scan. This paper introduces an automated yet interpretable pelvic trauma decision support system to assist radiologists in fracture detection and Tile grade classification. The method operates similarly to human interpretation of CT scans and first detects distinct pelvic fractures on CT with high specificity using a Faster-RCNN model that are then interpreted using a structural causal model based on clinical best practices to infer an initial Tile grade. The Bayesian causal model and finally, the object detector are then queried for likely co-occurring fractures that may have been rejected initially due to the highly specific operating point of the detector, resulting in an updated list of detected fractures and corresponding final Tile grade. Our method is transparent in that it provides finding location and type using the object detector, as well as information on important counterfactuals that would invalidate the system's recommendation and achieves an AUC of 83.3%/85.1% for translational/rotational instability. Despite being designed for human-machine teaming, our approach does not compromise on performance compared to previous black-box approaches.

Pose-dependent weights and Domain Randomization for fully automatic X-ray to CT Registration

Fully automatic X-ray to CT registration requires a solid initialization to provide an initial alignment within the capture range of existing intensity-based registrations. This work adresses that need by providing a novel automatic initialization, which enables end to end registration. First, a neural network is trained once to detect a set of anatomical landmarks on simulated X-rays. A domain randomization scheme is proposed to enable the network to overcome the challenge of being trained purely on simulated data and run inference on real Xrays. Then, for each patient CT, a patient-specific landmark extraction scheme is used. It is based on backprojecting and clustering the previously trained networks predictions on a set of simulated X-rays. Next, the network is retrained to detect the new landmarks. Finally the combination of network and 3D landmark locations is used to compute the initialization using a perspective-n-point algorithm. During the computation of the pose, a weighting scheme is introduced to incorporate the confidence of the network in detecting the landmarks. The algorithm is evaluated on the pelvis using both real and simulated x-rays. The mean (+-standard deviation) target registration error in millimetres is 4.1 +- 4.3 for simulated X-rays with a success rate of 92% and 4.2 +- 3.9 for real X-rays with a success rate of 86.8%, where a success is defined as a translation error of less than 30mm.

Revisiting Stereo Depth Estimation From a Sequence-to-Sequence Perspective with Transformers

Stereo depth estimation relies on optimal correspondence matching between pixels on epipolar lines in the left and right image to infer depth. Rather than matching individual pixels, in this work, we revisit the problem from a sequence-to-sequence correspondence perspective to replace cost volume construction with dense pixel matching using position information and attention. This approach, named STereo TRansformer (STTR), has several advantages: It 1) relaxes the limitation of a fixed disparity range, 2) identifies occluded regions and provides confidence of estimation, and 3) imposes uniqueness constraints during the matching process. We report promising results on both synthetic and real-world datasets and demonstrate that STTR generalizes well across different domains, even without fine-tuning. Our code is publicly available at https://github.com/mli0603/stereo-transformer.

Relational Graph Learning on Visual and Kinematics Embeddings for Accurate Gesture Recognition in Robotic Surgery

Automatic surgical gesture recognition is fundamentally important to enable intelligent cognitive assistance in robotic surgery. With recent advancement in robot-assisted minimally invasive surgery, rich information including surgical videos and robotic kinematics can be recorded, which provide complementary knowledge for understanding surgical gestures. However, existing methods either solely adopt uni-modal data or directly concatenate multi-modal representations, which can not sufficiently exploit the informative correlations inherent in visual and kinematics data to boost gesture recognition accuracies. In this regard, we propose a novel approach of multimodal relational graph network (i.e., MRG-Net) to dynamically integrate visual and kinematics information through interactive message propagation in the latent feature space. In specific, we first extract embeddings from video and kinematics sequences with temporal convolutional networks and LSTM units. Next, we identify multi-relations in these multi-modal features and model them through a hierarchical relational graph learning module. The effectiveness of our method is demonstrated with state-of-the-art results on the public JIGSAWS dataset, outperforming current uni-modal and multi-modal methods on both suturing and knot typing tasks. Furthermore, we validated our method on in-house visual-kinematics datasets collected with da Vinci Research Kit (dVRK) platforms in two centers, with consistent promising performance achieved.

Multimodal and self-supervised representation learning for automatic gesture recognition in surgical robotics

Self-supervised, multi-modal learning has been successful in holistic representation of complex scenarios. This can be useful to consolidate information from multiple modalities which have multiple, versatile uses. Its application in surgical robotics can lead to simultaneously developing a generalised machine understanding of the surgical process and reduce the dependency on quality, expert annotations which are generally difficult to obtain. We develop a self-supervised, multi-modal representation learning paradigm that learns representations for surgical gestures from video and kinematics. We use an encoder-decoder network configuration that encodes representations from surgical videos and decodes them to yield kinematics. We quantitatively demonstrate the efficacy of our learnt representations for gesture recognition (with accuracy between 69.6 % and 77.8 %), transfer learning across multiple tasks (with accuracy between 44.6 % and 64.8 %) and surgeon skill classification (with accuracy between 76.8 % and 81.2 %). Further, we qualitatively demonstrate that our self-supervised representations cluster in semantically meaningful properties (surgeon skill and gestures).

A Learning-based Method for Online Adjustment of C-arm Cone-Beam CT Source Trajectories for Artifact Avoidance

During spinal fusion surgery, screws are placed close to critical nerves suggesting the need for highly accurate screw placement. Verifying screw placement on high-quality tomographic imaging is essential. C-arm Cone-beam CT (CBCT) provides intraoperative 3D tomographic imaging which would allow for immediate verification and, if needed, revision. However, the reconstruction quality attainable with commercial CBCT devices is insufficient, predominantly due to severe metal artifacts in the presence of pedicle screws. These artifacts arise from a mismatch between the true physics of image formation and an idealized model thereof assumed during reconstruction. Prospectively acquiring views onto anatomy that are least affected by this mismatch can, therefore, improve reconstruction quality. We propose to adjust the C-arm CBCT source trajectory during the scan to optimize reconstruction quality with respect to a certain task, i.e. verification of screw placement. Adjustments are performed on-the-fly using a convolutional neural network that regresses a quality index for possible next views given the current x-ray image. Adjusting the CBCT trajectory to acquire the recommended views results in non-circular source orbits that avoid poor images, and thus, data inconsistencies. We demonstrate that convolutional neural networks trained on realistically simulated data are capable of predicting quality metrics that enable scene-specific adjustments of the CBCT source trajectory. Using both realistically simulated data and real CBCT acquisitions of a semi-anthropomorphic phantom, we show that tomographic reconstructions of the resulting scene-specific CBCT acquisitions exhibit improved image quality particularly in terms of metal artifacts. Since the optimization objective is implicitly encoded in a neural network, the proposed approach overcomes the need for 3D information at run-time.

Augment Yourself: Mixed Reality Self-Augmentation Using Optical See-through Head-mounted Displays and Physical Mirrors

Optical see-though head-mounted displays (OST HMDs) are one of the key technologies for merging virtual objects and physical scenes to provide an immersive mixed reality (MR) environment to its user. A fundamental limitation of HMDs is, that the user itself cannot be augmented conveniently as, in casual posture, only the distal upper extremities are within the field of view of the HMD. Consequently, most MR applications that are centered around the user, such as virtual dressing rooms or learning of body movements, cannot be realized with HMDs. In this paper, we propose a novel concept and prototype system that combines OST HMDs and physical mirrors to enable self-augmentation and provide an immersive MR environment centered around the user. Our system, to the best of our knowledge the first of its kind, estimates the user's pose in the virtual image generated by the mirror using an RGBD camera attached to the HMD and anchors virtual objects to the reflection rather than the user directly. We evaluate our system quantitatively with respect to calibration accuracy and infrared signal degradation effects due to the mirror, and show its potential in applications where large mirrors are already an integral part of the facility. Particularly, we demonstrate its use for virtual fitting rooms, gaming applications, anatomy learning, and personal fitness. In contrast to competing devices such as LCD-equipped smart mirrors, the proposed system consists of only an HMD with RGBD camera and, thus, does not require a prepared environment making it very flexible and generic. In future work, we will aim to investigate how the system can be optimally used for physical rehabilitation and personal training as a promising application.