Evaluation of a novel navigation platform for laparoscopic liver surgery with organ deformation compensation using injected fiducials.

In laparoscopic liver resection, surgeons conventionally rely on anatomical landmarks detected through a laparoscope, preoperative volumetric images and laparoscopic ultrasound to compensate for the challenges of minimally invasive access. Image guidance using optical tracking and registration procedures is a promising tool, although often undermined by its inaccuracy. This study evaluates a novel surgical navigation solution that can compensate for liver deformations using an accurate and effective registration method. The proposed solution relies on a robotic C-arm to perform registration to preoperative CT/MRI image data and allows for intraoperative updates during resection using fluoroscopic images. Navigation is offered both as a 3D liver model with real-time instrument visualization, as well as an augmented reality overlay on the laparoscope camera view. Testing was conducted through a pre-clinical trial which included four porcine models. Accuracy of the navigation system was measured through two evaluation methods: liver surface fiducials reprojection and a comparison between planned and navigated resection margins. Target Registration Error with the fiducials evaluation shows that the accuracy in the vicinity of the lesion was 3.78±1.89 mm. Resection margin evaluations resulted in an overall median accuracy of 4.44 mm with a maximum error of 9.75 mm over the four subjects. The presented solution is accurate enough to be potentially clinically beneficial for surgical guidance in laparoscopic liver surgery.

Efficiency, Accuracy and Clinical Applicability of a New Image-Guided Surgery System in 3D Laparoscopic Liver Surgery.

BACKGROUND: To investigate efficiency, accuracy and clinical benefit of a new augmented reality system for 3D laparoscopic liver surgery. METHODS: All patients who received laparoscopic liver resection by a new image-guided surgery system with augmented 3D-imaging in a university hospital were included for analysis. Digitally processed preoperative cross-sectional imaging was merged with the laparoscopic image. Intraoperative efficiency of the procedure was measured as time needed to achieve sufficient registration accuracy. Technical accuracy was reported as fiducial registration error (FRE). Clinical benefit was assessed trough a questionnaire, reporting measures in a 5-point Likert scale format ranging from 1 (high) to 5 (low). RESULTS: From January to March 2018, ten laparoscopic liver resections of a total of 18 lesions were performed using the novel augmented reality system. Median time for registration was 8:50 min (range 1:31-23:56). The mean FRE was reduced from 14.0 mm (SD 5.0) in the first registration attempt to 9.2 mm (SD 2.8) in the last attempt. The questionnaire revealed the ease of use of the system (1.2, SD 0.4) and the benefit for resection of vanishing lesions (1.0, SD 0.0) as convincing positive aspects, whereas image registration accuracy for resection guidance was consistently judged as too inaccurate. CONCLUSIONS: Augmented reality in 3D laparoscopic liver surgery with landmark-based registration technique is feasible with only little impact on the intraoperative workflow. The benefit for detecting particularly vanishing lesions is high. For an additional benefit during the resection process, registration accuracy has to be improved and non-rigid registration algorithms will be required to address intraoperative anatomical deformation.

pH-Responsive Side Chains as a Tool to Control Aqueous Self-Assembly Mechanisms.

pH-Tunable nanoscale morphology and self-assembly mechanism of a series of oligo(p-phenyleneethynylene) (OPE)-based bolaamphiphiles featuring poly(ethylene imine) (PEI) side chains of different length and degree of hydrolysis are described. Protonation and deprotonation of the PEI chains by changing the pH alters the hydrophilic/hydrophobic balance of the systems and, in turn, the strength of intermolecular interactions between the hydrophobic OPE moieties. Low pH values (3) lead to weak interaction between the OPEs and result in spherical nanoparticles, in which aggregation follows an isodesmic mechanism. In contrast, higher pH values (11) induce deprotonation of the polymer chains and lead to a stronger, cooperative aggregation into anisotropic nanostructures. Our results demonstrate that pH-responsive chains can be exploited as a tool to tune self-assembly mechanisms, which opens exciting possibilities to develop new stimuli-responsive materials.

Controlling Actuation Performance in Physically Cross-Linked Polylactone Blends Using Polylactide Stereocomplexation.

Within the field of shape-changing materials, synthetic chemical modification has been widely used to introduce key structural units and subsequently expand the mechanical functionality of actuator devices. The introduction of architectural elements that facilitate in situ control over mechanical properties and complete geometric reconfiguration of a device is highly desirable to increase the morphological diversity of polymeric actuator materials. The subject of the present study is a multiblock copolymer with semicrystalline poly(l-lactide) and poly(ε-caprolactone) (PLLA-PCL) segments. By harnessing the stereocomplexation of copolymer chains with a poly(d-lactide) oligomer (PDLA), we provide anchoring points for physical network formation and demonstrate how a blending process can be used to efficiently vary the mechanical properties of a shape-memory actuator. We investigate the effect of molecular structure on the actuation performance of the material in cyclic thermomechanical tests, with a maximum reversible shape change εrev' = 13.4 ± 1.5% measured at 3.1 wt % of polylactide stereocomplex content in the multiblock copolymer matrix. The thermophysical properties, crystalline structure, and phase morphology were analyzed by DSC, WAXS and AFM respectively, elucidating the structure-to-function relationship in physically cross-linked blended materials. The work demonstrates a one-step technique for manufacturing a polymeric actuator and tuning its performance in situ. This approach should greatly improve the efficiency of physically cross-linked actuator fabrication, allowing composition and physical behavior to be precisely and easily controlled.

Exceptionally Ductile and Tough Biomimetic Artificial Nacre with Gas Barrier Function.

Synthetic mimics of natural high-performance structural materials have shown great and partly unforeseen opportunities for the design of multifunctional materials. For nacre-mimetic nanocomposites, it has remained extraordinarily challenging to make ductile materials with high stretchability at high fractions of reinforcements, which is however of crucial importance for flexible barrier materials. Here, highly ductile and tough nacre-mimetic nanocomposites are presented, by implementing weak, but many hydrogen bonds in a ternary nacre-mimetic system consisting of two polymers (poly(vinyl amine) and poly(vinyl alcohol)) and natural nanoclay (montmorillonite) to provide efficient energy dissipation and slippage at high nanoclay content (50 wt%). Tailored interactions enable exceptional combinations of ductility (close to 50% strain) and toughness (up to 27.5 MJ m-3 ). Extensive stress whitening, a clear sign of high internal dynamics at high internal cohesion, can be observed during mechanical deformation, and the materials can be folded like paper into origami planes without fracture. Overall, the new levels of ductility and toughness are unprecedented in highly reinforced bioinspired nanocomposites and are of critical importance to future applications, e.g., as barrier materials needed for encapsulation and as a printing substrate for flexible organic electronics.

Extractable Free Polymer Chains Enhance Actuation Performance of Crystallizable Poly(ε-caprolactone) Networks and Enable Self-Healing.

Crosslinking of thermoplastics is a versatile method to create crystallizable polymer networks, which are of high interest for shape-memory actuators. Here, crosslinked poly(ε-caprolactone) thermosets (cPCLs) were prepared from linear starting material, whereby the amount of extractable polymer was varied. Fractions of 5⁻60 wt % of non-crosslinked polymer chains, which freely interpenetrate the crosslinked network, were achieved leading to differences in the resulting phase of the bulk material. This can be described as "sponge-like" with open or closed compartments depending on the amount of interpenetrating polymer. The crosslinking density and the average network chain length remained in a similar range for all network structures, while the theoretical accessible volume for reptation of the free polymer content is affected. This feature could influence or introduce new functions into the material created by thermomechanical treatment. The effect of interpenetrating PCL in cPCLs on the reversible actuation was analyzed by cyclic, uniaxial tensile tests. Here, high reversible strains of up to ∆ε = 24% showed the enhanced actuation performance of networks with a non-crosslinked PCL content of 30 wt % resulting from the crystal formation in the phase of the non-crosslinked PCL and co-crystallization with network structures. Additional functionalities are reprogrammability and self-healing capabilities for networks with high contents of extractable polymer enabling reusability and providing durable actuator materials.

Noncontinuously Responding Polymeric Actuators.

Reversible movements of current polymeric actuators stem from the continuous response to signals from a controlling unit, and subsequently cannot be interrupted without stopping or eliminating the input trigger. Here, we present actuators based on cross-linked blends of two crystallizable polymers capable of pausing their movements in a defined manner upon continuous cyclic heating and cooling. This noncontinuous actuation can be adjusted by varying the applied heating and cooling rates. The feasibility of these devices for technological applications was shown in a 140 cycle experiment of free-standing noncontinuous shape shifts, as well as by various demonstrators.

Photocatalytic Hydrogen Evolution Driven by [FeFe] Hydrogenase Models Tethered to Fluorene and Silafluorene Sensitizers.

It is successfully shown that photocatalytic proton reduction to dihydrogen in the presence of a sacrificial electron donor, such as trimethylamine (TEA) and ascorbate, can be driven by compact sensitizer-catalyst dyads, that is, dithiolate-bridged [FeFe] hydrogenase models tethered to organic sensitizers, such as fluorenes and silafluorenes (1 a-4 a). The sensitizer-catalyst dyads 1 a-4 a show remarkable and promising catalytic activities as well as enhanced stabilities during photocatalysis performed under UV-light irradiation. The photocatalysis was carried out both in non-aqueous and aqueous media. The latter experiments were performed by solubilizing the photocatalysts within micelles formed by either sodium dodecyl sulfate (SDS) or cetyltrimethylammonium bromide (CTAB). In this study a turnover number of 539 (7 h) is achieved under optimized conditions, which corresponds to an exceptionally high turnover frequency of 77 h-1 . Theoretical investigations as well as emission decay experiments were performed to understand the observed phenomena together with the mechanisms of photocatalytic H2 generation.

Understanding Toughness in Bioinspired Cellulose Nanofibril/Polymer Nanocomposites.

Cellulose nanofibrils (CNFs) are considered next generation, renewable reinforcements for sustainable, high-performance bioinspired nanocomposites uniting high stiffness, strength and toughness. However, the challenges associated with making well-defined CNF/polymer nanopaper hybrid structures with well-controlled polymer properties have so far hampered to deduce a quantitative picture of the mechanical properties space and deformation mechanisms, and limits the ability to tune and control the mechanical properties by rational design criteria. Here, we discuss detailed insights on how the thermo-mechanical properties of tailor-made copolymers govern the tensile properties in bioinspired CNF/polymer settings, hence at high fractions of reinforcements and under nanoconfinement conditions for the polymers. To this end, we synthesize a series of fully water-soluble and nonionic copolymers, whose glass transition temperatures (Tg) are varied from -60 to 130 °C. We demonstrate that well-defined polymer-coated core/shell nanofibrils form at intermediate stages and that well-defined nanopaper structures with tunable nanostructure arise. The systematic correlation between the thermal transitions in the (co)polymers, as well as its fraction, on the mechanical properties and deformation mechanisms of the nanocomposites is underscored by tensile tests, SEM imaging of fracture surfaces and dynamic mechanical analysis. An optimum toughness is obtained for copolymers with a Tg close to the testing temperature, where the soft phase possesses the best combination of high molecular mobility and cohesive strength. New deformation modes are activated for the toughest compositions. Our study establishes quantitative structure/property relationships in CNF/(co)polymer nanopapers and opens the design space for future, rational molecular engineering using reversible supramolecular bonds or covalent cross-linking.

Retinal slit lamp video mosaicking.

PURPOSE: To this day, the slit lamp remains the first tool used by an ophthalmologist to examine patient eyes. Imaging of the retina poses, however, a variety of problems, namely a shallow depth of focus, reflections from the optical system, a small field of view and non-uniform illumination. For ophthalmologists, the use of slit lamp images for documentation and analysis purposes, however, remains extremely challenging due to large image artifacts. For this reason, we propose an automatic retinal slit lamp video mosaicking, which enlarges the field of view and reduces amount of noise and reflections, thus enhancing image quality. METHODS: Our method is composed of three parts: (i) viable content segmentation, (ii) global registration and (iii) image blending. Frame content is segmented using gradient boosting with custom pixel-wise features. Speeded-up robust features are used for finding pair-wise translations between frames with robust random sample consensus estimation and graph-based simultaneous localization and mapping for global bundle adjustment. Foreground-aware blending based on feathering merges video frames into comprehensive mosaics. RESULTS: Foreground is segmented successfully with an area under the curve of the receiver operating characteristic curve of 0.9557. Mosaicking results and state-of-the-art methods were compared and rated by ophthalmologists showing a strong preference for a large field of view provided by our method. CONCLUSIONS: The proposed method for global registration of retinal slit lamp images of the retina into comprehensive mosaics improves over state-of-the-art methods and is preferred qualitatively.

Toward Anisotropic Hybrid Materials: Directional Crystallization of Amphiphilic Polyoxazoline-Based Triblock Terpolymers.

We present the design and synthesis of a linear ABC triblock terpolymer for the bottom-up synthesis of anisotropic organic/inorganic hybrid materials: polyethylene-block-poly(2-(4-(tert-butoxycarbonyl)amino)butyl-2-oxazoline)-block-poly(2-iso-propyl-2-oxazoline) (PE-b-PBocAmOx-b-PiPrOx). The synthesis was realized via the covalent linkage of azide-functionalized polyethylene and alkyne functionalized poly(2-alkyl-2-oxazoline) (POx)-based diblock copolymers exploiting copper-catalyzed azide-alkyne cycloaddition (CuAAC) chemistry. After purification of the resulting triblock terpolymer, the middle block was deprotected, resulting in a primary amine in the side chain. In the next step, solution self-assembly into core-shell-corona micelles in aqueous solution was investigated by dynamic light scattering (DLS) and transmission electron microscopy (TEM). Subsequent directional crystallization of the corona-forming block, poly(2-iso-propyl-2-oxazoline), led to the formation of anisotropic superstructures as demonstrated by electron microscopy (SEM and TEM). We present hypotheses concerning the aggregation mechanism as well as first promising results regarding the selective loading of individual domains within such anisotropic nanostructures with metal nanoparticles (Au, Fe3O4).

Hierarchical Self-Assembly of Double-Crystalline Poly(ferrocenyldimethylsilane)-block-poly(2-iso-propyl-2-oxazoline) (PFDMS-b-PiPrOx) Block Copolymers.

The step-wise solution self-assembly of double crystalline organometallic poly(ferrocenyldimethylsilane)-block-poly(2-iso-propyl-2-oxazoline) (PFDMS-b-PiPrOx) diblock copolymers is demonstrated. Two block copolymers are obtained by copper-catalyzed azide-alkyne cycloaddition (CuAAC), featuring PFDMS/PiPrOx weight fractions of 46/54 (PFDMS30-b-PiPrOx75) and 30/70 (PFDMS30-b-PiPrOx155). Nonsolvent induced crystallization of PFDMS in acetone leads in both cases to cylindrical micelles with a PFDMS core. Afterward, the structures are transferred into water for sequential temperature-induced crystallization of the PiPrOx corona, leading to hierarchical double crystalline superstructures, which are investigated using scanning electron microscopy, wide angle X-ray scattering, and differential scanning calorimetry.

Landmark detection for fusion of fundus and MRI toward a patient-specific multimodal eye model.

Ophthalmologists typically acquire different image modalities to diagnose eye pathologies. They comprise, e.g., Fundus photography, optical coherence tomography, computed tomography, and magnetic resonance imaging (MRI). Yet, these images are often complementary and do express the same pathologies in a different way. Some pathologies are only visible in a particular modality. Thus, it is beneficial for the ophthalmologist to have these modalities fused into a single patient-specific model. The goal of this paper is a fusion of Fundus photography with segmented MRI volumes. This adds information to MRI that was not visible before like vessels and the macula. This paper contributions include automatic detection of the optic disc, the fovea, the optic axis, and an automatic segmentation of the vitreous humor of the eye.

Controlling aqueous self-assembly mechanisms by hydrophobic interactions.

We report an innovative template-assisted synthetic protocol for the selective functionalization of terminal triple bonds in oligophenyleneethynylenes (OPE) by pre-organization in aqueous solution. By this approach, three new OPE-based bolaamphiphiles substituted with hydrophilic poly(2-ethyl-2-oxazoline) (PEtOx) chains of different length have been synthesized. The chain length was observed to strongly influence the aqueous supramolecular polymerization: bolaamphiphiles with longer hydrophilic chains aggregate into spherical nanoparticles in a stepwise fashion, whereas 2D anisotropic platelets are formed cooperatively if shorter PEtOx chains are used. Our results demonstrate that hydrophobic interactions can be strong enough to trigger cooperative effects in aqueous self-assembly processes.

Poly(2-vinyl pyridine)-block-poly(ethylene oxide) featuring a furan group at the block junction-synthesis and functionalization.

Furfuryl glycidyl ether (FGE) represents a highly versatile monomer for the preparation of reversibly cross-linkable nanostructured materials via Diels-Alder reactions. Here, the use of FGE for the mid-chain functionalization of a P2VP-b-PEO diblock copolymer is reported. The material features one furan moiety at the block junction, P2VP68 -FGE-b-PEO390 , which can be subsequently addressed in Diels-Alder reactions using maleimide-functionalized counterparts. The presence of the FGE moiety enables the introduction of dyes as model labels or the formation of hetero-grafted brushes as shell on hybrid Au@Polymer nanoparticles. This renders P2VP68 -FGE-b-PEO390 , a powerful tool for selective functionalization reactions, including the modification of surfaces.

Star-shaped drug carriers for doxorubicin with POEGMA and POEtOxMA brush-like shells: a structural, physical, and biological comparison.

The synthesis of amphiphilic star-shaped poly(ε-caprolactone)-block-poly(oligo(ethylene glycol)methacrylate)s ([PCL(18)-b-POEGMA](4)) and poly(ε-caprolactone)-block-poly(oligo(2-ethyl-2-oxazoline)methacrylate)s ([PCL(18)-b-POEtOxMA](4)) is presented. Unimolecular behavior in aqueous systems is observed with the tendency to form loose aggregates for both hydrophilic shell types. The comparison of OEGMA and OEtOxMA reveals that the molar mass of the macromonomer in the hydrophilic shell rather than the mere length is the crucial factor to form an efficiently stabilizing hydrophilic shell. A hydrophilic/lipophilic balance of 0.8 is shown to stabilize unimolecular micelles in water. An extensive in vitro biological evaluation shows neither blood nor cytotoxicity. The applicability of the polymers as drug delivery systems was proven by the encapsulation of the anticancer drug doxorubicin, whose cytotoxic effect was retarded in comparison to the free drug.

Hybrid Fe3O4@amino cellulose nanoparticles in organic media--heterogeneous ligands for atom transfer radical polymerizations.

We demonstrate an efficient strategy for the preparation of well-dispersed hybrid particles in organic media via a combination of the solution-based formation of magnetic nanoparticles (MNPs) and subsequent coating with amino celluloses of different degrees of polymerization. The coating process was verified by a combination of light scattering, thermogravimetry, and magnetic techniques. Further, the hybrid particles exhibit an average diameter of roughly 8 nm, as demonstrated by electron microscopy and light scattering. The stability of the so-called MNP@AC(x) hybrid particles (x represents the average degree of polymerization of the amino cellulose) in polar organic solvents such as DMAc was exploited by using the materials as heterogeneous ligands in the atom transfer radical polymerization (ATRP) of styrene. We could show that PS with a near-narrow molecular weight distribution (PDIs<1.3) and low Cu contents (5 ppm) can be prepared. The MNP@AC(x) particles could be separated from the reaction mixture afterwards by an external magnetic field and reused in further polymerizations.

Biocompatible multishell architecture for iron oxide nanoparticles.

The coating of super-paramagnetic iron oxide nanoparticles (SPIONs) with multiple shells is demonstrated by building a layer assembled from carboxymethyldextran and poly(diallydimethylammonium chloride). Three shells are produced stepwise around aggregates of SPIONs by the formation of a polyelectrolyte complex. A growing particle size from 96 to 327 nm and a zeta potential in the range of +39 to -51 mV are measured. Microscopic techniques such as TEM, SEM, and AFM exemplify the core-shell structures. Magnetic force microscopy and vibrating sample magnetometer measurements confirm the architecture of the multishell particles. Cell culture experiments show that even nanoparticles with three shells are still taken up by cells.

Statistical modeling of the eye for multimodal treatment planning for external beam radiation therapy of intraocular tumors.

PURPOSE: Ocular anatomy and radiation-associated toxicities provide unique challenges for external beam radiation therapy. For treatment planning, precise modeling of organs at risk and tumor volume are crucial. Development of a precise eye model and automatic adaptation of this model to patients' anatomy remain problematic because of organ shape variability. This work introduces the application of a 3-dimensional (3D) statistical shape model as a novel method for precise eye modeling for external beam radiation therapy of intraocular tumors. METHODS AND MATERIALS: Manual and automatic segmentations were compared for 17 patients, based on head computed tomography (CT) volume scans. A 3D statistical shape model of the cornea, lens, and sclera as well as of the optic disc position was developed. Furthermore, an active shape model was built to enable automatic fitting of the eye model to CT slice stacks. Cross-validation was performed based on leave-one-out tests for all training shapes by measuring dice coefficients and mean segmentation errors between automatic segmentation and manual segmentation by an expert. RESULTS: Cross-validation revealed a dice similarity of 95%±2% for the sclera and cornea and 91%±2% for the lens. Overall, mean segmentation error was found to be 0.3±0.1 mm. Average segmentation time was 14±2 s on a standard personal computer. CONCLUSIONS: Our results show that the solution presented outperforms state-of-the-art methods in terms of accuracy, reliability, and robustness. Moreover, the eye model shape as well as its variability is learned from a training set rather than by making shape assumptions (eg, as with the spherical or elliptical model). Therefore, the model appears to be capable of modeling nonspherically and nonelliptically shaped eyes.

Real-time multimodal retinal image registration for a computer-assisted laser photocoagulation system.

An algorithm for the real-time registration of a retinal video sequence captured with a scanning digital ophthalmoscope (SDO) to a retinal composite image is presented. This method is designed for a computer-assisted retinal laser photocoagulation system to compensate for retinal motion and hence enhance the accuracy, speed, and patient safety of retinal laser treatments. The procedure combines intensity and feature-based registration techniques. For the registration of an individual frame, the translational frame-to-frame motion between preceding and current frame is detected by normalized cross correlation. Next, vessel points on the current video frame are identified and an initial transformation estimate is constructed from the calculated translation vector and the quadratic registration matrix of the previous frame. The vessel points are then iteratively matched to the segmented vessel centerline of the composite image to refine the initial transformation and register the video frame to the composite image. Criteria for image quality and algorithm convergence are introduced, which assess the exclusion of single frames from the registration process and enable a loss of tracking signal if necessary. The algorithm was successfully applied to ten different video sequences recorded from patients. It revealed an average accuracy of 2.47 ± 2.0 pixels (∼23.2 ± 18.8 µm) for 2764 evaluated video frames and demonstrated that it meets the clinical requirements.