A novel approach to quantifying surgical workflow in robotic-assisted lobectomy.

INTRODUCTION: Understanding surgical workflow is critical for optimizing efficiencies and outcomes; however, most research evaluating workflow is impacted by observer subjectivity, limiting its reproducibility, scalability, and actionability. To address this, we developed a novel approach to quantitatively describe workflow within robotic-assisted lobectomy (RL). We demonstrate the utility of this approach by analysing features of surgical workflow that correlate with procedure duration. METHODS: RL was deconstructed into 12 tasks by expert thoracic surgeons. Task start and stop times were annotated across videos of 10 upper RLs (5 right and 5 left). Markov Networks were used to estimate both the likelihood of transitioning from one task to another and each task-transition entropy (i.e. complexity). Associations between the frequency with which each task was revisited intraoperatively and procedure duration were assessed using Pearson's correlation coefficient. RESULTS: Entropy calculations identified fissure dissection and hilar node dissection as tasks with especially complex transitions, while mediastinal lymph node dissection and division of pulmonary veins were less complex. The number of transitions to three tasks significantly correlated with case duration (fissure dissection (R = 0.69, p = 0.01), dissect arteries (R = 0.59, p = 0.03), and divide arteries (R = 0.63, p = 0.03)). CONCLUSION: This pilot demonstrates the feasibility of objectively quantifying workflow between RL tasks and introduces entropy as a new metric of task-transition complexity. These innovative measures of surgical workflow enable detailed characterization of a given surgery and might indicate behaviour that impacts case progression. We discuss how these measures can serve as a foundation and be combined with relevant clinical information to better understand factors influencing surgical inefficiency.

A Probabilistic Approach to Surgical Tasks and Skill Metrics.

Identifying and quantifying the activities that compose surgery is essential for effective interventions, computer-aided analyses and the advancement of surgical data science. For example, recent studies have shown that objective metrics (referred to as objective performance indicators, OPIs) computed during key surgical tasks correlate with surgeon skill and clinical outcomes. Unambiguous identification of these surgical tasks can be particularly challenging for both human annotators and algorithms. Each surgical procedure has multiple approaches, each surgeon has their own level of skill, and the initiation and termination of surgical tasks can be subject to interpretation. As such, human annotators and machine learning models face the same basic problem, accurately identifying the boundaries of surgical tasks despite variable and unstructured information. For use in surgeon feedback, OPIs should also be robust to the variability and diversity in this data. To mitigate this difficulty, we propose a probabilistic approach to surgical task identification and calculation of OPIs. Rather than relying on tasks that are identified by hard temporal boundaries, we demonstrate an approach that relies on distributions of start and stop times, for a probabilistic interpretation of when the task was performed. We first use hypothetical data to outline how this approach is superior to other conventional approaches. Then we present similar analyses on surgical data. We find that when surgical tasks are identified by their individual probabilities, the resulting OPIs are less sensitive to noise in the identification of the start and stop times. These results suggest that this probabilistic approach holds promise for the future of surgical data science.

Intersection of motor volumes predicts the outcome of ambush predation of larval zebrafish.

Escape maneuvers are key determinants of animal survival and are under intense selection pressure. A number of escape maneuver parameters contribute to survival, including response latency, escape speed and direction. However, the relative importance of these parameters is context dependent, suggesting that interactions between parameters and predatory context determine the likelihood of escape success. To better understand how escape maneuver parameters interact and contribute to survival, we analyzed the responses of larval zebrafish (Danio rerio) to the attacks of dragonfly nymphs (Sympetrum vicinum). We found that no single parameter explains the outcome. Instead, the relative intersection of the swept volume of the nymph's grasping organs with the volume containing all possible escape trajectories of the fish is the strongest predictor of escape success. In cases where the prey's motor volume exceeds that of the predator, the prey survives. By analyzing the intersection of these volumes, we compute the survival benefit of recruiting the Mauthner cell, a neuron in anamniotes devoted to producing escapes. We discuss how the intersection of motor volume approach provides a framework that unifies the influence of many escape maneuver parameters on the likelihood of survival.

How to Bring Surgery to the Next Level: Interpretable Skills Assessment in Robotic-Assisted Surgery.

INTRODUCTION: A surgeon's technical skills are an important factor in delivering optimal patient care. Most existing methods to estimate technical skills remain subjective and resource intensive. Robotic-assisted surgery (RAS) provides a unique opportunity to develop objective metrics using key elements of intraoperative surgeon behavior which can be captured unobtrusively, such as instrument positions and button presses. Recent studies have shown that objective metrics based on these data (referred to as objective performance indicators [OPIs]) correlate to select clinical outcomes during robotic-assisted radical prostatectomy. However, the current OPIs remain difficult to interpret directly and, therefore, to use within structured feedback to improve surgical efficiencies. METHODS: We analyzed kinematic and event data from da Vinci surgical systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to calculate values that can summarize the use of robotic instruments, referred to as OPIs. These indicators were mapped to broader technical skill categories of established training protocols. A data-driven approach was then applied to further sub-select OPIs that distinguish skill for each technical skill category within each training task. This subset of OPIs was used to build a set of logistic regression classifiers that predict the probability of expertise in that skill to identify targeted improvement and practice. The final, proposed feedback using OPIs was based on the coefficients of the logistic regression model to highlight specific actions that can be taken to improve. RESULTS: We determine that for the majority of skills, only a small subset of OPIs (2-10) are required to achieve the highest model accuracies (80-95%) for estimating technical skills within clinical-like tasks on a porcine model. The majority of the skill models have similar accuracy as models predicting overall expertise for a task (80-98%). Skill models can divide a prediction into interpretable categories for simpler, targeted feedback. CONCLUSION: We define and validate a methodology to create interpretable metrics for key technical skills during clinical-like tasks when performing RAS. Using this framework for evaluating technical skills, we believe that surgical trainees can better understand both what can be improved and how to improve.

Visual Threat Assessment and Reticulospinal Encoding of Calibrated Responses in Larval Zebrafish.

All visual animals must decide whether approaching objects are a threat. Our current understanding of this process has identified a proximity-based mechanism where an evasive maneuver is triggered when a looming stimulus passes a subtended visual angle threshold. However, some escape strategies are more costly than others, and so it would be beneficial to additionally encode the level of threat conveyed by the predator's approach rate to select the most appropriate response. Here, using naturalistic rates of looming visual stimuli while simultaneously monitoring escape behavior and the recruitment of multiple reticulospinal neurons, we find that larval zebrafish do indeed perform a calibrated assessment of threat. While all fish generate evasive maneuvers at the same subtended visual angle, lower approach rates evoke slower, more kinematically variable escape responses with relatively long latencies as well as the unilateral recruitment of ventral spinal projecting nuclei (vSPNs) implicated in turning. In contrast, higher approach rates evoke faster, more kinematically stereotyped responses with relatively short latencies, as well as bilateral recruitment of vSPNs and unilateral recruitment of giant fiber neurons in fish and amphibians called Mauthner cells. In addition to the higher proportion of more costly, shorter-latency Mauthner-active responses to greater perceived threats, we observe a higher incidence of freezing behavior at higher approach rates. Our results provide a new framework to understand how behavioral flexibility is grounded in the appropriate balancing of trade-offs between fast and slow movements when deciding to respond to a visually perceived threat.

Role of branchiomotor neurons in controlling food intake of zebrafish larvae.

The physical act of eating or feeding involves the coordinated action of several organs like eyes and jaws, and associated neural networks. Moreover, the activity of the neural networks controlling jaw movements (branchiomotor circuits) is regulated by the visual, olfactory, gustatory and hypothalamic systems, which are largely well characterized at the physiological level. By contrast, the behavioral output of the branchiomotor circuits and the functional consequences of disruption of these circuits by abnormal neural development are poorly understood. To begin to address these questions, we sought to evaluate the feeding ability of zebrafish larvae, a direct output of the branchiomotor circuits, and developed a qualitative assay for measuring food intake in zebrafish larvae at 7 days post-fertilization. We validated the assay by examining the effects of ablating the branchiomotor neurons. Metronidazole-mediated ablation of nitroreductase-expressing branchiomotor neurons resulted in a predictable reduction in food intake without significantly affecting swimming ability, indicating that the assay is robust. Laser-mediated ablation of trigeminal motor neurons resulted in a significant decrease in food intake, indicating that the assay is sensitive. Importantly, in larvae of a genetic mutant with severe loss of branchiomotor neurons, food intake was abolished. These studies establish a foundation for dissecting the neural circuits driving a motor behavior essential for survival.

Detection and capture of breast cancer cells with photoacoustic flow cytometry.

According to the Centers for Disease Control and Prevention, breast cancer is the most common cancer and the second leading cause of cancer related deaths among women. Metastasis­the presence of secondary tumors caused by the spread of cancer cells via the circulatory or lymphatic systems­significantly worsens the prognosis of any breast cancer patient. A technique is developed to detect circulating breast cancer cells in human blood using a photoacoustic flow cytometry method. A Q-switched laser is used to interrogate thousands of blood cells with one pulse as they flow through the beam path. Cells that are optically absorbing, either naturally or artificially, emit an ultrasound wave as a result of the photoacoustic (PA) effect. Breast cancer cells are targeted with chromophores through immunochemistry in order to enhance optical absorption. After which, the PA cytometry device is calibrated to demonstrate the ability to detect single cells. Cultured breast cancer cells are added to whole blood to reach a biologically relevant concentration of about 25 to 45 breast cancer cells per 1 mL of blood. An in vitro PA flow cytometer is used to detect and isolate these cells followed by capture with the use of a micromanipulator. This method can not only be used to determine the disease state of the patient and the response to therapy but also it can be used for genetic testing and in vitro drug trials since the circulating cell can be captured and studied.

Quantitative photoacoustics to measure single cell melanin production and nanoparticle attachment.

Photoacoustics can be used as a label-free spectroscopic method of identifying pigmented proteins and characterizing their intracellular concentration over time in a single living cell. The authors use a microscopic laser irradiation system with a 5 ns, Q-switched laser focused onto single cells in order to collect photoacoustic responses of melanoma cells from the HS936 cell line and gold nanoparticle labeled breast cancer cells from the T47D cell line. The volume averaged intracellular concentration of melanin is found to range from 29-270 mM for single melanoma cells and the number of gold nanoparticles (AuNP) is shown to range from 850-5900 AuNPs/cell. Additionally, the melanin production response to UV-A light stimulus is measured in four melanoma cells to find a mass production rate of 5.7 pg of melanin every 15 min.

Nanoparticle mediated thermal ablation of breast cancer cells using a nanosecond pulsed electric field.

In the past, ablation of cancer cells using radiofrequency heating techniques has been demonstrated, but the current methodology has many flaws, including inconsistent tumor ablation and significant ablation of normal cells. Other researchers have begun to develop a treatment that is more selective for cancer cells using metallic nanoparticles and constant electric field exposure. In these studies, cell necrosis is induced by heating antibody functionalized metallic nanoparticles attached to cancer cells. Our approach to studying this phenomenon is to use similarly functionalized metallic nanoparticles that are specific for the T47D breast cancer cell line, exposing these nanoparticle cell conjugates to a nanosecond pulsed electric field. Using fluorescent, polystyrene-coated, iron-oxide nanoparticles, the results of our pilot study indicated that we were able to ablate up to approximately 80% of the cells using 60 ns pulses in increasing numbers of pulses and up to approximately 90% of the cells using 300 ns pulses in increasing numbers of pulses. These quantities of ablated cells were achieved using a cumulative exposure time 6 orders of magnitude less than most in vitro constant electric field studies.

Optically absorbing nanoparticle mediated cell membrane permeabilization.

Membrane permeabilization is imperative for gene and drug delivery systems, along with other cell manipulation methods, since the average eukaryotic cell membrane is not permeable to polar and large nonpolar molecules. Antibody conjugated optically absorbing gold nanospheres are targeted to the cell membrane of T47D breast cancer cell line and irradiated with 5 ns pulse, 20 Hz, 532 nm light to increase membrane permeability. Up to 90% permeabilization with less than 6% death is reported at radiant exposures up to 10 times lower than those of other comparable studies.

Capture of circulating tumor cells using photoacoustic flowmetry and two phase flow.

Melanoma is the deadliest form of skin cancer, yet current diagnostic methods are unable to detect early onset of metastatic disease. Patients must wait until macroscopic secondary tumors form before malignancy can be diagnosed and treatment prescribed. Detection of cells that have broken off the original tumor and travel through the blood or lymph system can provide data for diagnosing and monitoring metastatic disease. By irradiating enriched blood samples spiked with cultured melanoma cells with nanosecond duration laser light, we induced photoacoustic responses in the pigmented cells. Thus, we can detect and enumerate melanoma cells in blood samples to demonstrate a paradigm for a photoacoustic flow cytometer. Furthermore, we capture the melanoma cells using microfluidic two phase flow, a technique that separates a continuous flow into alternating microslugs of air and blood cell suspension. Each slug of blood cells is tested for the presence of melanoma. Slugs that are positive for melanoma, indicated by photoacoustic waves, are separated from the cytometer for further purification and isolation of the melanoma cell. In this paper, we evaluate the two phase photoacoustic flow cytometer for its ability to detect and capture metastatic melanoma cells in blood.

Total internal reflection photoacoustic spectroscopy for the detection of ß-hematin.

Evanescent field sensing methods are currently used to detect many different types of disease markers and biologically important chemicals such as the HER2 breast cancer receptor. Hinoue et al. used Total Internal Reflection Photoacoustic Spectroscopy (TIRPAS) as a method of using the evanescent field to detect an optically opaque dye at a sample interface. Although their methods were successful at detecting dyes, the results at that time did not show a very practical spectroscopic technique, which was due to the less than typical sensitivity of TIRPAS as a spectroscopy modality given the low power (≈ 1 to 2 W) lasers being used. Contrarily, we have used an Nd:YAG laser with a five nanosecond pulse that gives peak power of 1 MW coupled with the TIRPAS system to increase the sensitivity of this technique for biological material sensing. All efforts were focused on the eventual detection of the optically absorbing material, hemozoin, which is created as a byproduct of a malarial infection in blood. We used an optically analogous material, ß-hematin, to determine the potential for detection in the TIRPAS system. In addition, four properties which control the sensitivity were investigated to increase understanding about the sensor's function as a biosensing method.

Enhanced photoacoustic detection of melanoma cells using gold nanoparticles.

BACKGROUND AND OBJECTIVES: We tagged melanoma cells with gold nanoparticles to show their viability for increasing sensitivity in a photoacoustic detection system. Ultimately, this study models the detection of circulating tumor cells, which are an important prognostic factor in the progress of melanoma. STUDY DESIGN/MATERIALS AND METHODS: A Q-switched, tunable Nd:YAG laser was used to irradiate cells in both a stationary and flow set-up. Photoacoustic signals were measured using a polyvinylidene fluoride (PVDF) film in the stationary test, and a commercially available ultrasonic probe for flow tests. Both unmodified melanoma cells and gold nanoparticle (AuNP) tagged melanoma were tested. RESULTS: AuNP tagged melanoma in a stationary set-up showed an average of 0.227 mV/mJ larger signal than the untagged, indicating a signal increase of 34%. At 500 nm there is a maximum difference of 0.295 mV/mJ, or a 41% increase. In flow tests, the ultrasound probe was able to detect single cells, but the increased signal from AuNP tagging was minimal. CONCLUSION: AuNP tagging proved to give an increased photoacoustic signal allowing greater sensitivity in stationary metastasized melanoma detection systems using photoacoustics.

An effective strategy for the synthesis of biocompatible gold nanoparticles using cinnamon phytochemicals for phantom CT imaging and photoacoustic detection of cancerous cells.

PURPOSE: The purpose of the present study was to explore the utilization of cinnamon-coated gold nanoparticles (Cin-AuNPs) as CT/optical contrast-enhancement agents for detection of cancer cells. METHODS: Cin-AuNPs were synthesized by a "green" procedure, and the detailed characterization was performed by physico-chemical analysis. Cytotoxicity and cellular uptake studies were carried out in normal human fibroblast and cancerous (PC-3 and MCF-7) cells, respectively. The efficacy of detecting cancerous cells was monitored using a photoacoustic technique. In vivo biodistribution was studied after IV injection of Cin-AuNPs in mice, and also a CT phantom model was generated. RESULTS: Biocompatible Cin-AuNPs were synthesized with high purity. Significant uptake of these gold nanoparticles was observed in PC-3 and MCF-7 cells. Cin-AuNPs internalized in cancerous cells facilitated detectable photoacoustic signals. In vivo biodistribution in normal mice showed steady accumulation of gold nanoparticles in lungs and rapid clearance from blood. Quantitative analysis of CT values in phantom model revealed that the cinnamon-phytochemical-coated AuNPs have reasonable attenuation efficiency. CONCLUSIONS: The results indicate that these non-toxic Cin-AuNPs can serve as excellent CT/ photoacoustic contrast-enhancement agents and may provide a novel approach toward tumor detection through nanopharmaceuticals.

Photoacoustic detection of melanoma micrometastasis in sentinel lymph nodes.

Melanoma is the deadliest form of skin cancer and has the fastest growth rate of all cancer types. Proper staging of melanoma is required for clinical management. One method of staging melanoma is performed by taking a sentinel node biopsy, in which the first node in the lymphatic drainage path of the primary lesion is removed and tested for the presence of melanoma cells. Current standard of care typically involves taking fewer than ten histologic sections of the node out of the hundreds of possible sections available in the tissue. We have developed a photoacoustic method that probes the entire intact node. We acquired a lymph node from a healthy canine subject. We cultured a malignant human melanoma cell line HS 936. Approximately 1 x 10(6) cells were separated and injected into the lymph node. We also had a healthy lymph node in which no melanoma cells were implanted. We used a tunable laser system set at 532 nm to irradiate the lymph nodes. Three piezoelectric acoustic detectors were positioned near the lymph node to detect photoacoustic pulses generated within the lymph nodes. We also acquired lymph nodes from pigs and repeated the experiments with increased amplification and improved sensors. We detected photoacoustic responses from a lymph node with as few as 500 melanoma cells injected into the tissue, while normal lymph nodes showed no response. Photoacoustic generation can be used to detect melanoma micrometastasis in sentinel lymph nodes. This detection can be used to guide further histologic study of the node, increasing the accuracy of the sentinel lymph node biopsy.