Skill transfer

 Reason: fancy with access to technology because thats very rare that there is a daVinci
just for research
 can laparoscopic skills be transfered to robotic surgery and vice versa
 rate the surgeons participating in this study  new anastomosis score to be validated

OSATS in the OR to Patient outcomes

 esophageal anastomosis and colorectal anastomosis because they have higher
complication rate
 Clinical validation
 New anastomoses score to be validated and applied

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RESEARCH PROPOSAL

Carly Garrow, University of Heidelberg, Medical Engineering

Development of the iSurgeon: An Expert Model- and Sensor-Based Training System

Minimally invasive surgery has become increasingly prevalent over the last decade for a diverse
assortment of surgical procedures, as patients prefer smaller incisions, shorter recovery time,
and less post-operative pain. However, laparoscopic surgery means slower learning curves for
surgeons-to-be, who must master the complex techniques that make an operation through only
a few small incisions possible 1 . Moreover, they must perform these operations by watching
from an indirect 2D camera. Current training options, such as virtual reality or direct
observation from an experienced surgeon, can be costly, do not provide the trainee with
individualized, realtime feedback, or may require substantial amounts of time from already
busy surgeons. Our solution is the iSurgeon, a training system that will decrease cost and time
requirements while improving teaching outcomes by “watching” a trainee’s movements,
comparing them to a model of expert movements, and then providing real-time feedback for
improvements. The iSurgeon was conceptualized by researchers at the University of Heidelberg
in 2014. I worked on the iSurgeon’s development team in 2015 and propose to extend my
contributions to the system.

The final version of the iSurgeon will use a Microsoft Kinect and NDI Polaris camera to track a
trainee’s arm and instrument movements during surgical tasks. In addition, a Myo armband will
be used to measure arm rotations. The motions tracked by these instruments will be compared
to the iSurgeon’s expert model, which will consist of the motions performed by expert surgeons
during the same surgical tasks. The iSurgeon will use these comparisons to provide real-time
feedback to the trainee through a virtual figure, or avatar. The avatar is a figure built around a
Kinect skeleton that is a compilation of motions created from the expert model. This type of
system will be a valuable tool in the training of laparoscopic surgeons because it will provide
expert feedback that can be personalized to the user, while avoiding the need for an available
surgeon or personal bias towards a trainee.

The development of this training system will take place at the Department of General, Visceral,
and Transplantation Surgery at the Heidelberg University Hospital under Dr. Felix Nickel, MME,
and Prof. Dr. Beat Müller. Prof. Müller is the head of the section of minimally invasive surgery.
Dr. Nickel oversees the clinic’s state-of-the-art minimally invasive surgery training center, which
is utilized by medical students, researchers, and surgeons from around Europe. The research
group is the ideal setting to learn about surgical processes, to collaborate with surgeons, and to
practice the application of engineering in a surgical setting.

During the summer of 2015, I was awarded a Research Internship in Science and Engineering
(RISE) through the DAAD, and I spent three months working on the earlier stages of the
iSurgeon. My role encompassed many responsibilities: I trained medical students on various
laparoscopic procedures; I collected data from surgeons for use in the expert model and from
novices for the validation of the system; and I researched methods for implementing a
machine-learning algorithm. The current version of the iSurgeon has an expert model that is
composed of data for the task of suture knot tying. The system is capable of recording a
trainee’s Research Proposal, 2

motions during suture knot tying, and afterwards comparing these motions to the expert
model. It has been validated for correctly identifying a user’s skill level and for test-retest
reliability 2 . As a recipient of a DAAD research grant, I will contribute to the development of
the iSurgeon by developing the system’s program to perform comparisons and to provide real-
time feedback through the avatar, integrating more advanced surgical procedures into the
expert model, and implementing the da Vinci robotic platform for data analysis.

Implementing real-time comparisons and the avatar will require several steps. The iSurgeon
must first be capable of recognizing the various steps of suture knot tying in real-time, which
will be completed by the end of October 2017. During November 2017, I will program the
iSurgeon to watch a trainee performing suture knot tying and compute differences between the
trainee’s motions and the motions compiled in the expert model. Lastly, the iSurgeon must be
capable of using these differences to both identify and communicate feedback to the user
through the avatar, which will be complete by the end of December. During January and
February 2018, I will evaluate the system’s effectiveness and pinpoint possible improvements
based on advice from novices and experts.

I will also spend that January familiarizing myself with one advanced surgical procedure and the
da Vinci surgical robot. This robot is one of the most recent advancements in minimally invasive
surgery and allows surgeons to operate with much greater precision under optimal viewing
conditions. The department of surgery in Heidelberg is one of the few institutions that has
access to the application programming interface (API) of the da Vinci robot. This access makes it
possible to record surgeons’ motions during our selected procedure using the da Vinci robotic
platform. We will begin recording of this procedure in February 2018 and complete this by
April. In May and June, I will use these recordings to create an expert model of our chosen
procedure in the iSurgeon knowledge database. This will leave July of 2018 to draft a
manuscript for publication and to finish up any loose ends.

While this project will be difficult and technical, I look forward to the challenge, and my
extensive background as an undergraduate researcher and intern will be a tremendous
contributing factor to my success on this project. Having started undergraduate research as a
freshman, I will have 4 years of research experience by the time I graduate with my bachelor’s
degree; this is arguably more research experience than that of some master’s students.

While at the University of Missouri, I have worked in two research labs. The first, the
Orthopedic Biomechanics Laboratory, exposed me to the intriguing field of surgery, to various
biomaterials, and to the research process. I am currently involved in the Computational
Neuroscience Laboratory and am collaborating with a team of 2 other students to create
individual neurons and compile them into a full model of the rodent micturition circuit. Through
this project, I have gained experience in programming in NEURON (a Python-based language),
have learned how to work and communicate effectively within a group, and have planned and
implemented an effective research plan. My honors undergraduate thesis will cover our
findings from this research project and will provide me with an opportunity to author a
technical research manuscript. Research Proposal, 3

Without much formal training in traditional programming languages, I anticipate that one of the
most difficult aspects of completing this project will be the extensive programming knowledge
required. However, my familiarity with NEURON and my training in Matlab have introduced me
to the concept of programming. Additionally, I have begun to prepare myself by taking online
programming classes in C++ and Python. Mastery of these programs will help me to better
communicate with the IT team and to contribute to the program behind the iSurgeon. These
classes are offered through edX.org, a website that provides online courses taught through a
variety of institutions such as Microsoft and MIT.

I have also gained more technical writing experience and knowledge about various bariatric
surgical procedures by interning at a medical device start-up company called Nanova
Biomaterials, Inc. Here, I was responsible for creating 3 surgical technique guides and several
other technical documents for our FDA 510(k) and CE Mark applications.

My RISE internship is another of my applicable experiences. Besides my contribution to the

iSurgeon project, I independently completed a research project that had been started by a
Fulbright graduate student in our research group. Once I took over this project, I trained and
evaluated over 50 medical students in 15 hours of laparoscopic training, which included suture
knot tying on a box trainer and teaching a laparoscopic cholecystectomy on a virtual reality
trainer. I was responsible for compiling and organizing the training data for all of the
participants. Through the challenge of managing this research project, I learned how to work
independently and had my first experience in writing research manuscripts.

My RISE experience also challenged me in other ways: I developed friendships with a diverse
group of people with very different backgrounds, ranging from Germans to refugees from Syria.
I experienced a different culture and successfully communicated in a language that I had
studied for 6 years but never had the chance to practice. It left me craving another opportunity
to enhance my cultural understanding, to further improve my German skills, and to explore
deeper the interconnections between medicine and engineering.

As a recipient of a DAAD Research Grant, I will be able to satisfy these cravings for challenge
through my involvement both inside and outside of the lab. While in Heidelberg, I will
participate in a scientific graduate program for MD-PhD students that is organized by Dr. Nickel.
This program provides workshops in scientific skills including statistics, scientific writing, journal
clubs, scientific presentations and social skills. The program has a strong focus on peer teaching
and will give me an additional opportunity outside of the surgical training center to collaborate
closely with other German and international scientists who are in Heidelberg during the time of
my internship. I also plan to attend surgical conferences to present our work and obtain
feedback.

In order to make the Heidelberg community my home for the next 10 months, I will join a
running club through the university and train for the SAS Half Marathon in April. I will also join
Open Uni-Heidelberg, an organization that helps integrate refugees into the local area and
university. Having studied German throughout high school and college, I look forward to
improving my spoken German skills and expanding my view of the world through the many
diverse people I am sure to meet during my time in Europe.

I chose to study biomedical engineering because of my interest in math and medicine and my
craving for challenge. Theodore Von Karman, an aerospace engineer, once said, “Scientists
discover the world that exists; engineers create the world that never was.” In my opinion,
creating a new and viable solution to solve a problem is one of the most difficult careers I can
think of, particularly when these solutions are geared towards the human body. The human
body is the most complex machine on this planet, and its mechanical properties and biological
processes are neither well understood nor simple to recreate. I want to work as a biomedical
engineer because the challenges and possibilities are endless. My interest lies specifically in
utilizing engineering to improve surgical technologies, and I am eager to begin seeing the
impact of my work on the medical field.

As technology has rapidly improved, surgery has adapted to allow for safer and more efficient
procedures. However, these changes in the way surgery is conducted have resulted in longer
and more difficult training periods for surgeons. Through my RISE experience, I came to
understand these difficulties faced by surgeons. As a biomedical engineer, my solution to this
issue lies in creating more efficient training modalities, a concept that comes to life with the
iSurgeon. My background knowledge in the subject, combined with my technical background,
will help me to better envision the final iSurgeon product. As an aspiring biomedical engineer, I
want to develop medical devices that help surgeons to be successful and are more beneficial to
patients. This opportunity will provide me with experience working in a clinical setting,
interacting with surgeons and understanding their needs, and utilizing my skillset to improve
others’ lives.

References

1. Gozen AS, Akin Y. (2015) Are structured curriculums for laparoscopic training useful? A
review of current literature. Curr Opin Urol 25(2): 163-167. Doi:
10.1097/mou.0000000000000138

2. Kowalewski K, Hendrie JD, Schmidt MW, Garrow CR, Bruckner T, Proctor T, Paul S, Adigüzel D,
Bodenstedt S, Erben A, Kenngott H, Erben Y, Speidel S, Müller-Stich BP, Nickel F. (2016).
Development and validation of a sensor- and expert model-based training system for
laparoscopic surgery: The iSurgeon. Surg Endosc. Epub. doi: 10.1007/s00464-016-5213-2