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 Danail Stoyanov · Zeike Taylor
Duygu Sarikaya · Jonathan McLeod
Miguel Angel González Ballester
Noel C. F. Codella et al. (Eds.)
LNCS 11041

OR 2.0 Context-Aware Operating Theaters,

Computer Assisted Robotic Endoscopy,
Clinical Image-Based Procedures,
and Skin Image Analysis
First International Workshop, OR 2.0 2018
5th International Workshop, CARE 2018
7th International Workshop, CLIP 2018
Third International Workshop, ISIC 2018
Held in Conjunction with MICCAI 2018
Granada, Spain, September 16 and 20, 2018, Proceedings

123
Lecture Notes in Computer Science 11041
Commenced Publication in 1973
Founding and Former Series Editors:
Gerhard Goos, Juris Hartmanis, and Jan van Leeuwen

Editorial Board
David Hutchison
Lancaster University, Lancaster, UK
Takeo Kanade
Carnegie Mellon University, Pittsburgh, PA, USA
Josef Kittler
University of Surrey, Guildford, UK
Jon M. Kleinberg
Cornell University, Ithaca, NY, USA
Friedemann Mattern
ETH Zurich, Zurich, Switzerland
John C. Mitchell
Stanford University, Stanford, CA, USA
Moni Naor
Weizmann Institute of Science, Rehovot, Israel
C. Pandu Rangan
Indian Institute of Technology Madras, Chennai, India
Bernhard Steffen
TU Dortmund University, Dortmund, Germany
Demetri Terzopoulos
University of California, Los Angeles, CA, USA
Doug Tygar
University of California, Berkeley, CA, USA
Gerhard Weikum
Max Planck Institute for Informatics, Saarbrücken, Germany
More information about this series at http://www.springer.com/series/7412
Danail Stoyanov Zeike Taylor
•

Duygu Sarikaya Jonathan McLeod

•

Miguel Angel González Ballester

Noel C. F. Codella et al. (Eds.)

OR 2.0 Context-Aware Operating Theaters,

Computer Assisted Robotic Endoscopy,
Clinical Image-Based Procedures,
and Skin Image Analysis
First International Workshop, OR 2.0 2018
5th International Workshop, CARE 2018
7th International Workshop, CLIP 2018
Third International Workshop, ISIC 2018
Held in Conjunction with MICCAI 2018
Granada, Spain, September 16 and 20, 2018
Proceedings

123
Editors
Danail Stoyanov Jonathan McLeod
University College London University of Western Ontario
London London, ON
UK Canada
Zeike Taylor Miguel Angel González Ballester
University of Leeds Universitat Pompeu Fabra
Leeds Barcelona
UK Spain
Duygu Sarikaya Noel C. F. Codella
University of Rennes IBM Research
Rennes Yorktown Heights, NY
France USA

Additional Workshop Editors see next page

ISSN 0302-9743 ISSN 1611-3349 (electronic)

Lecture Notes in Computer Science
ISBN 978-3-030-01200-7 ISBN 978-3-030-01201-4 (eBook)
https://doi.org/10.1007/978-3-030-01201-4

Library of Congress Control Number: 2018956291

LNCS Sublibrary: SL6 – Image Processing, Computer Vision, Pattern Recognition, and Graphics

© Springer Nature Switzerland AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the
material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
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The publisher, the authors and the editors are safe to assume that the advice and information in this book are
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 Additional Workshop Editors

Tutorial and Educational Chair

Anne Martel
University of Toronto
Toronto, ON
Canada

Workshop and Challenge Co-chair

Lena Maier-Hein
German Cancer Research Center
Heidelberg
Germany

OR 2.0 Context-Aware Operating Theaters, OR 2.0 2018

Anand Malpani Sandrine De Ribaupierre

Johns Hopkins University University of Western Ontario
Baltimore London
USA Canada
Marco A. Zenati
Harvard Medical School
Boston
USA

Integrating Medical Imaging and Non-Imaging Modalities,

CARE 2018

Luo Xiongbiao Tobias Reichl

Xiamen University KUKA Deutschland GmbH
Xiamen Augsburg
China Germany
Toby Collins
IRCAD
Strasbourg
France
VI Additional Workshop Editors

Clinical Image-Based Procedures, CLIP 2018

Klaus Drechsler Cristina Oyarzun Laura

Aachen University of Applied Sciences Fraunhofer IGD
Aachen Darmstadt
Germany Germany
Marius Erdt Raj Shekhar
Fraunhofer IDM@NTU Sheikh Zayed Institute
Singapore for Pediatric Surgical Innovation
Washington, DC
Marius George Linguraru
USA
Sheikh Zayed Institute
for Pediatric Surgical Innovation Stefan Wesarg
Washington, DC Fraunhofer IGD
USA Darmstadt
Germany

Skin Image Analysis, ISIC 2018

M. Emre Celebi Allan Halpern

University of Central Arkansas Memorial Sloan Kettering Cancer Center
Conway New York
USA USA
Kristin Dana
Rutgers University
Piscataway
USA
 OR 2.0 2018 Preface

Surgical robotic tools and digitally enhanced operating theaters have been giving surgeons
a helping hand for years. While they provide great control, precision, and flexibility to the
surgeons, they do not yet address the cognitive assistance needs in the operating theater.
We are on the verge of a new wave of innovations of artificial-intelligence-powered,
context-aware operating theaters. OR 2.0, Context-Aware Surgical Theaters, aimed to
highlight the potential use of a broad range of topics such as machine vision and per-
ception, robotics, surgical simulation and modeling, multi-modal data fusion and visu-
alization, image analysis, advanced imaging, advanced display technologies, human–
computer interfaces, sensors, wearable and implantable electronics and robots, visual
attention models, cognitive models, decision support networks to enhance surgical pro-
cedural assistance, context-awareness, and team communication in the operating theater,
human–robot collaborative systems, and surgical training and assessment in defining the
technologies of the next-generation operating theaters.
OR 2.0 was held in conjunction with the Medical Image Computing and Computer
Assisted Intervention (MICCAI) conference in Granada, Spain. OR 2.0 has its roots in
the M2CAI workshop series that started in 2009 in London (UK) and was organized
every year until 2016 in Athens; it was, however, a new movement of the domain
toward multidisciplinary approaches and teamed with a focus on translation and
clinical applications that define operating room technologies of the future.
The workshop featured clinicians, engineers, and industry partners. It hosted key-
note speakers, oral presentations, and a poster session of accepted papers on topics such
as cognitive models, process modeling, anonymization in operating theaters, smart
operating rooms, surgical data science, surgical process and discrete event simulation,
surgical training, perioperative process optimization, human–computer interfaces,
surgical workflow analysis, surgical phase recognition, automatic length, volume
estimation to aid surgical robots, motion-planning, tracking, use of RFID tags with
surgical instruments, as well as technical topics such as self-supervised learning, deep
learning, bidirectional rapidly exploring random trees, open research problems of
nonlinear trajectories, temporal coherence, segmentation, registration. OR 2.0 also
featured an open discussion forum of next-generation context-aware operating theater
technologies and their clinical impact.

September 2018 Duygu Sarikaya

Anand Malpani
Marco Zenati
Sandrine de Ribaupierre
 OR 2.0 2018 Organization

Organizing Board

Duygu Sarikaya University of Rennes, France

Anand Malpani The Johns Hopkins University, Baltimore, USA
Marco Zenati Harvard Medical School, Boston, USA
Sandrine de Ribaupierre University of Western Ontario, London, Canada

Advisory Board

Paolo Fiorini
Kanako Harad
Pierre Jannin
Ken Masamune
Thomas Neumuth
Nicolas Padoy
Russell H. Taylor
 CARE 2018 Preface

The 5th International Workshop on Computer-Assisted and Robotic Endoscopy

(CARE 2018) was held on September 16, 2018 in Granada, Spain. This half-day
workshop was held in conjunction with MICCAI 2018, the 21st International
Conference On Medical Image Computing and Computer-Assisted Intervention.
As in the previous four CARE workshops, our objective is to bring together
researchers, clinicians, and industry to advance the field of computer-assisted and
robotic endoscopy through the presentation of original research manuscripts and
invited keynotes from leading experts in academia, industry, and medicine. This year
we were pleased to welcome Dr. Sandrine de Ribaupierre, a distinguished pediatric
neurosurgeon and professor from Western University, Canada, who gave the keynote
presentation “Neuroendoscopy: What Are the Needs and Use for AR and VR?”. After
peer review, five papers were selected for oral presentation at CARE and the revised
manuscripts are presented in these proceedings. We thank the authors for their
high-quality papers and presentations at the workshop. It is their outstanding research
and hard work that make this workshop a success.
We would like to express our sincere gratitude to the reviewers who contributed their
time and effort in evaluating the papers. We would also like to thank KUKA
Deutschland GmbH and Intuitive Surgical for their support in sponsoring the best
papers and best presentation awards. Finally, we would like to thank the organizers of
MICCAI for supporting and facilitating this workshop.

September 2018 Jonathan McLeod

Xiongbiao Luo
Toby Collins
Tobias Reichl
 CARE 2018 Organization

Program Committee
Jonathan McLeod Intuitive Surgical, USA
Xiongbiao Luo Xiamen University, China
Toby Collins IRCAD, France
Tobias Reichl KUKA Deutschland GmbH, Germany
 CLIP 2018 Preface

On September 16, 2018, the 7th International Workshop on Clinical Image-Based

Procedures: From Planning to Intervention (CLIP 2018) was held in Granada, Spain in
conjunction with the 21st International Conference on Medical Image Computing and
Computer-Assisted Intervention (MICCAI). Following the tradition set in the past six
years, this year’s edition of the workshop was an exciting forum for the discussion and
dissemination of clinically tested, state-of-the-art methods for image-based planning,
monitoring, and evaluation of medical procedures.
Over the past few years, there has been considerable and growing interest in the
development and evaluation of new translational image-based techniques in the modern
hospital. For a decade or more, a proliferation of meetings dedicated to medical image
computing has created a need for greater study and scrutiny of the clinical application
and validation of such methods. New attention and new strategies are essential to
ensure a smooth and effective translation of computational image-based techniques into
the clinic. For these reasons and to complement other technology-focused MICCAI
workshops on computer-assisted interventions, the major focus of CLIP 2018
continued to be on filling gaps between basic science and clinical applications.
Members of the medical imaging community were encouraged to submit work
centered on specific clinical applications, including techniques and procedures based
on clinical data or already in use and evaluated by clinical users. Once again, the event
brought together world-class researchers and clinicians who presented ways to
strengthen links between computer scientists and engineers, and surgeons, interven-
tional radiologists, and radiation oncologists.
In response to the call for papers, 13 original manuscripts were submitted for
presentation at CLIP 2018. Each of the manuscripts underwent a meticulous
double-blind peer review by three members of the Program Committee, all of them
prestigious experts in the field of medical image analysis and clinical translations of
technology. A member of the Organizing Committee further oversaw the review of
each manuscript. Eight manuscripts were accepted for oral presentation at the
workshop. The accepted contributors represented a considerable diversity of countries
from different continents. Judging by the contributions received, the quality of CLIP
2018 maintained the high standards of previous years.
As always, the workshop featured prominent expert keynote speakers. Vesna
Prchkovska, Chief Operating Officer of the company QMENTA, provided her vision
of the translation of research to industry. Dr. Elisenda Eixarch, fetal surgeon from
Hospital Clínic and Hospital Sant Joan de Déu in Barcelona, presented her experience
in bringing technology to real use in fetal and perinatal care.
We would like to acknowledge the invaluable contributions of our entire Program
Committee, many members of whom have actively participated in the planning of the
workshop over the years, and without whose assistance CLIP 2018 would not be
possible. Our thanks also go to all the authors in this volume for the high quality
XII CLIP 2018 Preface

of their work and the commitment of time and effort. Finally, we are grateful to the
MICCAI organizers for supporting the organization of CLIP 2018.

September 2018 Miguel Angel González Ballester

Klaus Drechsler
Marius Erdt
Marius George Linguraru
Cristina Oyarzun Laura
Raj Shekhar
Stefan Wesarg
 CLIP 2018 Organization

Organizers

Klaus Drechsler Aachen University of Applied Sciences,

Marius Erdt
Miguel González Ballester
Marius George Linguraru
Cristina Oyarzun Laura
Raj Shekhar
Stefan Wesarg
Germany
Fraunhofer IDM@NTU, Singapore
ICREA - Universitat Pompeu Fabra, Spain
Children’s National Healthcare System, USA
Fraunhofer IGD, Germany
Children’s National Healthcare System, USA
Fraunhofer IGD, Germany

Program Committee
Mario Ceresa Pompeu Fabra University, Spain
Juan Cerrolaza Children’s National Medical Center, USA
Yufei Chen Tongji University, China
Jan Egger TU Graz, Austria
Gloria Fernández Esparrach Hospital Clinic Barcelona, Spain
Moti Freimann Harvard Medical School, USA
Debora Gil Universitat Autonoma de Barcelona, Spain
Tobias Heimann Siemens, Germany
Weimin Huang A*STAR, Institute for Infocomm Research,
Singapore
Xin Kang Sonavex, Inc., USA
Michael Kelm Siemens, Germany
Jianfei Liu Duke University, USA
Diana Nabers German Cancer Research Center, Germany
Mauricio Reyes University of Bern, Switzerland
Akinobu Shimizu Tokyo University of Agriculture
and Technology, Japan
Awais Mansoor Children’s National Health System, USA
Xinyang Liu Children’s National Health System, USA
Sukryool (Alan) Kang Children’s National Health System, USA
Yogesh Karpate Children’s National Health System, USA
Antonio Porras Children’s National Health System, USA
Carles Sanchez Ramos Universitat Autonoma de Barcelona, Spain
Stephan Zidowitz Fraunhofer MEVIS, Germany
Jiayin Zhou A*STAR, Institute for Infocomm Research,
Singapore
 ISIC 2018 Preface

The Third International Skin Imaging Collaboration (ISIC) Workshop and Challenge
on Skin Image Analysis was held at the Granada Conference Center, Granada, Spain,
on September 20, 2018, in conjunction with the 21st International Conference on
Medical Image Computing and Computer-Assisted Intervention (MICCAI).
The skin is the largest organ of the human body, and is the first area of assessment
performed by any clinical staff when a patient is seen, as it provides numerous insights
into a patient’s underlying health. For example, cardiac function, liver function,
immune function, and physical injuries can be assessed by examining the skin. In
addition, dermatologic complaints are also among the most prevalent in primary care.
Images of the skin are the most easily captured form of medical image in health care,
and the domain shares qualities with other standard computer vision datasets, serving
as a natural bridge between standard computer vision tasks and medical applications.
This workshop served as a venue to facilitate advancements and knowledge
dissemination in the field of skin image analysis, as well as to host a melanoma detection
challenge, raising awareness and interest in these socially valuable tasks. Invited speakers
included major influencers in computer vision and skin imaging, top-ranked participants
of the hosted challenge, and authors of accepted manuscripts on skin image analysis.
Authors were asked to submit full-length manuscripts for double-blind peer review.
A total of 28 submissions were received, and with a Program Committee composed of
31 experts in the field, reviewed by at least three reviewers. Based on the feedback and
critiques, ten of the best papers (36%) were selected for oral presentation at the
workshop, and included in the LNCS volume published by Springer.
For the associated challenge, participants were asked to perform three tasks on
dermoscopic images: lesion segmentation, attribute detection and localization, and
disease classification. Approximately 931 users registered for data download. In total,
115 submissions were made to the lesion segmentation task, 27 submissions to the
lesion attribute detection task, and 159 submissions to the disease classification task, all
with manuscripts supplied describing the approaches, hosted and made available on the
challenge website. Six participants were selected for presentation.
We thank the authors for submitting their excellent work, our reviewers for their
timely and detailed reviews, our invited speakers, challenge participants, and all our
attendees. We sincerely hope that the efforts coming together to make this workshop
possible will help advance the field and have a positive impact on health care around
the world.

September 2018 Noel C. F. Codella

M. Emre Celebi
Kristin Dana
Allan Halpern
 ISIC 2018 Organization

Steering Committee

Rogerio Feris IBM Research, USA

Anthony Hoogs Kitware, USA
John R. Smith IBM Research, USA

Workshop Chairs
Noel Codella IBM Research, USA
M. Emre Celebi University of Central Arkansas, USA
Kristin Dana Rutgers University, USA
Allan Halpern Memorial Sloan Kettering Cancer Center, USA

Challenge Organizers
Harald Kittler Medical University of Vienna, Austria
Philipp Tschandl Medical University of Vienna, Austria
Allan Halpern Memorial Sloan Kettering Cancer Center, USA
Brian Helba Kitware, USA
Noel Codella IBM Research, USA
David Gutman Emory University, USA

Challenge Team Members

Konstantinos Liopyris Memorial Sloan Kettering Cancer Center, USA
Michael Marchetti Memorial Sloan Kettering Cancer Center, USA
Stephen Dusza Memorial Sloan Kettering Cancer Center, USA
Aadi Kalloo Memorial Sloan Kettering Cancer Center, USA

Program Committee
Anne Gattiker IBM Research, USA
Begoña Acha University of Seville, Spain
Bishwaranja Bhattacharjee IBM Research, USA
Carmen Serrano University of Seville, Spain
Catarina Barata Instituto Superior Tecnico, Portugal
Cristina Vasconcelos UFF, Brazil
Dwarikanath Mahapatra IBM Research, Australia
Elena Bernardis University of Pennsylvania, USA
Euijoon Ahn University of Sydney, Australia
 ISIC 2018 Organization XVII

Haofu Liao University of Rochester, USA

Harald Kittler Medical University of Vienna, Austria
Ivan Diaz Charles III University of Madrid, Spain
Jinman Kim University of Sydney, Australia
Kivanc Kose Memorial Sloan Kettering Cancer Center, USA
Lequan Yu The Chinese University of Hong Kong,
SAR China
Linlin Shen Shenzhen University, China
Mario Guarracino National Research Council of Italy, Italy
Olivier Gevaert Stanford University, USA
Parneet Kaur Rutgers University, USA
Pegah Kharazmi University of British Columbia, Canada
Peter Soyer University of Queensland, Australia
Philipp Tschandl Medical University of Vienna, Austria
Reda Kasmi University of Bejaia, Algeria
Rob Novoa Stanford University, USA
Roberta Oliveira University of Porto, Portugal
Sandra Avila UNICAMP, Brazil
Suman Sedai IBM Research, Australia
Yanhui Guo University of Illinois at Springfield, USA
Yuexiang Li Shenzhen University, China
Yunzhu Li MIT, USA
Zongyuan Ge Monash University, Australia
 Contents

Proceedings of the First International Workshop on OR 2.0

Context-Aware Operating Theaters (OR 2.0 2018)

Perioperative Workflow Simulation and Optimization

in Orthopedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Juliane Neumann, Christine Angrick, Daniel Rollenhagen,
Andreas Roth, and Thomas Neumuth

A Method for the Context-Aware Assignment of Medical Device Functions

to Input Devices in Integrated Operating Rooms . . . . . . . . . . . . . . . . . . . . . 12
Stefan Franke, Max Rockstroh, Martin Kasparick, and Thomas Neumuth

Interactive Training and Operation Ecosystem for Surgical Tasks

in Mixed Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Ehsan Azimi, Camilo Molina, Alexander Chang, Judy Huang,
Chien-Ming Huang, and Peter Kazanzides

FaceOff: Anonymizing Videos in the Operating Rooms . . . . . . . . . . . . . . . . 30

Evangello Flouty, Odysseas Zisimopoulos, and Danail Stoyanov

A Novel Interoperable Safety System for Improved Coordination

and Communication in Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
David Arney, Geoffrey Rance, Srey Rithy, Julian M. Goldman,
and Marco A. Zenati

Generalized Trajectory Planning for Nonlinear Interventions. . . . . . . . . . . . . 46

Johannes Fauser, Igor Stenin, Julia Kristin, Thomas Klenzner,
Jörg Schipper, Dieter Fellner, and Anirban Mukhopadhyay

Automatic Cochlear Length and Volume Size Estimation . . . . . . . . . . . . . . . 54

Ibraheem Al-Dhamari, Sabine Bauer, Dietrich Paulus, Rania Helal,
Friedrich Lisseck, and Roland Jacob

Intelligent Interruption Management System to Enhance Safety

and Performance in Complex Surgical and Robotic Procedures . . . . . . . . . . . 62
Roger D. Dias, Heather M. Conboy, Jennifer M. Gabany,
Lori A. Clarke, Leon J. Osterweil, David Arney, Julian M. Goldman,
Giuseppe Riccardi, George S. Avrunin, Steven J. Yule,
and Marco A. Zenati
XX Contents

Performance Evaluation to Improve Training in Forceps-Assisted Delivery. . . 69

Mónica García-Sevilla, Juan De León-Luis, Rafael Moreta-Martínez,
David García-Mato, Rubén Pérez-Mañanes, José Calvo-Haro,
and Javier Pascau

Clinical Trial of Information Acquisition System for Surgical Instruments

in Digital Operation Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Kaori Kusuda, Kazuhiko Yamashita, Yoshitomo Ito, Kiyohito Tanaka,
Ken Masamune, and Yoshihiro Muragaki

Temporal Coherence-based Self-supervised Learning for Laparoscopic

Workflow Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Isabel Funke, Alexander Jenke, Sören Torge Mees, Jürgen Weitz,
Stefanie Speidel, and Sebastian Bodenstedt

Proceedings of the 5th International Workshop on Computer Assisted

Robotic Endoscopy (CARE 2018)

Endo3D: Online Workflow Analysis for Endoscopic Surgeries Based

on 3D CNN and LSTM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Weixiang Chen, Jianjiang Feng, Jiwen Lu, and Jie Zhou

Unsupervised Learning of Endoscopy Video Frames’ Correspondences

from Global and Local Transformation . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Mohammad Ali Armin, Nick Barnes, Salman Khan, Miaomiao Liu,
Florian Grimpen, and Olivier Salvado

Learning to See Forces: Surgical Force Prediction with RGB-Point Cloud

Temporal Convolutional Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Cong Gao, Xingtong Liu, Michael Peven, Mathias Unberath,
and Austin Reiter

Self-supervised Learning for Dense Depth Estimation

in Monocular Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Xingtong Liu, Ayushi Sinha, Mathias Unberath, Masaru Ishii,
Gregory D. Hager, Russell H. Taylor, and Austin Reiter

Wide-Area Shape Reconstruction by 3D Endoscopic System Based

on CNN Decoding, Shape Registration and Fusion . . . . . . . . . . . . . . . . . . . 139
Ryo Furukawa, Masaki Mizomori, Shinsaku Hiura, Shiro Oka,
Shinji Tanaka, and Hiroshi Kawasaki
 Contents XXI

Proceedings of the 7th International Workshop on Clinical

Image-Based Procedures: Translational Research in Medical
Imaging (CLIP 2018)

Patch-Based Image Similarity for Intraoperative 2D/3D Pelvis Registration

During Periacetabular Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Robert B. Grupp, Mehran Armand, and Russell H. Taylor

A Mixed Reality Guidance System for Robot Assisted Laparoscopic

Radical Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Abhishek Kolagunda, Scott Sorensen, Sherif Mehralivand,
Philip Saponaro, Wayne Treible, Baris Turkbey, Peter Pinto,
Peter Choyke, and Chandra Kambhamettu

Fusion of Microelectrode Neuronal Recordings and MRI Landmarks

for Automatic Atlas Fitting in Deep Brain Stimulation Surgery . . . . . . . . . . . 175
Eduard Bakštein, Tomáš Sieger, Filip Růžička, Daniel Novák,
and Robert Jech

Preoperative Planning and Simulation Framework for Twin-to-Twin

Transfusion Syndrome Fetal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Jordina Torrents-Barrena, Rocío López-Velazco, Narcís Masoller,
Brenda Valenzuela-Alcaraz, Eduard Gratacós, Elisenda Eixarch,
Mario Ceresa, and Miguel Ángel González Ballester

Automatic Teeth Segmentation in Cephalometric X-Ray Images

Using a Coupled Shape Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Andreas Wirtz, Johannes Wambach, and Stefan Wesarg

Fully-Automated Analysis of Body Composition from CT in Cancer

Patients Using Convolutional Neural Networks . . . . . . . . . . . . . . . . . . . . . . 204
Christopher P. Bridge, Michael Rosenthal, Bradley Wright,
Gopal Kotecha, Florian Fintelmann, Fabian Troschel,
Nityanand Miskin, Khanant Desai, William Wrobel, Ana Babic,
Natalia Khalaf, Lauren Brais, Marisa Welch, Caitlin Zellers,
Neil Tenenholtz, Mark Michalski, Brian Wolpin, and Katherine Andriole

Image-Based Bronchial Anatomy Codification for Biopsy Guiding

in Video Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Esmitt Ramírez, Carles Sánchez, Agnés Borràs, Marta Diez-Ferrer,
Antoni Rosell, and Debora Gil

Clinical Implementation of DeepVoxNet for Auto-Delineation of Organs

at Risk in Head and Neck Cancer Patients in Radiotherapy . . . . . . . . . . . . . 223
Siri Willems, Wouter Crijns, Agustina La Greca Saint-Esteven,
Julie Van Der Veen, David Robben, Tom Depuydt, Sandra Nuyts,
Karin Haustermans, and Frederik Maes
XXII Contents

Proceedings of the Third International Skin Imaging Collaboration

Workshop (ISIC 2018)

Deeply Supervised Rotation Equivariant Network for Lesion

Segmentation in Dermoscopy Images. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Xiaomeng Li, Lequan Yu, Chi-Wing Fu, and Pheng-Ann Heng

Skin Image Analysis for Erythema Migrans Detection and Automated

Lyme Disease Referral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
P. Burlina, N. Joshi, E. Ng, S. Billings, A. Rebman, and J. Aucott

Severity Assessment of Psoriatic Plaques Using Deep CNN Based

Ordinal Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Anabik Pal, Akshay Chaturvedi, Utpal Garain, Aditi Chandra,
Raghunath Chatterjee, and Swapan Senapati

Generating Highly Realistic Images of Skin Lesions with GANs. . . . . . . . . . 260

Christoph Baur, Shadi Albarqouni, and Nassir Navab

A Hyperspectral Dermoscopy Dataset for Melanoma Detection . . . . . . . . . . . 268

Yanyang Gu, Yi-Ping Partridge, and Jun Zhou

A Deep Residual Architecture for Skin Lesion Segmentation . . . . . . . . . . . . 277

G. M. Venkatesh, Y. G. Naresh, Suzanne Little, and Noel E. O’Connor

A Multi-task Framework for Skin Lesion Detection and Segmentation. . . . . . 285

Sulaiman Vesal, Shreyas Malakarjun Patil, Nishant Ravikumar,
and Andreas K. Maier

Skin Lesion Synthesis with Generative Adversarial Networks . . . . . . . . . . . . 294

Alceu Bissoto, Fábio Perez, Eduardo Valle, and Sandra Avila

Data Augmentation for Skin Lesion Analysis . . . . . . . . . . . . . . . . . . . . . . . 303

Fábio Perez, Cristina Vasconcelos, Sandra Avila, and Eduardo Valle

A Structure-Aware Convolutional Neural Network for Skin

Lesion Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Kevin Thandiackal and Orcun Goksel

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Proceedings of the First International
Workshop on OR 2.0 Context-Aware
Operating Theaters (OR 2.0 2018)
 Perioperative Workflow Simulation
and Optimization in Orthopedic Surgery

Juliane Neumann1(B) , Christine Angrick1 , Daniel Rollenhagen1 ,

Andreas Roth2 , and Thomas Neumuth1
1
Innovation Center Computer Assisted Surgery,
Leipzig University, Leipzig, Germany
Juliane.Neumann@iccas.de
2
Department of Orthopaedics, Traumatology and Reconstructive Surgery,
Division of Joint Replacement and Orthopaedics,
University Hospital Leipzig, Leipzig, Germany

Abstract. Operating room management aims at the efficient coordi-

nation of surgical procedures by maximizing the number of surgical
cases while minimizing the required surgery time, with the main goal
of improving the patient outcome. Discrete Event Simulation can be uti-
lized to describe, analyze and predict the impact of procedural changes in
perioperative processes. The aim of this work is to provide a simulation
approach for a holistic perioperative optimization. Therefore, two differ-
ent process simulation techniques, namely Business Process Simulation
and 3D Process Flow Simulation, were utilized. It could be shown that
perioperative simulation could lead to the improvement of OR utiliza-
tion, reduction of process duration and a decrease in personnel workload.

Keywords: Surgical process simulation · Discrete event simulation

Perioperative process opitimization · Operating room management

1 Motivation
The goal of the operating room (OR) management is the effective coordination
and execution of surgical procedures in order to create a safe, efficient, and struc-
tured environment with the ultimate goal of optimizing the patient outcome. Due
to the fact that the surgical department is the most cost-intensive department
of the hospital, the OR management aims at maximizing the number of sur-
gical cases while minimizing the required time, resources and related costs. In
the last decades, numerous methods and technical approaches have been devel-
oped to improve OR scheduling and OR efficiency in order to increase capacity
utilization and patient throughput, e.g. formula-based equations [1], statistical
methods [2] and process- or discrete-event-simulation (DES) models. DES mod-
els aim at describing, analyzing and predicting procedural changes of dynamic
systems over the time. Simulation is an essential methodology to (re-)design,

c Springer Nature Switzerland AG 2018

D. Stoyanov et al. (Eds.): OR 2.0/CARE/CLIP/ISIC 2018, LNCS 11041, pp. 3–11, 2018.
https://doi.org/10.1007/978-3-030-01201-4_1
4 J. Neumann et al.

analyze, execute and evaluate processes in respect of different perspectives,

objectives, and stakeholders. DES is in the focus of widespread developments
for the improvement of pre- and postoperative processes (e.g. [3,4]). However,
only a few efforts have been given to the process optimization of intraopera-
tive processes. Fernández-Gutiérrez et al. analyzed and simulated perioperative
(pre-, intra- and postoperative) workflows in order to find the optimal develop-
ment of new complex procedures in multimodal imaging environments [5] and
for the efficient utilization of scarce medical equipment [6]. Currently, there are
no simulation studies available, which focus on the streamlining of intraoperative
processes and their impact on OR capacity utilization and on the execution of
pre- and postoperative processes. The OR is a highly complex environment, all
processes are intertwined and have a significant impact on each other. Even small
delays can lead to timing problems that affect the entire surgical team and the
overall OR performance. This complexity requires the analysis of processes from
different perspectives. Most simulation approaches focus on temporal (process
duration), behavioral (activities and interactions of personnel) and operational
aspects (availability of resources, capacity of facilities) of the pre- and postoper-
ative processes. There is no research available on how the structural perspective
(environmental aspects, e.g. layout of the OR and surgical department) is influ-
encing the perioperative processes.
The aim of this work is to provide a DES approach for a holistic perioper-
ative process optimization with a focus on the combination of behavioral, tem-
poral, operational and structural perspective. Two different process simulation
techniques, namely Business Process Simulation (BPS) and 3D Process Flow
Simulation were utilized. Process re-engineering methods based on the com-
puter simulation are used to improve OR capacity utilization and perioperative
process efficiency as well as simultaneously reduce the workload of the OR per-
sonnel by minimizing waiting times and overwork time. For this purpose, the
DES models were implemented with perioperative data from Total Hip Replace-
ment (THR) and Total Knee Replacement (TKR) surgeries. The optimization
objective is to increase the number of surgeries to three cases per day by reduc-
ing the intraoperative incision-to-closure-time (ICT) through the optimization of
the OR layout. Furthermore, the processes for surgery follow-up and OR prepa-
ration (closure-to-incision time (CIT)) should be streamlined in order to reduce
vacancies and utilizing the available resources to capacity without overburden.
To ensure a persistent high-quality patient treatment, the performance duration
of perioperative activities should not be reduced.

2 Materials and Methods

2.1 Data Acquisition
THR is a orthopedic procedure in which the hip joint is replaced by a prosthetic
implant to treat arthritis pain or hip fractures. During TKR the knee joint is
replaced to relieve debilitating pain or osteoarthritis. For the intraoperative sim-
ulation 15 THR and 7 TKR surgeries and for pre- and postoperative simulation
 Perioperative Workflow Simulation and Optimization in Orthopedic Surgery 5

30 (total or partial) knee- and hip replacement surgeries were recorded at the
University Hospital Leipzig in 2016. In the pre- and postoperative environment,
temporal and procedural process information for every OR staff member as well
as CIT (OR turnover times) were acquired. In the intraoperative setting struc-
tural data (on-site measurement), surgical process data (surgical activities for
THR and TKR), OR layout (number and the arrangement of instrument tables
for left- and right side THR and TKR), instrument handover (number, duration
and path of handovers between surgeon and scrub nurse), travel paths (number,
duration and travel path of the circulator) as well as ICT was recorded. In addi-
tion, an ergonomic assessment was performed for every OR team member with
the OWAS method (Ovako Working Posture Assessment System), which is used
to evaluate the most common work postures for the back, arms, and legs.

2.2 Discrete Event Simulation

DES provides an environment for process design, analysis, re-engineering, and

evaluation. It is also used to predict the impact of procedural changes over
the time and to quantitatively evaluate different alternative process configu-
rations [3]. Thereby, DES relies on the modeling of activities, which are exe-
cuted by processing the transitions between a list of events. The events are usu-
ally described with instructions and a logic for executing the simulation, which
enables the imitation of complex behavior. There are various DES methods and
tools for different applications and objectives available. In this paper, BPS has
been used for the simulation of the behavioral, temporal and operational per-
spective. For the assessment of structural dynamic changes and their impact on
the underlying processes, 3D Process Flow Simulation has been utilized.
Business Process Simulation
For the modeling, analysis, and evaluation of complex, flexible processes, business
process modeling is widely used in academic and industry. Especially, BPMN 2.0
has been proven successful in the modeling of the perioperative process environ-
ment [7]. In addition, BPMN is regarded as the most appropriate standard avail-
able for BPS. The pre- and postoperative processes in the orthopedic department
were modeled with the Signavio Editor [8] in the BPMN 2.0 format. For BPS
the free business process simulator BIMP [9] was used.
3D Process Flow Simulation
Following the argumentation and assessment in [5], 3D Process Flow Simulation
was utilized for the intraoperative process optimization. Therefore, Delmia by
Dassault Systems [10] was used, which provides a 3D Modeling environment
and logical process simulation. Delmia was initially designed for manufacturing
industry but has also a widespread distribution in healthcare (e.g. [4,5]).
6 J. Neumann et al.

3 Simulation Experiments
3.1 Pre- and Postoperative Simulation

Initially, the pre- and postoperative activities of all OR team members (surgeon,
assistant, scrub nurse, circulator, anesthesiologist and nurse anesthetist) were
modeled in BPMN format and supplemented with the recorded activity dura-
tion (mean duration and standard deviation under normal distribution). The
BPMN models were simulated with BIMP in different scenarios for the whole
workday with 2 or 3 surgeries. In order to analyze which and how many surgeries
are feasible with the currently available OR- and personnel-capacities, different
combinations of THR and TKR were simulated. According to the intraoperative
data acquisition, the initial mean ICT was set to 64,24 min (std 19,74) for THR
and 90,0 min (std 22,67) for TKR. The simulation scenarios were then instan-
tiated 250 times (mean working days per year) and the minimum, average and
maximum process duration (Cycle Time (CT)) for one workday were calculated
via simulation. The normal working period of the OR staff is scheduled to 8 h,
which has been defined as an upper boundary for the CT. In addition, waiting
times in the process flow resulting from process bottlenecks or scarce resources
were simulated. In order to determine the current personnel utilization, the work-
load of the staff was also simulated. Thereby, only the pre- and postoperative
main tasks were analyzed.
In the first optimization step, the pre- and postoperative processes were
streamlined with methods of Business Process Re-engineering by parallelization
and summarization of activities, redistribution of responsibilities and temporal
alignment of the process. After this optimization step, the BPMN models were
adapted to the optimized processes and the simulation scenarios were repeated.
In the second step, the intraoperative process optimization was performed. After-
wards, the simulation was repeated with improved ICTs.

3.2 Intraoperative Process Simulation

The aim of the intraoperative process optimization was to shorten the ICT by
improving the OR layout, instrument table positions and setups for THR and
TKR. For this purpose, the existing table setups were analyzed and simulated
considering the duration, number, and paths of instrument handovers. Based on
the simulation scenario, new setup suggestions are designed and compared to the
initial setups. When creating the new setups, both the ergonomic aspects of the
OWAS evaluation method and the average rotational movements necessary for
the handovers were included. Further, a possible optimization of the circulators’
travel paths was simulated together with the initial and optimized setups.
A 3D simulation environment was created with Delmia and the existing lay-
outs and table positions were modeled and simulated based on the intraopera-
tive recorded data (see Fig. 1). The number and the duration of handovers were
included in the simulation in order to obtain the total handover time for THR
and TKR. The alternative setups for the left and right side of the operated hip
 Perioperative Workflow Simulation and Optimization in Orthopedic Surgery 7

Fig. 1. 3D simluation scenario of the orthopedic OR modeled in Delmia (left TKR).

respectively the left and right side of the knee were designed, simulated, analyzed
and compared with regard to the handover times and travel paths.

4 Results
4.1 Initial Situation
Conventional OR Capacity Planning
OR capacities are optimally utilized if a maximum of surgeries can be performed
in the work time. Formula-based equations are the state-of-the-art (e.g. [1]) for
capacity calculation and planning. These methods are used to define a baseline
for the verification of the perioperative simulation:

Cases per year 581

Current Surgeries per day = = = 2, 3 (1)
W orking days per year 250
Possible THR and TKR surgeries per working day (8 h-1 h for supportive tasks):
W ork time − 1 h 420
P ossibleT HR = = = 3, 4
meanICT (T HR) + meanCIT (T HR) (64 + 60)
(2)
W ork time − 1 h 420
P ossibleT KR = = = 2, 8
meanICT (T KR) + meanCIT (T KR) (90 + 60)
(3)
Possible surgeries per day for a combination of THR and TKR:
420
P ossibleT HR/T KR = = 3, 2 (4)
(72 + 60)
According to conventional planning, 3 surgeries per day should be feasible with
3THR and a combination of THR and TKR without overwork time (>8 h).
8 J. Neumann et al.

Analysis of the Initial Situation with Business Process Simulation

Firstly, the CTs of the existing situation for different THR and TKR combi-
nations were simulated (Fig. 2 (light gray)). Two surgeries can be performed
without any further process optimization with the disadvantage of an insuffi-
cient OR utilization, which results in unused resource capacities. The target
of three surgeries per day could be only achieved with 3THR (avg. CT 8,2 h).
All combination with one to three TKRs widely exceed the maximum CT of
8 (avg. CT: 3TKR = 9,7 h, 2TKR + 1THR = 9,2 h, 1TKR + 2THR = 8,7 h). The
simulation results correspond with the calculation based on the conventional
capacity planning method with minor differences for 2THR + 1TKR. In addi-
tion, the workload of the OR personnel was simulated and is presented in Fig. 3
(light gray). The upper boundary of 8 h work time per day should not be fully
exploited in order to have free capacities for supportive and non-value-added
tasks (e.g. supply refill, travel paths etc.). According to the recommendation
of [1], the optimal workload is set to 7 h. The maximum workload is set to 4 h
per day for the nurse anesthetist, who is responsible for more than one OR and
acts as an anesthetist circulator. The simulation results indicate that only 3THR
and the combination of 2THR + 1TKR could be performed within one work day.
The optimal boundary of 7 h could not be achieved by any surgery combination
without further process optimization.

Fig. 2. CT simulation results of THR and TKR combinations: 2 surgeries (left side) and
of 3 surgeries (right side). The red line marks the 8 h work time/day boundary. The
results after pre-, intra- and postoperative optimization (Target CT) are numbered.
(Color figure online)

4.2 Pre- and Postoperative Process Optizimation

For perioperative process optimization several process alignments, such as paral-
lelization and summarization of activities, redistribution of responsibilities and
 Perioperative Workflow Simulation and Optimization in Orthopedic Surgery 9

temporal optimization of the process were proposed. Based on these optimiza-

tions a decrease of the CTs could be achieved (Fig. 2, dark gray). Still, it is not
possible to perform three surgeries with at least one TKR in the time period of
8 h. In Fig. 3 (dark gray) the optimized workload is represented. Through the
process optimization, a reduction and a better balancing of workload between
the OR team members have been achieved. Especially, the workload of the anes-
thesiologist has been reduced to less than 8 h while the workload of the nurse
anesthetists was slightly increased by 1 h (Fig. 3, dark blue).

Fig. 3. Personnel workload of THR/TKR with numbered results after perioperative

optimization (Target workload). Red line is the 8 h work time/day boundary and the
green line is the optimal boundary. Gray: decrease and dark blue: increase of workload.
(Color figure online)

4.3 Intraoperative Setup Optimization

Based on 3D Flow Simulation, optimal setups for THR and TKR were defined
and evaluated in the real intraoperative OR environment. ICTs were recorded
for 8 THR and TKR surgeries, which results in a decrease of 9,45 min for
THR (54,75 min (std 15,04)) and 3,25 min for TKR (86,75 min (std 21,91)). The
improved ICT were included in the perioperative optimization and the BPS sim-
ulation study was repeated (Fig. 2 (blue)). The results of the perioperative opti-
mization indicate that it would be possible to perform 3THR or 2THR + 1TKR
in the work time of one day (avg. CT 8,2 h). This result also corresponds with
the current case mix of THR and TKR at the University Hospital, which is
about 2,3:1 (409 THR, 172 TKR in 2016). Also, the workload of the OR mem-
bers (Fig. 3 blue) could be decreased to the intended 7 h boundary for 3THR
and 2THR + 1TKR.
Another random document with
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