Parameter evaluation for Virtual Laparoscopic Simulation

Shamyl Bin Mansoor, Zaheer Mukhtar, Muddassir Malik, Zohaib Amjad, Hammad Qureshi
School of EECS, National university of Sciences & Technology, Islamabad, Pakistan {shamyl.mansoor,zaheer.mukhtar,zohaib.amjad,muddassir.malik,hammad.qureshi}@seecs.edu.pk
Abstract Virtual Reality based surgical simulators have become quite common for training of surgeons for different surgical skills. Simulators have been widely used particularly in minimal invasive surgery. In this paper we find parameters that would be required to create a real time working simulation for exercises given in the Fundamentals of Laparoscopic Surgery curriculum. We use peg transfer exercise as our example in this work and create simulations for parameter analysis using SOFA, an open source surgical framework [1]. The parameters we choose are generic and can be used to create other more complex simulations like cholecystectomy [2] (gall bladder removal) and appendectomy (appendix removal). We show the implementation of these parameters and their behavior in a virtual reality surgical simulation. This work can be used by researchers and developers to choose the right parameters in the context of the simulation they are developing. It also shows the cost and behavior of achieving good visualization (frames per second), physical characteristics and a realistic behavioral model to be used in simulations for training purposes. Keywords: Surgical Simulations, Virtual Biomechanical Modeling, Laparoscopic Surgery Reality,

Open or traditional surgery requires a number of challenging skills that are typically attained over a long period of time with lots of hands on experience. However, in recent years laparoscopic or minimal invasive surgery has become quite popular as it allows for quick patient recovery, less chance of post operative infections and allows a surgeon to perform many such operations in a single day, which is due to the small incisions that are made in the body as shown in figure 1. These advantages have resulted in laparoscopic surgery becoming more common than traditional invasive surgery, while making the task of surgeons more challenging and difficult. Performing minimal invasive surgery requires special skills like expert hand eye coordination, precise movement of laparoscopic instruments within a confined space and the ability to successfully perform surgery without damaging any of the organs. These special psychomotor skills cannot be acquired without hands on practice.

I.

INTRODUCTION

Simulators have played an important role in the training of personnel for skills that would be difficult to acquire otherwise. Pilots are trained using sophisticated flight simulators which allow training under scenarios that would either not be possible in real life or would be too expensive and dangerous to be replicated for training purposes. For example pilots are trained for dangerous scenarios such as recovering from a stall, landing in bad weather conditions and crash landing scenarios. Other areas in which simulators are used include marine simulators, military command and control simulators and surgical simulators etc. Surgery is generally a critical procedure in which a slight mistake can be fatal. Therefore, it requires acquisition of skills that are difficult to learn for a new practitioner and require a lot of time and practice. Surgical simulators provide a mechanism and platform where good surgery skills may be acquired and developed in a cost effective manner. Moreover, the error margin in a surgery is very limited therefore the training system should ideally allow surgeons to learn from their mistakes, contain mechanisms for training surgeons and also evaluate the skill of the surgeon as he/she performs the simulated surgery.

Figure 1: Open (left) and laparoscopic (right) incisions. Laparoscopic surgery requires limited incisions compared to open surgery

The paper is formatted as follows. Firstly in section II we discuss recent work in the surgical simulations area, then in section III we discuss the importance of modeling the peg transfer exercise for our experimentation. In section IV we discuss the methods that we have used in order to model this exercise using the open source framework SOFA, in section V we present the selection of parameters to evaluate and describe our results and finally conclude in section VI, analyzing our results and discuss the future improvements.

This research has been funded by National ICT R&D Fund, Ministry of IT&T, Government of Pakistan

II.

RECENT WORK

Recently a lot of research has been conducted to create realistic real time surgical simulators that allow surgeons to train in performing complex tasks and procedures. The need for such simulators is critical since training on human beings is unethical and dangerous. Therefore simulators are required that are realistic in behavior allowing surgeons to learn in an environment that simulates the real world effectively. Although this is a difficult task, but with the computation power that is available these days it has become feasible to develop these complex surgical simulations that exhibit realistic behavior in real time. It is also required that behavior of surgery simulation environment is interactive therefore efficient algorithms for deformable modeling and collision detection is required [3]. There are several techniques available that allow the modeling of physical characteristics of objects in a virtual reality environment [4]. For example in order to mathematically model the behavior of a rigid object, Newtonian mechanics proves useful as it can be used to model the behavior of the object in response to forces in the environment, such as friction, gravity etc. Hence it is important that the Newtonian mechanics behind these models is accurately simulated. Similarly for a non-rigid or a deformable object, deformation should occur when a force is applied. For instance when a pen is poked in ones hand, the skin along with the flesh deforms in the direction of the force applied. Moreover the deformation is not at a single point but on a surface and can be non-linear in nature. We must cater for such behavior while modeling a procedure that involves deformable and non-deformable objects. There are several methods in literature that make it possible to realistically model the behavior of an object [4]. One of these methods [5] uses hierarchical multi-resolution finite element modeling to improve the real time behavior of deformable objects. Another method [6] has been proposed that improves the real time performance of deformable body simulation using non-linear finite elements whereas [7] utilize GPU (Graphical Processing Unit) processing to improve the real time performance for soft tissue modeling using non-linear FEM. In this paper, we experiment with different techniques to model an exercise that is used to train surgeons for laparoscopic instrument handling, depth perception and hand eye coordination. We experiment with different parameters and find the best ones that are suitable in modeling the exercise. The results can be used in modeling and simulating of other laparoscopic surgery simulation exercises as well. III. THE PEG TRANSFER EXERCISE

that a surgical resident, fellow or practicing surgeon must perform and acquire expertise in. Competence level of a surgeon is evaluated on the basis of his performance on the different exercises that form the part of the fundamentals of laparoscopic surgery. These exercises include peg transfer, pattern cutting, ligating loop, suturing with an intracorporeal knot and suturing with an extracorporeal knot. In laparoscopic surgery a surgeon must use a monocular optical system to develop new cues to enable depth perception, be able to manipulate objects within a confined space and use both hands in a complimentary manner to cut, dissect, and suture. In this paper we concentrate on the peg transfer exercise which is used for developing hand eye coordination skills. It is one of the basic exercises of the FLS curriculum which requires the user to lift pegs from one side of the board, transfer them in mid air to the other hand and replace them on the other side of the board. Figure 2 shows a snapshot of the peg transfer exercise that we have developed using SOFA. This exercise is important as it trains surgeons to attain a higher level of hand eye coordination which is required in

Figure 2 Peg Transfer Exercise. Torus is moved from one peg to another peg using both hands.

In this paper we analyze parameters that are best suited to create simulations which are part of the basic exercises in the Fundamentals of Laparoscopic Surgery curriculum [8]. We show our results by simulating the peg transfer exercise using different parameters. These parameters define the behavior of the model with respect to application of different forces. The fundamentals of Laparoscopic Surgery curriculum (FLS) has been developed as a standard learning curriculum for surgeons to attain the basic psychomotor skill set that is required for performing laparoscopic surgery. There are five basic exercises

performing laparoscopic surgery. Peg transfer exercise is available in the commercial simulators including LapSim[9] and LapMentor [10]. Using the LapSim system available at the Holy Family Hospital [11] (our project collaborators) we performed the peg transfer exercise and noted that there are several problems with the LapSims peg transfer simulation. The pegs when pulled hard actually pass through the cylinders and the virtual laparoscopic instrument collides with the box surface incorrectly. It was noted that the instrument actually sinks into the box, which in reality should act like two rigid objects colliding with each other. Their collision models are not accurate and perhaps one of the reasons for that is their model focuses more on visualization than on actual modeling of the behavior. In our experiments we carefully model the exercise with proper application of collision models so that the behavior is as realistic as possible. Applying multiple collision models results in decreased frame rate as more calculations are required. The method for developing the exercise is detailed in the next section. IV. MODELING THE EXERCISE

In this section, we elaborate different methods that we have used to model the peg transfer exercise. We use an open source framework SOFA to develop our exercises. SOFA is a modular

framework that includes a number of different algorithms that can be applied to test the behavior of the simulation. In order to model and simulate the peg transfer exercise we find the best combination of techniques based on the criteria defined by [12]. Although the criterion has been defined for soft-tissue modeling, it is quite similar to what we require for performing our peg transfer exercise. The factors required for modeling soft tissue consist of identification of the relevant biomechanical properties and efficient computation and validation of the response behavior. We model our objects in this exercise by simulating the behavior of rigid plastic objects by adopting youngs modulus and Poisson distribution values that correspond to plastic materials. We also determine the efficiency of our system by computing the time required for effective visualization and good frame rates. In order to effectively model an object the first requirement is a good physical model of the object which can be a surface or a volumetric model. In our exercise we have used tetrahedrons to model objects. The second requirement is to model the behavior of the object. We need to model three objects in our peg transfer exercise; pegs, floor and torus. The floor is considered as a rigid object with no elastic properties. Similarly we consider the cylinders as rigid objects with no elastic properties. The torus which is the shape of a donut has been modeled as a deformable object. These characteristics are similar to the real life peg transfer model that contains rigid cylinders, rigid floor, however the torus may be made up of plastic, rubber or metal. In this exercise along with accuracy of the peg model, we are also concerned about accuracy of modeling the collisions between the pegs and their surroundings that consists of the cylinders and the floor. These collisions should be realistic and perform in real time as the users should be able to visualize a realistic behavior. If the frame rate goes below 20 Hz then the simulation will show jitter and will respond slowly to the user interaction. This will affect the trainees learning process and it will also make it hard to evaluate trainees skills. Therefore it is important that whenever a simulation is modeled, it should be real-time in behavior and support interactivity. The volumetric mesh models that we have used in our simulations have been modeled in 3D studio max and converted to meshes readable by SOFA using the method developed by [13]. This method uses the surface model to generate the tetrahedrons based mesh that is readable by SOFA and used in our simulations.

The physical model of the peg can be modeled in two ways; using Finite Element Modeling [14] or using Mass Spring models. In finite element modeling an object is divided into smaller finite elements and forces and displacements on each element are calculated and then as a final step integrated to calculate the overall deformation effect of forces acting on the object. In mass springs models, all the connections in a mesh are modeled using springs. The elasticity of the spring models the deformable behavior of the object. We have modeled the peg using both methods but FEM is better in terms of modeling realistic behavior than mass spring models [14] which are not as accurate. Figure 3 shows the model of the peg that we have created using tetrahedron FEM and Mass Spring method to simulate its deformable behavior. The FEM based model treats the tetrahedron as the base element and finds the deformation on every element and its effect on neighboring tetrahedrons. In mass spring model every point is connected with springs, therefore every edge of each tetrahedron is considered a spring. In both methods the elasticity is defined by the young modulus value which models the stress strain relationship for each element. SOFA only needs this value to be given as a parameter and generates the stiffness matrix. Stiffness matrix can however be defined separately and passed as a parameter to both FEM and Mass Spring methods if the stiffness of each element is non-uniform. We have conducted experiments with dense and coarse meshes of the volumetric models. The denser an object is the more realistic it becomes but requires more computation times as can be seen from the decrease in the frame rate of the simulation in our results. On the other hand a coarse object would require fewer computations but would behave in a less realistic manner.

Figure 4 Point collision model with visual model

Figure 3 FEM on the left and Mass Spring on the right

The other important factor in this simulation is the collision models. Collision detection is a very important component of any virtual reality system. Collision detection pipeline first performs coarse collision that is fast and then performs accurate collision that is slow to compute. There are three kinds of collision algorithms in general use [15]. In the first algorithm all the objects are enclosed in spheres or bounding boxes and collision is performed between them. The issue in this algorithm is that objects that have a large variation in width, depth and height result in visibly wrong collisions. In the second method axis aligned bounding boxes are used. These boxes are variable in one of the principle directions and are therefore suitable for enclosing a wide variety of objects. This algorithm is however slower than the first one. In the third algorithm bounding boxes are aligned with respect to the Eigen vector of the object. This results in fine collision detection. We have applied and experimented with four types of collision models, namely point, line, triangle and spherical

models. In SOFA all these collision models can be applied independently as well as grouped together for a single object. We have tested our frame rate and behavior by combining different collision models. A point model simply considers the vertex as a collision point and if there is a collision detected there is a collision response that should be generated. Figure 4 shows some points in 3- dimensional space which model the floor in our peg transfer exercise with point collision model applied. We can see the point model maps to every vertex of the floor, whereas there is no collision on the edges. In order to have collision on the edges we apply the line collision model which maps to the edges of the shape. There is a response if a collision is detected only at these edges. In our simulation independent collision models are not of much use but are useful only if grouped. The triangle model when applied to a surface breaks it into triangles or can be applied to a mesh model that is made of triangles. In order for our model to work as a floor, we need to apply the triangle model, as our mesh is triangular; therefore the collision model maps all the triangles of the mesh, filling the hollow space left due to the line model. So now if a peg falls on the floor, it collides and bounces based on the collision response of the floor as well as the pegs elastic properties. Figure 5 shows the line and triangle models applied to the floor mesh.

Figure 6 Sphere collision model with different values for radii

The sphere collision model is more useful for irregular shapes as can be seen in figure 6. V. EXPERIMENTAL RESULTS AND DISCUSSION

We have modeled our simulations using the open source framework SOFA on an Intel Core i3 processor 3.06 GHz with 2GB of RAM and built in graphics memory of 64 MB. Our simulation has a rigid floor, 6 rigid cylinders and a deformable peg, the shape of a donut. The experiments have been carried out with two kinds of physical modeling, FEM and Mass Springs. We vary the density of our peg model and combine it with different collision models to note down the frames per second which determines the visualization performance. Since we have used physical modeling, that means that our simulations are modeled based on the physical characteristics rather than being just ordinary graphical models. In order to evaluate the different parameters we have conducted experiments on our simulation by varying the parameter N which is the number of tetrahedrons that model the density of peg in our simulations. N is varied in our experiments and simulation is run to note the visualization performance. Table 1 show the results based on the Finite Element model of the peg. On the x-axis are the different collision models which include the line, triangle, spherical, line and triangle combined, line and sphere combined, sphere and triangle combined and finally sphere, triangle and line combined. The colors denote the density of the mesh. Red denotes the coarsest model while Orange denotes the densest model. On the y axis are the frames per second.

Figure 5 Line collision model on the left and triangle model on the right

Directly testing the geometry of two volumetric objects for collision when they contain hundreds of polygons is very expensive. Bounding volumes are used which cover the whole volume of the object for overlap before the geometry intersection test can be performed [15]. One such model is the spherical model which when applied to a mesh creates spheres of a defined radius that cover the volume of the mesh. The important parameter here is the radius of the sphere which can be increased to cover the overall volume of the model. Here we notice that for our regular shaped floor mesh, the triangle model suffices and we do not need the sphere collision model. Figure 6 shows the spherical model applied to our floor mesh with radius values as 1 and 10 respectively. On the left the sphere model does not cover the volume of the object whereas increasing the radius of the sphere covers the volume of the floor mesh but using the sphere model for our floor mesh is not suitable as it covers extra volume due to the volume of the spheres. If we decrease the radius then we dont cover the entire volume of the floor.

Table 1 Frames per second for FEM based Model

We can see a general trend in the results that in every collision model the more dense the object mesh is, the lower the frame rate is, which is understandable since a more dense mesh requires more calculations for the behavior model as well

as the collision models applied on this mesh. For example the line model with the densest model has 1621 tetrahedrons and a frame rate of about 50 frames per second whereas the coarsest mesh has a frame rate of 150 fps. In the case of sphere, triangle and line collision models combined, we can see in Table 1 and Table 2 that the frames per second are the lowest. This is valid behavior since every collision model is being evaluated moreover in FEMs case it is even slower than Mass Spring method. Therefore the denser the mesh the less the frame rate is. It should be noted that only a line model may not suffice while modeling realistic behavior of a non-linear volumetric model. We must combine these collision models to find the most realistic behavior. Table 2 shows our results with the peg modeled using the mass springs method.

cylinders, but since they are rigid objects we have modeled them as rigid objects with collision models only rather than deformable objects. We can have as complex simulation as possible to have the most realistic physical model behavior, but our results show that the complex model is more expenisve requiring morealculations affecting visualization performance and user interactivity. Therefore it is necessary to find a tradeoff between complexity and visualization. It is also important that while modeling an exercise we model the objects that have interaction with more accurate physics and use simple modeling for the objects that would only be visualized. For example in our peg transfer simulation the floor is modeled in a simple rigid way with collision modeling. We do not need a sophisticated model for the floor. VI. CONCLUSION AND FUTURE WORK

From our experiments we can conclude that the most realistic behavior is by using FEM combined with three collision models. We also conclude that this increases the complexity which drops the visualization frame rate. Therefore in order to model a realistic simulation a trade off is required between complexity and visualization. When modeling a simulation we need to see which objects would be manipulated by the user and which would not, based on which we can give more realistic and complex behavior to one object and simpler and less realistic behavior to the other one.
Table 2 Frames per Second for Mass Springs Model

In this case we can see that frame rates are generally higher than the FEM model. This is because mass springs methods is simpler than FEM and requires less computations. The only problem as mentioned earlier is that modeling using mass springs does not give realistic behavior as compared to Finite Element modeling. Therefore the most ideal parameters for modeling a simulation are to have a dense mesh with a combination of collision models and finite element model to model the physical behavior of the object. An example using these parameters is shown in figure 7. Deformable behavior can be seen of the peg as it deforms due to being pulled from one side.

This is an ongoing project and we intend to apply our results to more sophisticated simulation scenes being developed by our team. In the future work we would also like to add an input device other than a mouse to improve on the usability of our simulations. ACKNOWLEDGMENT We would like to acknowledge Dr Arshad Ali, Principal SEECS, NUST, Dr Qasim Sheikh, Director Innovation, NUST and Dr Asif Zafar, Head Surgical Unit II, Holy Family Hospital for their support in this project.

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[3] [4] Figure 7 Deformable behavior of the torus using FEM with a dense mesh [5]

We have used FEM and Mass Springs mehtods to model the deformable behavior of the peg. It is possible that we use these methods to simualte the rigid behavior of the floor or the

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