A Survey of auditory display in image-guided interventions <s> Alerts <s> OBJECTIVES ::: Direct haptic (force or tactile) feedback is not yet available in commercial robotic surgical systems. Previous work by our group and others suggests that haptic feedback might significantly enhance the execution of surgical tasks requiring fine suture manipulation, specifically those encountered in cardiothoracic surgery. We studied the effects of substituting direct haptic feedback with visual and auditory cues to provide the operating surgeon with a representation of the forces he or she is applying with robotic telemanipulators. ::: ::: ::: METHODS ::: Using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Sunnyvale, Calif), we compared applied forces during a standardized surgical knot-tying task under 4 different sensory-substitution scenarios: no feedback, auditory feedback, visual feedback, and combined auditory-visual feedback. ::: ::: ::: RESULTS ::: The forces applied with these sensory-substitution modes more closely approximate suture tensions achieved under ideal haptic conditions (ie, hand ties) than forces applied without such sensory feedback. The consistency of applied forces during robot-assisted suture tying aided by visual feedback or combined auditory-visual feedback sensory substitution is superior to that achieved with hand ties. Robot-assisted ties aided with auditory feedback revealed levels of consistency that were generally equivalent or superior to those attained with hand ties. Visual feedback and auditory feedback improve the consistency of robotically applied forces. ::: ::: ::: CONCLUSIONS ::: Sensory substitution, in the form of visual feedback, auditory feedback, or both, confers quantifiable advantages in applied force accuracy and consistency during the performance of a simple surgical task. <s> BIB001 </s> A Survey of auditory display in image-guided interventions <s> Alerts <s> Purpose We developed a surgical navigation system that warns the surgeon with auditory and visual feedback to protect the facial nerve with real-time monitoring of the safe region during drilling. <s> BIB002 </s> A Survey of auditory display in image-guided interventions <s> Alerts <s> BACKGROUND ::: A neuronavigation interface with extended function as compared with current systems was developed to aid during temporal bone surgery. The interface, named EVADE, updates the prior anatomical image and visualizes the bone drilling process virtually in real-time without need for intra-operative imaging. Furthermore, EVADE continuously calculates the distance from the drill tip to segmented temporal bone critical structures (e.g. the sigmoid sinus and facial nerve) and produces audiovisual warnings if the surgeon drills in too close vicinity. The aim of this study was to evaluate the accuracy and surgical utility of EVADE in physical phantoms. ::: ::: ::: METHODOLOGY/PRINCIPAL FINDINGS ::: We performed 228 measurements assessing the position accuracy of tracking a navigated drill in the operating theatre. A mean target registration error of 1.33±0.61 mm with a maximum error of 3.04 mm was found. Five neurosurgeons each drilled two temporal bone phantoms, once using EVADE, and once using a standard neuronavigation interface. While using standard neuronavigation the surgeons damaged three modeled temporal bone critical structures. No structure was hit by surgeons utilizing EVADE. Surgeons felt better orientated and thought they had improved tumor exposure with EVADE. Furthermore, we compared the distances between surface meshes of the virtual drill cavities created by EVADE to actual drill cavities: average maximum errors of 2.54±0.49 mm and -2.70±0.48 mm were found. ::: ::: ::: CONCLUSIONS/SIGNIFICANCE ::: These results demonstrate that EVADE gives accurate feedback which reduces risks of harming modeled critical structures compared to a standard neuronavigation interface during temporal bone phantom drilling. <s> BIB003 </s> A Survey of auditory display in image-guided interventions <s> Alerts <s> In cochlear implantation (CI), the insertion of the electrode array into the appropriate compartment of the cochlea, the scala tympani, is important for an optimal hearing outcome. The current surgical technique for CI depends primarily on the surgeon's skills and experience level to achieve the correct placement of the electrode array, and the surgeon needs to confirm that the exact placement is achieved prior to completing the procedure. Thus, a surgical navigation system can help the surgeon to access the scala tympani without injuring important organs in the complex structure of the temporal bone. However, the use of a surgical microscope has restricted the effectiveness of the surgical navigation because it has been difficult to deliver the navigational information to the surgeon from outside of the surgeon's visual attention. We herein present a clinical feasibility study of an auditory feedback function developed as a computer-surgeon interface that can guide the surgeon to the preset cochleostomy location. As a result, the surgeon could confirm that the drilling point was correct, while keeping his or her eyes focused on the microscope. The proposed interface reduced the common frustration that surgeons experience when using surgical navigation during otologic surgeries. <s> BIB004 </s> A Survey of auditory display in image-guided interventions <s> Alerts <s> Image-guided navigation (IGN) systems provide automation support of intra-operative information analysis and decision-making for surgeons. Previous research showed that navigated-control (NC) systems which represent high levels of decision-support and directly intervene in surgeons' workflow provide benefits with respect to patient safety and surgeons' physiological stress but also involve several cost effects (e.g. prolonged surgery duration, reduced secondary-task performance). It was hypothesised that less automated distance-control (DC) systems would provide a better solution in terms of human performance consequences. N = 18 surgeons performed a simulated mastoidectomy with NC, DC and without IGN assistance. Effects on surgical performance, physiological effort, workload and situation awareness (SA) were compared. As expected, DC technology had the same benefits as the NC system but also led to less unwanted side effects on surgery duration, subjective workload and SA. This suggests that IGN systems ... <s> BIB005
Alerts are sounds that are played back when the source data reach a predetermined threshold. These are common in the operating environment  . The purpose of alerts is to indi-cate that an event has taken place or is about to occur, thereby prompting the listener to take action. In the reviewed literature, alerts have been described by 7 of the 15 articles. For instrument tracking, the alert plays back when the distance of the tracked instrument to a certain structure has passed a predetermined distance threshold  BIB002 BIB004  BIB003 BIB005 , or in the case of Kitagawa et al. BIB001 , when applied during telerobotic suture tying tension reaches a desired threshold. For volumetric resection, Willems et al.  implement an alert when the tip of the tracked instrument encroached a predefined contour. The alert played back twice per second with a frequency of 510 Hz and duration of 0.1 seconds. For temporal bone drilling, Cho et al. BIB002 create three absolute distance margins of 2, 4, and 6 mm from the facial nerve, which correspond to alerts of 900, 600, and 300 Hz, respectively, played back for 20 ms. In a second article BIB004 , two alerts play back when the tip was within 5 mm of either the scala vestibuli or the scala tympani. If the distance to the scala vestibuli is greater than the distance to the scala tympani, an alert of 900 Hz is played; if the distance to the scala tympani is greater than the distance to the scala vestibuli, an alert of 300 Hz is played. Strauss et al.  describe playing back an alert when the instrument reaches a "minimal distance," but detailed descriptions of the auditory display method are not provided in the text. For telerobotic suture tension, Kitagawa et al. BIB001 describe an "[audio feedback] mode, which provided a single tone when the magnitude of the applied tension reached the [optimal] manual tension," although detailed descriptions of the auditory display method are not provided.