• Joseph Davids, Savvas-George Makariou, Hutan Ashrafian, Ara Darzi, Hani J Marcus, and Stamatia Giannarou.
• Department of Surgery and Cancer, Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, St. Mary's Praed St., Paddington, London, United Kingdom; Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
• World Neurosurg. 2021 May 1; 149: e669-e686.

Background/ObjectiveTechnical skill acquisition is an essential component of neurosurgical training. Educational theory suggests that optimal learning and improvement in performance depends on the provision of objective feedback. Therefore, the aim of this study was to develop a vision-based framework based on a novel representation of surgical tool motion and interactions capable of automated and objective assessment of microsurgical skill.MethodsVideos were obtained from 1 expert, 6 intermediate, and 12 novice surgeons performing arachnoid dissection in a validated clinical model using a standard operating microscope. A mask region convolutional neural network framework was used to segment the tools present within the operative field in a recorded video frame. Tool motion analysis was achieved using novel triangulation metrics. Performance of the framework in classifying skill levels was evaluated using the area under the curve and accuracy. Objective measures of classifying the surgeons' skill level were also compared using the Mann-Whitney U test, and a value of P < 0.05 was considered statistically significant.ResultsThe area under the curve was 0.977 and the accuracy was 84.21%. A number of differences were found, which included experts having a lower median dissector velocity (P = 0.0004; 190.38 ms-1 vs. 116.38 ms-1), and a smaller inter-tool tip distance (median 46.78 vs. 75.92; P = 0.0002) compared with novices.ConclusionsAutomated and objective analysis of microsurgery is feasible using a mask region convolutional neural network, and a novel tool motion and interaction representation. This may support technical skills training and assessment in neurosurgery.Copyright © 2021 Elsevier Inc. All rights reserved.

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