Surgical Innovation最新文献

Background: Precise preoperative localization of liver tumors facilitates successful surgical procedures, Intraoperative ultrasonography is a sensitive imaging modality. However, the presence of small non-palpable isoechoic intraparenchymal lesions may be challenging intraoperatively.

Methodology and material description: Onyx® is a non-adhesive liquid agent comprised of ethylene-vinyl alcohol usually used dissolved in dimethyl-sulfoxide and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy and ultrasonography and a macroscopic black shape. This embolization material has been increasingly used for the embolization of intracranial arteriovenous malformations. We present the novel application of Onyx® on liver surgery.

Current status: We present the case of a female, 55 years-old, whose medical history revealed an elective sigmoidectomy (pT3N1a). After 17 months of follow up, by PET-CT scan, the patient was diagnosed of a small intraparenchymal hypo-attenuated 13 mm tumor located at segment V consistent with metachronous colorectal liver metastasis. Open metastasectomy was performed, ultrasonography-guided Onyx® infusion was delivered the day after, intraoperative ultrasonography showed a palpable hyperechoic material with a posterior acoustic shadowing artifact around the lesion. Onyx® is a promising new tool, without any previous application on liver surgery, feasible with advantages in small not palpable intraparenchymal liver lesions.

Laparoscopic TAPP (Trans-Abdominal PrePeritoneal) is a minimally invasive surgical procedure used to repair inguinal hernias. Arguably, one important aspect to TAPP hernia repair is the identification of anatomical landmarks and the correct use of various laparoscopic instruments. There are very few studies regarding the use of artificial intelligence in laparoscopic inguinal hernia repair and more specifically in TAPP. The aim of this study is to evaluate the feasibility and usefulness of AI in the recognition of anatomical landmarks and tools in laparoscopic TAPP videos. Imaging data have been exported from 20 Laparoscopic TAPP videos that have been performed by the authors and another 5 high quality TAPP videos from the internet (free access) performed by other surgeons. In total 1095 selected images have been exported for annotation. To accomplish the AI result of computer vision, the YOLOv8 model of deep learning was used. In total 2716 segmented areas of interest have been exported. The AI model was able to detect the various classes with a maximum F1 score of .82 when the confidence threshold was set to .406. The mAP50 was .873 for all classes. The Precision was above 50% when the confidence was over 10%. The Recall rate was above 50% when confidence was less than 70%. These results suggest that the model is effective at balancing precision and recall, capturing both true positives and minimizing false negatives. Artificial Intelligence recognition of anatomical landmarks and laparoscopic instruments in TAPP is feasible with acceptable success rates.

Introduction: Computerized simulation (CS) of surgery in virtual reality (VR), augmented reality (AR) and mixed reality (MR) settings are used to teach foundational skills, but its applicability in advanced training is to be determined. This review aims to summarize the types of CS available for laparoscopic colorectal surgery (CRS) and its utility in assessment of proficiency.

Methods: A systematic review of CS in laparoscopic CRS was done on PubMed, Embase, Scopus and Cochrane Library databases.

Results: Eleven relevant observational studies were identified. The most common procedure simulated was laparoscopic colectomy. Assessment using performance metrics measured by the simulator such as path length moved by laparoscopic tools, procedure time and number of discrete movements had the most consistent differentiating ability between expert and non-expert cohorts. Surgeons fared similarly in proficiency scores in assessment with CS compared to assessment with traditional cadaveric or porcine models.

Conclusion: CS of laparoscopic CRS may be used in assessment of proficiency using performance metrics measuring economy of movement. CS may be a viable assessment tool in advanced surgical training, but further studies should assess utility of incorporating it as a formal assessment tool in training programs.

Background: To date, several chest drainage systems are available, such as digital drainage systems (DDS) and traditional systems with continuous suction or water seal. However, none of these systems were yet shown to be favorable in the treatment of complex situations such as persistent air leaks or residual spaces. We present in-vitro as well as clinical data of a novel hybrid drainage system consisting of an optimized digital drainage system (ODDS) and an underwater seal drainage system (UWSD).

Methods: For in-vitro analysis, a DDS and an ODDS were connected to a pleural cavity simulator. Different air leaks were produced and data on intrapleural pressure and air flow were analyzed. Furthermore, we tested the hybrid drainage system in 10 patients with potential air leaks after pulmonary surgery.

Results: In in-vitro analysis, we could show, that with advanced pump technology, pressure fluctuations caused by the drainage system when trying to maintain a set pressure level in patients with airleaks were much smaller when using an ODDS and could even be eliminated when using a fluid collection canister with sufficient buffer capacity. This minimized air leak boosts caused by the drainage system. Optimizing the auto-pressure regulation algorithms also led to a reduced airflow through the fistula and promoted rest. Switching to a passive UWSD also reduced the amount of airflow. Clinical application of the hybrid drainage system yielded promising results.

Conclusion: The novel hybrid drainage system shows promising results in the treatment of patients with complex clinical situations such as persistent air leaks.

Background: Laparoscopy represented one of the most innovative surgical techniques approached in the surgery field. Dexmedetomidine association with general anesthesia promotes the response control to trauma by altering the neuroinflammatory reflex, provides better clinical outcomes in the postoperative period and reduces the excessive use of drugs with risk for addiction. This trial aims to evaluate the potential drug treatment of dexmedetomidine on organic function, with the targets in neuroinflammation, perioperative pain control and blood pressure measurements in a medium-sized surgical model.

Methods: Fifty-two patients were randomized in two groups: Sevoflurane and Dexmedetomidine - A (dexmedetomidine infusion [1 μg/kg loading, .2-.5 μg/kg/h thereafter]) vs Sevoflurane and Saline .9% - B. Three blood samples were collected at three times: before surgery, 4 to 6 hours after surgery and 24 hours postoperatively. The primary outcome was inflammatory and endocrine mediators dosage analisys. Finally, we evaluated pain and opioid use as secondary outcomes, also the hemodynamic values.

Results: In Dexmedetomidine group A, a reduction of Interleukin 6 was found during 4-6 hours after surgery. A reduction of IL-10 was noted in the measurement of its values 24 hours after the procedure, with statistical significance. Also, systolic and diastolic blood pressure, as well heart rate were attenuated, and there was a lower incidence of pain and opioid consumption in the first postoperative hour (P < .0001) in the anesthetic recovery room.

Conclusions: Dexmedetomidine provided anti-inflammatory activity, sympatholytic effect and analgesia with cardiovascular safety. It reinforces the therapeutic nature of highly selective α2-adrenergic agonists when combined within anesthetic interventions.

Background: Bone cancer is a severe condition often leading to patient mortality. Diagnosis relies on X-rays, MRIs, or CT scans, which require time-consuming manual review by experts. Thus, developing an automated system is crucial for accurate classification of malignant and healthy bone.Methods: Differentiating between them poses a challenge as they may exhibit similar physical characteristics. The initial step is selecting the optimal edge detection method. Two feature sets are then generated: one with the histogram of oriented gradients (HOG) and one without. Performance evaluation involves two machine learning models: Support Vector Machine (SVM) and Random Forest.Results: Including HOG consistently yields superior results. The SVM model with HOG achieves an F-1 score of 0.92, outperforming the Random Forest model's .77. This study aims to develop reliable methods for bone cancer classification. The proposed automated method assists surgeons in accurately detecting malignant bone regions using modern image analysis techniques and machine learning models. Incorporating HOG significantly enhances performance, improving differentiation between malignant and healthy bone.Conclusion: Ultimately, this approach supports precise diagnoses and informed treatment decisions for bone cancer patients.

Introduction: Surgical training using simulation can fill gaps in traditional surgical residency learning. We hypothesize that arthroscopy training conducted on a virtual reality simulator will be preferred by orthopaedic surgery residents over a traditional dry lab simulation model.

Methods: 38 orthopaedic surgery residents at a single U.S. residency program were randomized to train for a shoulder arthroscopy procedure using either a virtual reality simulator or a table-top dry lab simulator. Training and learning preferences were then asked of the resident participants.

Results: Junior residents were likely to report training preference for the virtual reality simulator compared to senior residents [15/24 (62.5%) v. 8/14 (57.1%); P = .043]. Simulator preference was not influenced by subspecialty interest, prior arthroscopy experience, or simulator experience. Virtual reality simulation was associated with positive attitude towards arthroscopy and high chance of reporting learning gains on general arthroscopic understanding. Senior residents were 4.7 times more likely than juniors to report learning gains via staff discussion pre- and post-operatively. A majority of residents [34/38 (89.5%)] reported, however, wanting more simulation for training surgical skills.

Conclusion: Simulation is a desired and potentially valuable adjunct to training orthopaedic residents in arthroscopy. Training needs do evolve; and junior arthroscopists may benefit more from virtual reality platforms for general skills. Senior residents preferred dry lab simulation, possibly because it allowed for handling of actual instruments and implants.

Introduction: Cholelithiasis is one of the most common diseases encountered in gastroenterology. Laparoscopic cholecystectomy can be labelled as difficult if the surgery continues for more than 60 minutes or if the cystic artery is injured before ligation or clipping. Predicting difficult laparoscopic cholecystectomy can help the surgeon to be prepared for intraoperative challenges such as adhesions in triangle of Calot, injury to cystic artery or gall stone spillage; and improve patient counseling.

Methods: In this cross-sectional study, we evaluated 269 patients with diagnosed cholelithiasis and planned for laparoscopic cholecystectomy in the general surgery department of Civil Hospital Karachi. After approval of the institution review board of the Civil Hospital, the data of all the patients was collected along with informed consent. The patients were selected via nonprobability, consecutive sampling.

Results: The prevalence of difficult LC during procedure was 14.5% (39/269). Contingency table showed the true positive, negative and false positive and negative observation and using these observation to compute accuracy. Sensitivity, specificity, PPV, NPV and accuracy of serum c-reactive protein (CRP) in predicting the difficult laparoscopic cholecystectomy in patients of cholelithiasis was 87.2%, 97%, 82.9%, 97.8% and 95.5% respectively. Effect modifiers like age, gender and BMI were controlled by stratification analysis and observed that diagnostic accuracy was above 90% in all stratified groups as presented in the following tables. 175 (65.06%) of 279 patients were females indicating female predominance. In general, 41 patients (15.05%) had CRP serum levels greater than 11 mg/dL out of which 34 patients had to undergo difficult laparoscopic cholecystectomy (DLC), while 223 out of 228 patients with serum CRP levels of less than 11 mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders.

Conclusion: C Reactive Protein is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high C Reactive Protein CRP levels in serum have more chances of complication intraoperatively and increased chances of conversion from laparoscopic to open surgery. Preoperative C Reactive Protein (CRP) with values >11 mg/dL was associated with the highest odds of presenting difficult laparoscopic cholecystectomy (DLC) in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population.

Purpose: Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region.

Methods: The "Hippocratic Corpus" original text was thoroughly studied to identify all Hippocrates' contributions in Orthopaedics and Traumatology. Volume III of his works, especially "On Fractures", "On Joints", and "Mochlicon" includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system.

Results: In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures' healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases.

Conclusions: Hippocrates' contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19^th and 20^th centuries.

Background: Gynecomastia is a benign condition that develops due to the proliferation of breast tissue in men. Surgical excision is the most effective treatment method. Minimally invasive techniques can be used to avoid visible scarring. We evaluated the efficacy and safety of air-assisted subcutaneous mastectomy in the treatment of gynecomastia.

Patient and methods: 10 patients with gynecomastia underwent air-assisted subcutaneous mastectomy and liposuction through a single axillary incision, between June 2022 and February 2023. Demographic and clinical data of the patients, duration of surgery, and complications were recorded. The satisfaction levels of the patients regarding physical appearance, mental status, and social environment were measured. The body Q questionnaire was performed preoperatively and in the postoperative third month.

Results: The median age was 26 (range, 18-54). Surgical excision was measured as a median of 69 gr (range, 41-177), and liposuction volume was measured as a median of 210 ccs (range, 63-400). The median operation time was 50 minutes (range, 21-60) for excision and 21 minutes (range, 20-75) for liposuction. Body, chest, and nipples related appearance satisfaction levels were measured preoperatively as a median of 44 (range, 36.5-52), 31 (range, 27.5-39), and 51.5 (range, 21-69.8) points vs postoperatively as 92 (range, 92-100), 93 (range, 93-94.8) and 90 (range, 90-100) points, respectively. The patients had a median follow-up of 6 months (range, 3-11). No complications were observed during the follow-up period.

Conclusion: Air-assisted subcutaneous mastectomy and liposuction is a feasible technique that may provide good cosmetic outcomes by avoiding anterior chest wall scarring.