Improving the Safety of Laparoscopic Cholecystectomy with Indocyanine Green Dye Using Critical View of Safety Plus.

BACKGROUND: During a laparoscopic cholecystectomy, the critical view of safety is obtained through dissection of the gallbladder from the liver until there is anterior and posterior visualization of the cystic duct and cystic artery. This view is used to allow for proper identification of the cystic duct and artery that will be clipped and incised during the operation. Indocyanine green (ICG) can be used during the operation to directly visualize the biliary tract because of its excretion through the biliary system and elimination via the GI tract. Using a laparoscope capable of visualizing ICG allows for identification of bile duct anatomy to include: common hepatic bile duct, cystic duct, and aberrant, or accessory bile ducts. Additionally, visualization of the biliary structures using ICG prior to clipping and incision will allow for identification and prevention of missed biliary anatomy which could reduce incidence of bile leak, a known complication of cholecystectomies. We propose that visualization of the critical view of safety with ICG fluoroscopy be termed the critical view of safety plus. PURPOSE: We hypothesized that using the critical view of safety plus method for laparoscopic cholecystectomy will yield better scores and increase the decision of the control surgeon to choose to cut and proceed with the operation when compared with the traditional critical view of safety. RESEARCH DESIGN: Comparision of operative photos of critical view of safety and critical view of safety plus which were randomized, double blinded, and graded by a single control surgeon. STUDY SAMPLE: Our study consisted of fifty patients of which 72% female (n = 36) and 28% male (n = 14). The ethnic background included 76% non-Hispanic (n = 38) and 24% Hispanic or of Latino/a origin (n = 12). The average age of our patient was 49 years old (range 20 to 93 years old). Inclusion criteria consisted of patients undergoing laparoscopic cholecystectomy greater than or equal to 18 years old. Exclusion criteria included allergy to indocyanine dye or iodine and pregnancy. ANALYSIS: The scores were evaluated using Chi-squared and paired T-test analysis using MedCalc, MedCalc Sofware Ltd, Belgium. RESULTS: The decision to cut and proceed with the operation was chosen 29 times (58%) when viewing the critical view of safety plus vs 22 times (44%) with the critical view of safety (χ2 = 65.822, p < 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 times (16%) vs 11 times (22%) with critical view of safety (χ2 = 65.822, p < 0.0001) as shown in Fig. 2. The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p = 0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: "two structures connected to the gallbladder" (average 1.54 vs 1.50, p = 0.598), "cystic plate clearance" (average 1.42 vs 1.28, p = 0.018), and "hepatocystic triangle clearance" (average 1.4 vs 1.26, p =0.0334). CONCLUSION: We recommend routine use of ICG fluoroscopy to obtain the critical view of safety plus to allow for improved visualization of the biliary tree, identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury.

Validation of an artificial intelligence platform for the guidance of safe laparoscopic cholecystectomy.

BACKGROUND: Many surgical adverse events, such as bile duct injuries during laparoscopic cholecystectomy (LC), occur due to errors in visual perception and judgment. Artificial intelligence (AI) can potentially improve the quality and safety of surgery, such as through real-time intraoperative decision support. GoNoGoNet is a novel AI model capable of identifying safe ("Go") and dangerous ("No-Go") zones of dissection on surgical videos of LC. Yet, it is unknown how GoNoGoNet performs in comparison to expert surgeons. This study aims to evaluate the GoNoGoNet's ability to identify Go and No-Go zones compared to an external panel of expert surgeons. METHODS: A panel of high-volume surgeons from the SAGES Safe Cholecystectomy Task Force was recruited to draw free-hand annotations on frames of prospectively collected videos of LC to identify the Go and No-Go zones. Expert consensus on the location of Go and No-Go zones was established using Visual Concordance Test pixel agreement. Identification of Go and No-Go zones by GoNoGoNet was compared to expert-derived consensus using mean F1 Dice Score, and pixel accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: A total of 47 frames from 25 LC videos, procured from 3 countries and 9 surgeons, were annotated simultaneously by an expert panel of 6 surgeons and GoNoGoNet. Mean (± standard deviation) F1 Dice score were 0.58 (0.22) and 0.80 (0.12) for Go and No-Go zones, respectively. Mean (± standard deviation) accuracy, sensitivity, specificity, PPV and NPV for the Go zones were 0.92 (0.05), 0.52 (0.24), 0.97 (0.03), 0.70 (0.21), and 0.94 (0.04) respectively. For No-Go zones, these metrics were 0.92 (0.05), 0.80 (0.17), 0.95 (0.04), 0.84 (0.13) and 0.95 (0.05), respectively. CONCLUSIONS: AI can be used to identify safe and dangerous zones of dissection within the surgical field, with high specificity/PPV for Go zones and high sensitivity/NPV for No-Go zones. Overall, model prediction was better for No-Go zones compared to Go zones. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.

The SAGES MASTERS program presents the 10 seminal articles for Roux-en-Y gastric bypass.

BACKGROUND: One of the eight clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program is bariatric surgery which includes three anchoring procedures. For each anchoring procedure sentinel articles have been identified to enhance participant surgeon lifelong learning. Roux-en-Y gastric bypass (RYGB) is one of the 3 anchoring procedures for the Bariatric Pathway. In this article we present the top 10 seminal articles regarding the RYGB which surgeons should be familiar with. METHODS: The literature was systematically searched to identify the most cited papers on RYGB. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list and using expert consensus selected the seminal articles that every bariatric surgeon should read. These articles were reviewed in detail by committee members and are presented here. RESULTS: The top 10 most cited sentinel papers on RYGB focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented here, including expert appraisal and commentary. CONCLUSION: The seminal articles presented here have supported the widespread acceptance and use of the RYGB by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.

Defining the Applicant Pool for Postgraduate Year-2 Categorical General Surgery Positions.

OBJECTIVE: In the spring of 2010, a categorical general surgery postgraduate year (PGY)-2 position became available at our academic medical center secondary to attrition of a PGY-1 resident. We sought to study the unique characteristics of applicants to that position and to describe the selection process with hopes to stimulate additional studies about the unique challenges of recruiting applicants into advanced standing positions. DESIGN: Applications were received via e-mail and reviewed to characterize the applicant pool. An Excel spreadsheet was used to organize data. Characteristics assessed included United States Medical Licensing Examination (USMLE) scores, Educational Commission for Foreign Medical Graduates status, Alpha Omega Alpha Honor Society status, sex, academic performance, number of case logs, volunteer and job experience, leadership roles, research experience including submissions, and advanced degrees. These characteristics were compared to those of the PGY-1 applicants through the Match that year. SETTING: Academic medical center. PARTICIPANTS: Applicants for a categorical general surgery PGY-2 position in 2010. RESULTS: A total of 129 applicants provided the requested documents. There were 104 males, 25 females, no Alpha Omega Alpha Honor Society candidates, and 82 international candidates. Of all, 46 candidates experienced academic difficulties. Quantitative averages include USMLE 1: 214.17, USMLE 2: 215.74, American Board of Surgery In Training Examination (ABSITE) percentile = 51.96, ABSITE 2 = 46.00, grand total case log: 192.10. Advanced degrees included 2 MBAs, 6 MPHs, and 7 nonphysiology MSs. The selection process to fill the position started on 3/25/2010 when the announcement was published and ended on 5/11/2010 when the offer of acceptance was sent. The selected applicant integrated well with the peers and just graduated from our residency as one of the leaders of the graduating class. CONCLUSIONS: Although the attrition rate in general surgery remains high, there is a dearth of literature about how best to replace residents. The hardship of replacing residents highlights the importance of studying this group to improve the recruitment process and the quality of replacement residents. The selection process was time consuming and presented its own challenges given the lack of a computerized system for screening. It lasted nearly 7 weeks requiring faculty time commitment to mine through application data/e-mails, correspond with applicants, conduct interviews, and ultimately select an applicant for the position. This is the first study to investigate the applicant pool to advanced standing positions in general surgery and we present it as a pilot study to stimulate further research efforts.

Surgical Technique for Laparoscopic Removal of a Magnetic Lower Esophageal Sphincter Augmentation Device.

BACKGROUND: Nissen fundoplication is the current gold standard for surgical management of gastroesophageal reflux disease; however, a magnetic antireflux device is now an alternative surgical procedure. The early literature shows good reflux control with minimal complications, and therefore placement of these devices is growing in popularity. As more of these devices are placed, there will be cases in which they will need to be removed. A laparoscopic method for removing the device is presented here. MATERIALS AND METHODS: We present a case of a 42-year-old female with history of gastroesophageal reflux who underwent a laparoscopic placement of a magnetic lower esophageal sphincter augmentation device and repair of a small hiatal hernia. She had a complicated postoperative course before presenting to our institution with a 2-year history of persistent dysphagia and requesting the device be removed. Laparoscopic removal of the device was performed. RESULTS: After laparoscopic removal of the patient's magnetic lower esophageal sphincter augmentation device, she had subjective improvement in her dysphagia but is now being medically managed for gastroesophageal reflux and for delayed gastric emptying. CONCLUSIONS: Laparoscopic removal of magnetic lower esophageal sphincter augmentation devices will sometimes be necessary and may be challenging if the surgeon encounters significant scar tissue around the gastroesophageal junction. Postoperative complications are similar to those encountered with foregut surgeries and include postoperative delayed gastric emptying.

Transanal Minimally Invasive Surgery (TAMIS): Standardizing a Reproducible Procedure.

BACKGROUND: The recent introduction of transanal minimally invasive surgery (TAMIS) offers a safe and cost-effective method for the local resection of rectal neoplasms. The ability to standardize a technique for TAMIS will lead to the most reproducible outcomes and enable teaching. METHODS: A retrospective, IRB-approved chart review was conducted of 32 patients who underwent the TAMIS procedure at one institution over a 3-year period. RESULTS: TAMIS was performed for 11 benign and 21 malignant lesions. The majority of resections were full thickness (29/32) and all were R0. Average distance from the anal verge was 7.5 ± 3 cm, defect circumference was 43.7 ± 10%, operative time was 131 ± 80 min, and length of stay was 1.1 ± 1 days. Two patients had morbidities requiring readmission and further treatment for (1) an aspiration pneumonia with CHF exacerbation and (2) a rectal abscess. CONCLUSIONS: This report outlines an operative technique for TAMIS that is reproducible for the excision of rectal lesions, associated with low morbidity.