Development of a plant-based surgical training model for fluorescence-guided cancer surgery.

BACKGROUND: Fluorescence-guided surgery (FGS) can help surgeons to discriminate tumor tissue from adjacent normal tissues using fluorescent tracers. METHODS: We developed a surgical training model, manufactured using sustainable vegetable organic material with indocyanine green (ICG)-containing "tumor." Surgeons evaluated the model with both the closed-field and endoscopic fluorescence imaging devices and assessed its efficacy to identify residual tumor after enucleation using electrocautery. RESULTS: Strong correlations of fluorescence were obtained at all working distance (3, 5, 7, and 10 cm), showing the robustness of fluorescence signal for the closed-field and endoscopic fluorescence imaging devices. The higher fluorescence signals were obtained in the wound bed in the closed-field fluorescence imaging device and the residual tumor could be clearly identified by fluorescence endoscopy. CONCLUSIONS: Our FGS training model may provide experience for surgeons unfamiliar with optical surgery and subsequent tissue interactions. The model seemed particularly helpful in teaching surgeons the principles of FGS.

The learning curve in endoscopic transsphenoidal skull-base surgery: a systematic review.

BACKGROUND: The endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC. METHODS: A systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons' experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English. RESULTS: The systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency. CONCLUSIONS: The review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.

Percutaneous endoscopic transforaminal discectomy and unilateral biportal endoscopic discectomy for lumbar disc herniation: a comparative analysis of learning curves.

OBJECTIVE: The purpose of this study was to investigate the learning curve of percutaneous endoscopic transforaminal discectomy (PETD) and interlaminar unilateral biportal endoscopic discectomy (UBED) in the treatment of lumbar disc herniation (LDH). METHODS: Between 2018 and 2023, 120 consecutive patients with lumbar disc herniation (LDH) treated by endoscopic lumbar discectomy were retrospectively included. The PETD group comprised 87 cases, and the UBED group comprised 33 cases. Cumulative sum analysis was used to evaluate the learning curve, with the occurrence of complications or unresolved symptoms defined as surgical failure, and variables of different phases of the learning curve being compared. RESULTS: The learning curve analysis identified the cutoff point at 40 cases in the PETD group and 15 cases in the UBED group. In the mastery phase, both PETD and UBED demonstrated a significant reduction in operation times (approximately 38 min for PTED and 49 min for UBED). In both PETD and UBED groups, the surgical failure rates during the learning and mastery phases showed no statistically significant differences. The visual analogue scale at the last follow-up was significantly lower than before surgery in both the PETD and UBED groups. CONCLUSION: PETD and UBED surgery are effective in the treatment of LDH with a low incidence of complications. However, achieving mastery in PETD necessitates a learning curve of 40 cases, while UBED requires a minimum of 15 cases to reach proficiency.

Safety and efficacy of three-dimensional versus two-dimensional endoscopy in otolaryngology surgery and training: A systematic review.

OBJECTIVE: Three-dimensional (3D) endoscopy has been developed to provide depth perception to allow for improved visualisation during otolaryngology surgery. We conducted a systematic review to determine the surgical safety and efficacy of 3D endoscopy in comparison to two-dimensional (2D) endoscopy in performing otolaryngology procedures, and the role of 3D endoscopy as a training tool for novice otolaryngology surgeons. METHODS: Primary studies were identified through MEDLINE, Embase and Web of Science databases, which were searched for articles published through June 2022 that compared the outcomes of 2D and 3D endoscopy in otolaryngology surgical procedures or otolaryngology-relevant simulations. Candidate articles were independently reviewed by two authors. RESULTS: A total of 18 full-text articles met inclusion criteria for this study. In clinical trials (n = 8 studies, 362 subjects), there were no significant differences in performance time, intraoperative or postoperative complications with 3D endoscopes when compared to 2D. In simulation studies (n = 10 studies, 336 participants), 3D endoscopes demonstrated a decreased error rate (n = 5 studies) and shorter performance time (n = 3 studies). Studies also reported improved depth perception (n = 14 studies) and visualisation preference (n = 5 studies) with 3D over 2D systems. The 3D systems were found to have a shorter learning curve and better manoeuvrability among novice surgeons. CONCLUSION: 3D endoscopy showed equivalent safety and efficacy compared to 2D endoscopy in otolaryngology surgery. The improved depth perception and performance for novices using 3D endoscopes suggests the technology may be superior to 2D endoscopes as a training tool for otolaryngology surgeons.

Validation of a synthetic simulation model of endoscopic rectus sheath plication.

PURPOSE: Literature reviews outline minimally invasive approaches for abdominal diastasis in patients without skin excess. However, few surgeons are trained in endoscopic rectus sheath plication, and no simulated training programs exist for this method. This study aimed to develop and validate a synthetic simulation model for the training of skills in this approach under the Messick validity framework. METHODS: A cross-sectional study was carried out to assess the participants' previous level of laparoscopic/endoscopic skills by a questionnaire. Participants performed an endoscopic plication on the model and their performance was evaluated by one blinded observer using the global rating scale OSATS and a procedure specific checklist (PSC) scale. A 5-level Likert survey was applied to 5 experts and 4 plastic surgeons to assess Face and Content validity. RESULTS: Fifteen non-experts and 5 experts in abdominal wall endoscopic surgery were recruited. A median OSATS score [25 (range 24-25) vs 14 (range 5-22); p < 0.05 of maximum 25 points] and a median PSC score [11 (range 10-11) vs 8 (range 3-10); p < 0.05 of maximum 11 points] was significantly higher for experts compared with nonexperts. All experts agreed or strongly agreed that the model simulates a real scenario of endoscopic plication of the rectus sheath. CONCLUSION: Our simulation model met all validation criteria outlined in the Messick framework, demonstrating its ability to differentiate between experts and non-experts based on their baseline endoscopic surgical skills. This model stands as a valuable tool for evaluating skills in endoscopic rectus sheath plication.

Telesimulation Training for Endoscopic Mitral Valve Surgery: An Air-Pilot Training Concept for Distance Training.

OBJECTIVE: The aim of this study was to validate and assess the feasibility and impact of telesimulation training on surgical skills using a portable mitral valve telesimulator. METHODS: A telesimulation course composed of 3 online modules was designed based on backwards chaining, preassessment and postassessment, performance feedback, hands-on training on a telesimulator, and the theoretical content. A fully 3-dimensional-printed and transportable telesimulator was developed and sent out to the participants with instruments that were needed. Feedback about the platform was obtained from participants to validate its value as a training tool. Theoretical and technical assessments were carried out before and after the course. Technical assessments were based on the accuracy and time taken to place sutures at the anterior and posterior mitral annulus. RESULTS: In total, 11 practicing cardiac surgeons from Oceania, Asia, Europe, and North America completed the course. Theoretical preassessment and postassessment showed that participants scored significantly higher on postassessment (mean 87.5% vs 68.1%, P < 0.004). The participant evaluation scores of the simulator as a tool for endoscopic mitral valve surgery was 4 to 5 out of 5. There was a significant improvement in the speed (median 14.5 vs 39.5 s, P < 0.005) and the accuracy to place sutures in the mitral valve annulus following course completion (P < 0.001). CONCLUSIONS: Here we validated the educational value of a novel telesimulation platform and validated the feasibility to teach participants at a distance the knowledge and skills for endoscopic mitral valve surgery. Future studies will be required to validate the improvement in skills during surgery.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument.

PURPOSE: To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery. METHODS: A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. RESULTS: The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. CONCLUSION: A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Validity of A Novel Simulator for Percutaneous Transforaminal Endoscopic Discectomy.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) has steep learning curves and a high incidence of complications, but currently, efficient and economical training methods are lacking. This study aimed to validate a novel simulator for PTED. METHODS: The simulated PTED included puncturing and establishing the working channel (PEWC) and endoscopic discectomy, with the PEWC being the tested module. Eleven experts and 21 novices were included and introduced to the simulator and tasks; all participants completed the PEWC. Outcomes included: total operation time, number of fluoroscopy for positioning the working sheath, number of spinal risk region invasion, Global Rating Scale (GRS) and a modified GRS, etc. The Mann-Whitney U test was used to compare 2 groups. Spearman's correlation coefficient analyzed continuous variables. RESULTS: Experts outperformed novices in total operation time (P = 0.001), requiring fewer number of fluoroscopies for positioning the working sheath (P = 0.003). Additionally, experts had a lower number of spinal risk region invasions (P = 0.016) and higher scores on both the GRS (P < 0.001) and modified GRS (P < 0.001). PTED experience correlated with GRS scores (P = 0.001) and modified GRS (P < 0.001). The overall realism scored a median of 4 (3.75-5), and educational value had a median of 4 (range 3-5). CONCLUSIONS: This study demonstrates the validity of the novel simulator, revealing significant associations between PTED experience and performance metrics in a simulated PEWC setting. Furthermore, the PEWC module also offers a good realistic design and high education value according to experts.

Is YouTube a Reliable and Quality Source on Unilateral Biportal Endoscopic Spine Surgery? A Cross-Sectional Study.

OBJECTIVE: This study aimed to evaluate the quality and reliability of YouTube videos focusing on unilateral biportal endoscopic spine surgery, a novel technique for spinal decompression in degenerative spinal disease. METHODS: This cross-sectional study, conducted in February 2023, involved an online search on YouTube using the term "unilateral biportal endoscopic spine surgery". Video popularity was assessed using the Video Power Index. Video reliability and quality were measured using the Global Quality Scale, the Journal of the American Medical Association benchmark criteria, and the modified DISCERN instrument. RESULTS: Ninety-three videos were included for evaluation. Uploader profiles were categorized by continent, with 61.3% from Asia, 35.5% from the United States, 2.2% from Africa, and 1.1% from Australia. When comparing 3 groups as South Korea, United States, and other countries, no significant differences were observed in the technical characteristics of the videos. However, the educational quality and reliability of the videos were higher in those uploaded from South Korea (P < 0.001).When the videos were divided into 2 groups according to their educational quality, significant difference were noted in video duration, loading time, video quality, and reliability (P < 0.001). CONCLUSIONS: The YouTube videos on unilateral biportal endoscopic spine surgery showed high quality and reliability. However, videos from South Korea were found to have higher educational quality and reliability, while other specifications were similar for all videos. Furthermore, it was determined that videos uploaded more recently and with longer duration were of higher quality.

Learning Curve of Biportal Endoscopic Spinal Surgery: A Retrospective 2-Center Study.

OBJECTIVE: Biportal endoscopic spinal surgery (BESS) technique is a novel, useful, and minimally invasive therapeutic strategy for lumbar degenerative diseases, which has advantages over other surgical techniques. However, the degree of technical difficulty in learning BESS is controversial and not well established. This study aims to determine the learning curve of BESS technique through cumulative sum (CUSUM) analysis. METHODS: A total of 144 consecutive patients who underwent BESS with lumbar decompressive discectomy between 2017 and 2023 were included. A retrospective bicenter study was performed. RESULTS: Three doctors with endoscopy experience employed the BESS technique for 51, 42, and 46 procedures, respectively. The CUSUM test of the 3 doctors showed adequate technical ability at the 45th, 41st, and 44th operations respectively. Two doctors without endoscopy experience gave up further use of BESS technique due to technical difficulties after initial attempt. The overall complication rates of the 3 surgeons using the BESS technique were 3.92% (n = 2), 6.82% (n = 3), and 2.17% (n = 1), respectively. CONCLUSIONS: Our study demonstrated that BESS is an effective treatment, and the learning curves of BESS for lumbar discectomy using CUSUM analysis were 41 ∼ 45 cases in trainees with endoscopic experience. Endoscopic experience contributes to the learning curve of the BESS technique.

EndoViT: pretraining vision transformers on a large collection of endoscopic images.

PURPOSE: Automated endoscopy video analysis is essential for assisting surgeons during medical procedures, but it faces challenges due to complex surgical scenes and limited annotated data. Large-scale pretraining has shown great success in natural language processing and computer vision communities in recent years. These approaches reduce the need for annotated data, which is of great interest in the medical domain. In this work, we investigate endoscopy domain-specific self-supervised pretraining on large collections of data. METHODS: To this end, we first collect Endo700k, the largest publicly available corpus of endoscopic images, extracted from nine public Minimally Invasive Surgery (MIS) datasets. Endo700k comprises more than 700,000 images. Next, we introduce EndoViT, an endoscopy-pretrained Vision Transformer (ViT), and evaluate it on a diverse set of surgical downstream tasks. RESULTS: Our findings indicate that domain-specific pretraining with EndoViT yields notable advantages in complex downstream tasks. In the case of action triplet recognition, our approach outperforms ImageNet pretraining. In semantic segmentation, we surpass the state-of-the-art (SOTA) performance. These results demonstrate the effectiveness of our domain-specific pretraining approach in addressing the challenges of automated endoscopy video analysis. CONCLUSION: Our study contributes to the field of medical computer vision by showcasing the benefits of domain-specific large-scale self-supervised pretraining for vision transformers. We release both our code and pretrained models to facilitate further research in this direction: https://github.com/DominikBatic/EndoViT .

Evaluation of skill acquisition characteristics depending on the size of a dry box.

BACKGROUND: Few studies have analyzed the effect of the size of the working space in training on the acquisition of endoscopic skills. In this study, adult- and infant-sized dry boxes (DBs) were used to verify how the size of the working space in training affects forceps manipulation and learning curve. MATERIAL AND METHODS: Seventy-two medical students were enrolled. The task was peg transfer. The training environment was divided into adult- and infant-sized DBs. Skill evaluations were also divided into adult- and infant-sized DBs (four groups in total). The forceps manipulation characteristics and task completion time were compared before and after training. RESULTS: Regarding skill evaluations using adult-sized DBs, there were no significant differences between the infant- and adult-sized DB-trained groups. Regarding skill evaluations using infant-sized DBs, there were no significant differences between the groups before training. After training, there was no significant difference in the total path length or average acceleration of the forceps between the groups. However, the infant-sized DB-trained group had a significantly faster average forceps velocity and faster task completion time than the adult-sized DB-trained group. CONCLUSION: Training with a small DB is more efficient in acquiring smoother and faster forceps manipulation in a small working space.

A force sensor improves trainee technique for rigid endoscopy.

OBJECTIVE: Developing skills in rigid endoscopy poses challenges to the surgical trainee. This study investigates whether a modified manikin can improve the technical skill of junior operators by providing direct quantitative feedback. METHODS: A force-sensing pad was incorporated into the oral cavity of a life support manikin. Junior trainees and senior otolaryngologists were invited to perform rigid endoscopy and received real-time feedback from the force sensor during the procedure. RESULTS: There was a significant inverse correlation between operator seniority and the weight applied to the oral cavity (p < 0.0001). All junior trainee operators applied less weight after five attempts (346 ± 90.95 g) compared to their first attempt (464 ± 85.79 g). This gave a statistically significant decrease of 118 g (standard deviation = 107.27 g, p = 0.007) when quantitative feedback was provided to learning operators. CONCLUSION: This low-cost, simple model allows trainees to rehearse a high-risk procedure in a safe environment and adjust their operative technique.

Experimental model for transforaminal endoscopic spine

Abstract Purpose: To validate the porcine spine as a model for learning and practicing transforaminal percutaneous endoscopic lumbar procedures (TF-PELP). Methods: TF-PELP was performed in three porcine cadaver lumbar spine levels. Anatomical features of the current cadaver were compared to human and porcine spines. Performance and documentation of endoscopic procedures were described. Results: This study shows that this representative animal model reflects anatomical characteristics of the human spine. Transforaminal approaches were successfully completed. Although lower disc heights make disc puncture more difficult, the outside-in technique is feasible and more useful to identify anatomical parameters and to practice different surgical steps and maneuvers. Conclusion: This is an effective and representative model for learning and practicing this procedure. Difficulties of the procedure, as well as the differences compared to the human spine, were described.

Endoscopic sinus surgery dissection courses using a real simulator: the benefits of this training / Cursos de dissecção de cirurgia endoscópica nasossinusal em simulador real - os benefícios deste treinamento

ABSTRACT INTRODUCTION: Endonasal surgeries are among the most common procedures performed in otolaryngology. Due to difficulty in cadaver acquisition and the intrinsic risks of training residents during operations on real patients, nasosinusal endoscopic dissection courses utilizing real simulators, such as the Sinus Model Otorhino Neuro Trainer are being developed as a new technique to facilitate the acquisition of better anatomical knowledge and surgical skill. OBJECTIVE: To evaluate the efficacy of nasosinusal endoscopic dissection courses with the Sinus Model Otorhino Neuro Trainer simulator in the training of otolaryngology surgeons. METHODS: A prospective, longitudinal cohort study was conducted with 111 otolaryngologists who participated in a theoretical and practical course of endoscopic surgery dissection using the Sinus Model Otorhino Neuro Trainer simulator, with application of questionnaires during and after the course. RESULTS: From the ten procedures performed utilizing the simulator, the evaluation revealed mean scores from 3.1 to 4.1 (maximum of 5). Seventy-seven participants answered the questionnaire six months after the end of the course. 93% of them reported that they could perform the procedures more safely following the course, 98% reported an improvement in their anatomical and clinical knowledge, and 85% related an improvement in their surgical ability. After the course, the number of endoscopic surgeries increased in 40% of the respondents. CONCLUSION: Endoscopic sinus dissection courses using the Sinus Model Otorhino Neuro Trainer simulator proved to be useful in the training of otolaryngologists.

RESUMO INTRODUÇÃO: Cirurgias endonasais são as cirurgias mais realizadas na otorrinolaringologia. Devido à dificuldade de adquirir cadáveres e ao risco inerente em realizar treinamento em pacientes reais, cursos de dissecção endoscópica nasossinusal em simuladores reais, como o sinus model otorhino - neuro trainer - S.I.M.O.N.T, são uma nova proposta de aquisição de maior conhecimento anatômico e habilidades cirúrgicas. OBJETIVO: Avaliar a eficácia dos cursos de dissecção de cirurgia endoscópica nasossinusal com simulador S.I.M.O.N.T. no treinamento de cirurgiões otorrinolaringologistas. MÉTODO: Estudo de coorte contemporâneo longitudinal com 111 otorrinolaringologistas que participaram de curso teórico - prático de dissecção endoscópica nasossinusal em simulador real S.I.M.O.N.T., com aplicação de questionários durante e após a realização do curso. RESULTADOS: Dos dez procedimentos realizados no simulador, a avaliação apontou para médias de notas que variaram de 3,1 a 4,1 (máximo de 5). Setenta e sete participantes responderam a avaliação 6 meses após o curso. Declararam que houve aumento da segurança após o curso, 93% dos mesmos; 98% disseram ter aumentado o conhecimento anátomo-clinico e 85% declararam um aumento da habilidade cirúrgica. Quarenta por cento aumentaram o número de cirurgias endonasais após o curso. CONCLUSÃO: Cursos de dissecção de cirurgia endonasais com simulador real S.I.M.O.N.T. mostraram ser úteis para o treinamento de otorrinolaringologistas.

La evaluación diagnóstica en los programas de posgrado del Centro Nacional de Cirugía de Mínimo Acceso / Diagnostic evaluation in postgraduate courses of the National Center of Minimun Access Surgery

Para elevar la calidad del posgrado se expone la utilidad de la aplicación de evaluaciones diagnósticas en los programas referidos a temas de cirugía laparoscópica y endoscopia digestiva. Se dio respuesta a la interrogante que refiere si existen diferencias de niveles de formación previa, en los alumnos de posgrado del Centro Nacional de Cirugía de Mínimo Acceso (CNCMA), al identificar las desigualdades de los que matricularon en 6 programas de estudio de posgrado en los años 2010 y 2011. Se aplicaron pruebas diagnósticas que permitieron ponderar los errores cometidos por los estudiantes en las temáticas de los programas de posgrado a impartir, detectando diferencias en las condiciones cognoscitivas iniciales en el período analizado. Los porcentajes generales de errores se presentaron por debajo del 50 por ciento con la excepción del Curso de Cirugía laparoscópica ginecológica que tuvo un 51 por ciento general de errores. Los resultados avalaron la pertinencia de la aplicación de las pruebas diagnósticas para permitir que los profesores puedan saber qué grado de conocimientos previos poseen los alumnos, necesarios para asimilar los contenidos de los programas docentes y en qué grado pueden haber alcanzado ya los objetivos propuestos en dichos programas

For the purpose of increasing the quality of postgraduate education, this paper presented the advantages of diagnostic evaluations in the programs including topics of laparoscopic surgery and digestive endoscopy. It gave response to the question of whether there are differences in the previous levels of formation of undergraduate students of the National Center of Minimum Access Surgery by way of identifying the inequalities among those who registered for 6 postgraduate studies in 2010 and 2011. Diagnostic tests were applied, which allowed weighing the mistakes made by the students in postgraduate topics and detecting the differences in the initial cognitive conditions during the analyzed period. The general percentages of mistakes were under 50 percent, except for the laparoscopic gynecological surgery course that showed 51 percent of mistakes. The results supported the importance of using diagnostic tests so that the professor can know in advance the level of knowledge of the participating students to assimilate the contents of the educational programs, and also to what extent they could have reached the objectives put forward in these programs