Assessment of changes in vessel area during needle manipulation in microvascular anastomosis using a deep learning-based semantic segmentation algorithm: A pilot study.

Appropriate needle manipulation to avoid abrupt deformation of fragile vessels is a critical determinant of the success of microvascular anastomosis. However, no study has yet evaluated the area changes in surgical objects using surgical videos. The present study therefore aimed to develop a deep learning-based semantic segmentation algorithm to assess the area change of vessels during microvascular anastomosis for objective surgical skill assessment with regard to the "respect for tissue." The semantic segmentation algorithm was trained based on a ResNet-50 network using microvascular end-to-side anastomosis training videos with artificial blood vessels. Using the created model, video parameters during a single stitch completion task, including the coefficient of variation of vessel area (CV-VA), relative change in vessel area per unit time (ΔVA), and the number of tissue deformation errors (TDE), as defined by a ΔVA threshold, were compared between expert and novice surgeons. A high validation accuracy (99.1%) and Intersection over Union (0.93) were obtained for the auto-segmentation model. During the single-stitch task, the expert surgeons displayed lower values of CV-VA (p < 0.05) and ΔVA (p < 0.05). Additionally, experts committed significantly fewer TDEs than novices (p < 0.05), and completed the task in a shorter time (p < 0.01). Receiver operating curve analyses indicated relatively strong discriminative capabilities for each video parameter and task completion time, while the combined use of the task completion time and video parameters demonstrated complete discriminative power between experts and novices. In conclusion, the assessment of changes in the vessel area during microvascular anastomosis using a deep learning-based semantic segmentation algorithm is presented as a novel concept for evaluating microsurgical performance. This will be useful in future computer-aided devices to enhance surgical education and patient safety.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Prototype of Low-Cost Microvascular Clips for Laboratory Use.

BACKGROUND: Vascular neurosurgical procedures require temporary or permanent surgical clips to treat cerebral aneurysms, arteriovenous malformations, or bypass surgery. In this scenario, surgical clips should have specific characteristics such as high-quality material, proper design, closing force, and biocompatibility. Due to these characteristics, the price of these clips does not allow their availability at the experimental surgery laboratory worldwide. METHODS: We describe here the technique for manufacturing handcrafted clips of low cost, using dental stainless steel or titanium wire of 0.18 mm, 0.20 mm, or 0.22 mm in diameter. We must complete six steps to obtain the clip using our hands and small electrician needle nose pliers for wire molding. RESULTS: These clips have a closing force of 30-60 gr/cm2 (depending on the wire diameter). They can be used in the experimental surgery laboratory to clip arteries or veins during vascular microsurgery procedures. Also, they can be used as temporary clips with confidence in low-flow bypass (v.gr. superficial temporal artery to middle cerebral artery or occipital artery to posterior inferior cerebellar artery anastomoses). CONCLUSIONS: Making practical low-cost clips for use in laboratory procedures or during low-flow anastomosis as temporary clips is possible. The main advantages are the low cost and the worldwide availability of the basic materials. The main disadvantage is the learning curve to get the ability to master the manufacturing of these clips.

An objective skill assessment framework for microsurgical anastomosis based on ALI scores.

INTRODUCTION: The current assessment and standardization of microsurgical skills are subjective, posing challenges in reliable skill evaluation. We aim to address these limitations by developing a quantitative and objective framework for accurately assessing and enhancing microsurgical anastomosis skills among surgical trainees. We hypothesize that this framework can differentiate the proficiency levels of microsurgeons, aligning with subjective assessments based on the ALI score. METHODS: We select relevant performance metrics from the literature on laparoscopic skill assessment and human motor control studies, focusing on time, instrument kinematics, and tactile information. This information is measured and estimated by a set of sensors, including cameras, a motion capture system, and tactile sensors. The recorded data is analyzed offline using our proposed evaluation framework. Our study involves 12 participants of different ages ([Formula: see text] years) and genders (nine males and three females), including six novice and six intermediate subjects, who perform surgical anastomosis procedures on a chicken leg model. RESULTS: We show that the proposed set of objective and quantitative metrics to assess skill proficiency aligns with subjective evaluations, particularly the ALI score method, and can effectively differentiate novices from more proficient microsurgeons. Furthermore, we find statistically significant disparities, where microsurgeons with intermediate level of skill proficiency surpassed novices in both task speed, reduced idle time, and smoother, briefer hand displacements. CONCLUSION: The framework enables accurate skill assessment and provides objective feedback for improving microsurgical anastomosis skills among surgical trainees. By overcoming the subjectivity and limitations of current assessment methods, our approach contributes to the advancement of surgical education and the development of aspiring microsurgeons. Furthermore, our framework emerges to precisely distinguish and classify proficiency levels (novice and intermediate) exhibited by microsurgeons.

Comparison of the microvascular anastomotic Coupler™ system with hand-sewn suture for end to end veno-venous anastomosis for head and neck reconstruction with free flap transfer: Medico-economic retrospective case-control study.

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon.

One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist.

BACKGROUND: Cold forceps and snares are each effective for removing polyps of 1-3 mm, while snares are more effective for polyps of 4-10 mm in size. If, in the same patient, polyps of 1-3 mm are removed with forceps and those of 4-10 mm with snares, two devices are used. If cold snares are used to resect all lesions of 1-10 mm (one-device colonoscopy), there is a potential for lower costs and less plastic waste. METHODS: A single high detecting colonoscopist prospectively measured the feasibility of cold snaring all colorectal lesions of ≤10 mm in size, along with the associated costs and plastic waste reduction. RESULTS: 677 consecutive lower gastrointestinal endoscopies (not for inflammatory bowel disease) were assessed. Of 1430 lesions of 1-3 mm and 1685 lesions of 4-10 mm in size, 1428 (99.9%, 95%CI 99.5%-100%) and 1674 (99.3%, 95%CI 98.8%-99.7%), respectively, were successfully resected using cold snaring. Among 379 screening and surveillance patients, universal cold snaring of lesions ≤10 mm saved 35 and 47 cold forceps per 100 screening and surveillance patients, respectively. CONCLUSION: Cold snare resection of all lesions ≤10 mm (one-device colonoscopy) was feasible, and reduced costs and plastic waste.

Novices can assess microsurgery performance, and this is enhanced using the Manual Suture Parameters for Training and Assessment (M-SParTA) scoring system.

This study explores how novices could effectively evaluate the quality of microsurgical suturing. That would be enhanced with using a novel Manual Suture Parameters for Training and Assessment (M-SParTA), which supported novices with guidance on the objective parameters, in order to increased the accuracy of scoring ability. We also propose the following initial framework to train novices in microsuturing using a standardised task: 1) Exposure; 2) Assessment; 3) Hands-on and self-assessment. The independent learning cycle with targeted supervision provides novices with greater autonomy and a less stressful environment that could enhance skills training.

Experimental Assessment of the Performance of Dual Pneumatic Vitreous Cutters According to Gauge and Cut Rate.

PURPOSE: To compare and analyze the performance of dual pneumatic ultra-high-speed vitreous cutters based on their cut rates, vacuum levels, and diameters in terms of flow rate and cutting time. METHODS: The Constellation Vision System was used to remove egg white for 30 seconds, after which we calculated the flow rate by measuring the change in weight. We then measured the time required to remove 4 mL of egg white. We tested the UltraVit (UV) 7,500 cuts per minute (cpm) probe and the Advanced UltraVit (AUV) 10,000 cpm probe in biased open duty cycle mode, using 23-, 25-, and 27-gauge probes, respectively. RESULTS: In biased open duty cycle, the flow rate tended to decrease as the cut rates increased for all three gauges. At the same cut rates, the flow rate increased as the vacuum level increased (p < 0.05), and as the diameter increased (p < 0.05). Among cutters with the same diameter, the AUV cutter showed higher flow rates than the UV cutter, with increases of 0.267 mL/min (18.5%) at 27 gauge, 0.627 mL/min (20.8%) at 25 gauge, and 1.000 mL/min (20.7%) at 23 gauge (all p < 0.05). The times required to remove 4 mL of egg white took longer with the UV cutter than the AUV cutter for all three gauges (all p < 0.05). CONCLUSIONS: The use of a smaller gauge vitreous cutter may reduce the flow rate and increase the time required for vitrectomy, but this can be partially compensated for by increasing the vacuum level as well as using a vitreous cutter with a higher maximum cut rate, improved port size, and improved duty cycle.

Self-Assessment Versus Peer-Assessment in Microsurgery Learning: A Comparative Retrospective Study in a Surgery Residents Cohort.

INTRODUCTION: In surgical learning, self-assessment allows the physician to identify and improve his strong and weak points. However, its scientific validity has yet to be demonstrated. The aim of this study was to analyze if there is a link between self-assessment accuracy and improvement in surgical skills. We make the hypothesis that an accurate self-assessment allows a greater improvement MATERIAL AND METHOD: We set up a retrospective cohort study at the tertiary University Hospital of Angers. Between 2019 and 2021, twenty-eight surgery residents took part into a microsurgery program and were included in the study. For two weeks, they performed anastomosis training on inert material and living anesthetized rats under microscope. Each resident was evaluated during the workshop by senior surgeons on 10 items: movement stability and fluidity, instrument manipulation, needles, dissection, clamp setting, vessel manipulation, suture, checking before clamp removal, checking after clamp removal, watertighness. Self-assessment was performed by the residents with the same grid, at the end of the workshop. Residents' and senior's evaluations were double-blind. We retrospectively analyzed the concordance between senior objective assessment and self-assessment, and the effect of an accurate self-assessment on technical improvement. RESULTS: Data for twenty-five residents were analyzed, 14 were female (56%). The mean age was 29 years. Surgical specialties were orthopedics (44%), maxillofacial surgery (45.4%), neurosurgery (12%), gynecology (4%) and vascular surgery (4%). According to Cohen's kappa coefficient, 14 residents (56%) underestimated themselves, 7 (28%) were concordant with peer-assessment and 4 (16%) overestimated themselves. The concordance between self and peer assessment during sessions was positive for the most objective items, and negative for the most subjective items. Technical skills improvement in term of peer-assessment averages was positive for each item in each group, without statistical differences between groups. CONCLUSION: We found that the ability to self-assess in a fast-track microsurgery module for surgery residents varied according to analyzed gestures. We demonstrated an improvement in term of self-assessment for objective items, and a decrease for subjective items. However, we didn't find any relation between improvement curve and the accuracy of self-assessment.

Evaluation of a Full-Time Microsurgeon Educator on Resident Training, Research Collaboration, and Grant Funding.

BACKGROUND: The value of a fully trained microsurgeon dedicated to a laboratory setting at an academic institution is largely unknown. Microsurgery training lacks a national standard despite its highly complicated nature. Our study aims to evaluate the impact of a single laboratory-dedicated microsurgeon on the microsurgical training of integrated plastic surgery residents and collaborative efforts in research. METHOD: We devised a three-faceted microsurgical training curriculum, including a collaborative multi-institutional microsurgery course, novel high-fidelity simulator models, and a dedicated microsurgeon. We cataloged grant funding achieved through support to other divisions' protocols. Time, in hours, spent on training and the number of anastomoses completed with the microsurgical educator in a laboratory setting over a 4-year period (2017-2021) were evaluated. Resident independence scores were collected from attending microsurgeons to quantify the translation of microsurgical training. RESULTS: Purchasing and maintenance costs of rats in our rodent facility decreased by $16,533.60 as 198 rats were replaced by our models. The residents who participated in our novel microsurgical training program were able to independently perform anastomoses in the OR by their postgraduate year 6. Additionally, the surgical support offered by our laboratory-dedicated microsurgeon led to a total of $24,171,921 in grant funding between 2017 and 2020. CONCLUSION: Hiring an expert microsurgical educator to train residents in a laboratory has proved promising in accelerating microsurgical mastery. Novel training modules, alternatives to animal models, save resources in housing and animal costs. The addition of a research-oriented-microsurgeon has improved collaborative efforts to advance a range of surgical fields.

Can Mentorship Shatter the Glass Ceiling in Academic Microsurgery? A National Survey of Microsurgery Fellowship-Trained Women.

BACKGROUND: The "leaky pipeline" phenomenon has caused women to remain underrepresented at higher levels of academic plastic surgery. No study has considered the availability of mentorship within any subset of academic plastic surgery. The purpose of this study was to evaluate the current representation of women in academic microsurgery and to determine the impact of mentorship on career progression. METHODS: An electronic survey was designed to determine the availability and quality of mentorship respondents received at different stages of their career (from medical student to attending physician). The survey was distributed to women who completed a microsurgery fellowship and were current faculty at an academic plastic surgery program. RESULTS: Twenty-seven of 48 survey recipients participated (56.3% response rate). Most held an associate professor (20.0%) or assistant professor (40.0%) position. Respondents had an average of 4.1 ± 2.3 mentors throughout their entire training. A minority of mentors were microsurgery trained (28.3%), and only 29.2% of respondents reported female mentorship throughout their training. Attending physicians least often received formative mentorship (52.0%). Fifty percent of respondents sought female mentors, citing that they desired female insight. Of those who did not seek female mentors, 72.7% cited a lack of access to female mentors. CONCLUSIONS: Evidenced by female trainees being unable to find female mentors and low rates of mentorship at the attending physician level, there is currently not enough capacity to meet the demand for female mentorship by women pursuing academic microsurgery. Many individual and structural barriers to quality mentorship and sponsorship exist within this field.

Racial/Ethnic and Gender Disparities Over the Last Decade Within Microsurgery and Craniofacial Fellowship Training.

BACKGROUND: Racial/ethnic and gender disparities persist in plastic surgery at nearly all levels of training, becoming more pronounced at each stage. Recent studies have demonstrated that the proportion of female plastic surgery residents has increased to nearly 40%, yet only 11% of full professors of plastic surgery are female. Other studies have identified severe declines in underrepresented minority plastic surgery representation between plastic surgery residents and academicians with only 1.6% of Black/African American and 4.9% of Hispanic/Latinx full professors of plastic surgery. Often, residents seek fellowship for advanced training before seeking an academic professorship. This study aims to describe the racial/ethnic and gender representation of microsurgery and craniofacial fellows. METHODS: Names and photos of graduated fellows for the past 10 years (2012-2021) were extracted from microsurgery and craniofacial fellowship Web sites. Using a 2-person evaluation method, race/ethnicity and gender were primarily determined by photographic and surname and verified, when possible, through online confirmation methods (articles, social media). Distributions were analyzed with descriptive statistics and compared with the US population. RESULTS: Among 30 microsurgery fellowships, 180 graduated fellows (52.7%) were identified, resulting in 66 female fellows (36.7%) and the following racial/ethnic distribution: 113 (62.8%) White, 49 (27.2%) Asian, 12 (6.7%) Hispanic/Latinx, and 6 (3.3%) Black/African American. Among 31 craniofacial fellowships, 136 graduated fellows (45.0%) were identified, resulting in 38 female fellows (27.9%) and the following racial/ethnic distribution: 75 (55.1%) White, 45 (33.1%) Asian, 8 (5.9%) Hispanic/Latinx, and 8 (5.9%) Black/African American. The intersection between race/ethnicity and gender revealed the most disproportionately low representation among Black women. Relative to the US population, Hispanic/Latinx (0.31-fold) and Black/African American (0.48-fold) fellows were underrepresented, White (0.90-fold) fellows were nearly equally represented, and Asian (5.42-fold) fellows are overrepresented relative to the US population. Furthermore, despite pursuing fellowships at a greater rate, Asian and Black fellows are not reaching adequate representation among academic plastic surgeons. CONCLUSION: This study demonstrates that female racial/ethnic minorities are disproportionately underrepresented among microsurgery and craniofacial fellowships. Efforts should be made to improve the recruitment of fellows of underrepresented backgrounds and thus improve the pipeline into academic careers.

Low cost and easy acquisition: corn grain in microsurgery training.

OBJECTIVES: develop an easily accessible model for training the initial motor practice in microsurgery using corn kernels. METHODS: ten corn kernels (Zea mays) were used. A 7mm longitudinal cut was made on one side of the corn grain. The training consisted of performing 4 simple knots between the edges of the incision, using 10-0 mononylon thread. The parameters analyzed were 1) cost of the model; 2) assembly time of the model test system; 3) time for performing the knots; 4) distance between the knots. RESULTS: in all corn kernels tested, it was possible to perform the proposed microsurgical suture training, without any difficulty in the procedure. The average time to perform the 4 knots was 6.51±1.18 minutes. The total cost of the simulator model was R$3.59. The average distance between the knots was 1.7±0.3mm. The model developed from corn grains has an extremely low cost when compared to the use of animals or high-tech simulators. Other advantages are the easy availability of canned corn kernels and the possibility of making more than four knots along the 7mm incision. CONCLUSION: the training model developed has low cost, is easy to acquire and viable for training basic manual skills in microsurgery.

Objective Burn Scar Assessment in Clinical Practice Using the Cutometer©: Introduction and Validation of a Standardized Measurement Protocol.

An objective burn scar assessment is essential to informed therapeutic decision-making and to monitor scar development over time. However, widely employed scar rating scales show poor inter-rater reliability. For this study we developed a standardized measurement protocol for the Cutometer© applicable for objective burn scar assessment in everyday clinical practice. We developed a measurement protocol for the Cutometer© MPA 580 including a scar site relocation technique based on anatomical landmarks. The protocol emerged through several steps: Identifying key factors for valid and reliable measurements, preliminary testing, specification of technical details, refining the protocol and final testing. Consecutively, the protocol was validated for inter-rater reliability by assessing 34 burn scars in 17 patients by four clinicians and computing an Intra-class Correlation Coefficient (ICC). Parameter R0, representing scar pliability, was identified as the best suited output parameter yielding excellent inter-rater reliability for average measures (ICC 0.92 [95% CI 0.86; 0.96]) and acceptable reliability for single measures (ICC: 0.74 [0.61; 0.84]). The pressure applied on the measuring probe was identified as an influential confounding factor for reliable measurements. Rater gender did not influence reliability of measurements. The introduced standardized measurement protocol for the Cutometer© MPA 580 enables an objective and reliable burn scar assessment for clinical as well as research purposes.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Skills assessment after a grape-based microsurgical course for ophthalmology residents: randomised controlled trial.

AIMS: To introduce and assess a course using grapes as training models for ophthalmology residents to acquire basic microsurgical skills. METHODS: Ophthalmology residents who were novices at microsurgery were included. Participants were randomised into a 1:1 ratio to a 4-hour training programme based on fruit models (group A) or virtual reality (VR) modulator and silicone suture pads (group B), respectively. Before and after training, questionnaires were designed to measure their self-confidence with ophthalmic operations and with their coming role as surgical assistants. After training, each participant provided their interest in further studying microsurgery and was assessed for their general competence of ophthalmic microsurgery on porcine eyes. RESULTS: Eighty-three participants were included, with 42 ones in group A and 41 ones in group B. After training, participants in group A performed better in the uniformities of the suture span (p<0.05), suture thickness (p<0.05) and tissue protection (p<0.05) during the corneal suturing assessment. The overall scores of corneal suturing and circular capsulorhexis in the porcine eye in group A were comparable to those in group B (p=0.26 and 0.87, respectively). Group A showed a more positive attitude to withstand the training for more than 4 hours (p<0.001), as well as a higher willingness to receive more times of the training in the future (p<0.001). CONCLUSIONS: Training models based on grapes are equal to VR simulators and silicon suture pads to provide solid training tasks for ophthalmology residents to master basic microsurgical skills, and might have advantages in lower economic cost, and easy availability. TRIAL REGISTRATION NUMBER: ChiCTR2000040439.