New generation evaluations: video-based surgical assessments : A technology update.

BACKGROUND: Surgical skill training, assessment, and feedback are the backbone of surgical training. High-quality skills require expert supervision and evaluation throughout a resource-intensive multi-year training process. As technological barriers to internet access and the ability to save and upload surgical videos continue to improve, video-based assessment technology is emerging as a tool that could reshape surgical training for the next generation of surgeons. Video-based assessment platforms have the potential to allow surgeons from across the globe to upload their surgical videos online and receive high-quality, standardized, and unbiased feedback. They combine visual recordings of a surgeon's operative technique, with standardized grading tools that have the potential to significantly impact surgical training and technical skill acquisition across the world. METHOD: The platforms included in this review are in various stages of development after a thorough discussion with national experts on the SAGES TAVAC (Technology and Value Assessments) Committee. For each VBA program, a description of its platform was given and a literature review was obtained using a PubMed search performed from inception until December 2021. RESULTS: The study reviewed all video-based assessment programs currently available in the market, identified their strengths and weaknesses, and how they can be optimized in future. CONCLUSION: The technological platforms will play a key role in the training and technical skill acquisition of the next generation of surgeons and can have an immense impact on patient care across the world. There is immense potential for all these platforms to grow and become incorporated within the framework of an effective surgical training program.

A SAGES technology and value assessment and pediatric committee evaluation of mini-laparoscopic instrumentation.

BACKGROUND: The TAVAC and Pediatric Committees of SAGES evaluated the current use of mini-laparoscopic instrumentation to better understand the role this category of devices plays in the delivery of minimally invasive surgery today. METHODS: The role of mini-laparoscopic instrumentation, defined as minimally invasive instruments of between 1 and 4 mm in diameter, was assessed by an exhaustive review of the peer reviewed literature on the subject between 1990 and 2021. The instruments, their use, and their perceived value were tabulated and described. RESULTS: Several reported studies propose a value to using mini-laparoscopic instrumentation over the use of larger instruments or as minimally invasive additions to commonly performed procedures. Additionally, specifically developed smaller-diameter instruments appear to be beneficial additions to our minimally invasive toolbox. CONCLUSIONS: The development of small instrumentation for the effective performance of minimally invasive surgery, while perhaps best suited to pediatric populations, proves useful as adjuncts to a wide variety of adult surgical procedures. Mini-laparoscopic instrumentation thus proves valuable in selected cases.

Senhance Robotic Platform in Pediatrics: Early US Experience.

INTRODUCTION: Different robotic systems have been used widely in human surgery since 2000, but pediatric patients require some features that are lacking in the most frequently used robotic systems. HYPOTHESIS: The Senhance® robotic system is a safe and an effective device for use in infants and children that has some advantages over other robotic systems. METHODS: All patients between 0 and 18 years of age whose surgery was amenable to laparoscopy were offered enrollment in this IRB-approved study. We assessed the feasibility, ease and safety of using this robotic platform in pediatric patients including: set-up time, operative time, conversions, complications and outcomes. RESULTS: Eight patients, ranging from 4 months to 17 years of age and weighing between 8 and 130 kg underwent a variety of procedures including: cholecystectomy (3), inguinal herniorrhaphy (3), orchidopexy for undescended testes (1) and exploration for a suspected enteric duplication cyst (1). All robotic procedures were successfully performed. The 4-month-old (mo), 8 kg patient underwent an uneventful robotic exploration in an attempt to locate a cyst that was hidden in the mesentery at the junction of the terminal ileum and cecum, but ultimately the patient required an anticipated laparotomy to palpate the cyst definitively and to excise it completely. There was no blood loss and no complications. Robotic manipulation with the reusable 3 mm instruments proved successful in all cases. CONCLUSIONS: Our initial experience with the Senhance® robotic platform suggests that this is a safe and effective device for pediatric surgery that is easy to use, and which warrants continued evaluation. Most importantly, there appears to be no lower age or weight restrictions to its use.

The Creation of a Pediatric Surgical Checklist for Adult Providers.

Purpose: To address the need for a pediatric surgical checklist for adult providers. Background: Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications. Methods: Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias. Results: 42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies. Conclusion: The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes. Funding: Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.

Cannabinoid Hyperemesis Syndrome Complicated by Pneumomediastinum: Implications for Pediatric Surgeons.

BACKGROUND: Cannabinoid Hyperemesis Syndrome (CHS) is a form of cyclic vomiting syndrome characterized by episodic vomiting occurring every few weeks or months and is associated with prolonged and frequent use of high-dose cannabis. CHS in the pediatric population has been increasingly reported over the last decade and can lead to life-threatening complications such as pneumomediastinum, which warrant careful consideration for surgical intervention. CASE PRESENTATION: A 17-year-old female with no significant past medical history presented to the emergency department with abdominal pain, nausea, and vomiting for 24 hours. She had four episodes of green-yellow emesis followed by dry heaves. She also complained of chest and back pain, worse with deep inspiration. Upon further history, the patient reported a similar episode of abdominal pain and repetitive vomiting six months prior to the current episode. She smoked cannabis at least once daily and has done so for the past two years. Chest X-ray revealed a subtle abnormal lucency along the anteroposterior window and anterior mediastinum, consistent with a small amount of pneumomediastinum without any other acute intrathoracic abnormalities. Follow-up chest computed tomography with contrast showed multiple foci of air within the anterior and posterior mediastinum tracking up to the thoracic inlet. There was no evidence of contrast extravasation; however, small esophageal perforation could not be excluded. Given uncomplicated pneumomediastinum without frank contrast extravasation, the patient was treated medically with piperacillin-tazobactam, metronidazole, and micafungin for microbial prophylaxis; hydromorphone for pain control; as well as with pantoprazole, ondansetron, and promethazine. Nutrition was provided via total parenteral nutrition. The patient was intensely monitored for signs of occult esophageal perforation, but none were detected. She was advanced to a soft diet on hospital day eight, solid food diet on day nine, at which point antibiotics were discontinued, and the patient was subsequently discharged. CONCLUSION: CHS in an increasingly common disorder encountered in the pediatric setting due to rising prevalence of cannabis use. The management of CHS and potentially life-threatening complications such as pneumomediastinum should be given careful consideration. Pneumomediastinum can be a harbinger of more sinister pathology such as esophageal perforation, which may warrant urgent surgical intervention.

Assessment of the da Vinci Single Port Robotic Platform on Cholecystectomy in Adolescents.

Background: The new da Vinci single port (SP) robotic platform has great appeal for pediatric surgery. To assess its efficacy and identify potential challenges, 7 adolescents underwent SP cholecystectomy. Materials and Methods: The surgeon controls three fully wristed elbowed instruments, and the first fully wristed da Vinci endoscope through a single 2.5 cm cannula. Instruments can reach 24 cm deep and triangulate distally. Instruments can also reach anatomy anywhere within 360° of port placement. A vertical incision was made through the umbilicus for port access. The cystic duct and cystic artery were dissected, clipped, divided, and hook cautery was used to remove the gallbladder. Patient characteristics and outcomes were collected and analyzed. Results: Patients were American Society of Anesthesiologists (ASA) classes I, II, and III; mean age was 17 years; mean weight was 72 kg; and 6 of 7 patients were female. There were no fatalities, and there were no returns to the operating room. Mean estimated blood loss was 2 mL and mean case duration was 126 minutes. Five out of seven patients were treated as outpatients, and none of them required narcotics on discharge. One patient reported bilateral shoulder pain 1 day postoperatively and was taking hydrocodone/acetaminophen at the time of 13-day follow-up. Conclusions: SP robotic platform cholecystectomy in adolescents appears to be safe and effective. The wristed movement of the robotic instruments improves surgeon dexterity, and the single incision hidden in the contour of the umbilicus provides good cosmesis. This series sets an exciting precedent and provides a glimpse of what is possible in pediatric robotic surgery. Clinical Trial Registration number 2014-0396.

Single port robotic splenectomy for pyruvate kinase deficiency in a five-year-old patient, a case report of a surgical first.

INTRODUCTION: Adoption of robotic surgery in pediatrics has been slow. Robotic surgery within spatially-constrained workspaces in children makes traditional platforms less translatable. Da Vinci's newest single port (SP) robotic platform provides narrow, and deep access, making pediatric robotic surgery more feasible. CASE PRESENTATION: A five-year old female presented with hepatosplenomegaly due to hemolytic anemia from pyruvate kinase deficiency (PKD). When she progressed to requiring monthly transfusions, a splenectomy was performed to avoid the complications associated with frequent blood transfusions. The robotic approach was used to remove the intact spleen because traditional minimally invasive surgery can result in post-operative splenosis. DISCUSSION: The patient successfully underwent single-port, robotic splenectomy - the first known splenectomy in a child using this approach. Furthermore, during the operation an accessory spleen was encountered in the omentum and was also successfully removed robotically. The patient tolerated the procedure well. CONCLUSION: This case demonstrates that the SP robot can be used for splenectomy to eliminate the risk of splenosis and achieve a superior cosmetic result.

Our initial experience of the transaxillary totally endoscopic approach for hemithyroidectomy.

OBJECTIVE: To report our initial experience with the transaxillary totally endoscopic (TATE) approach to the thyroid gland. STUDY DESIGN: A historic cohort study of patients undergoing TATE procedures compared with open procedures for hemithyroidectomy with isthmusectomy. SETTING: Private-practice otolaryngology group. SUBJECT AND METHODS: Patients selected for benign thyroid disease confirmed by fine-needle aspiration and requiring hemithyroidectomy with isthmusectomy. A historic cohort study of 24 patients who underwent TATE procedures for hemithyroidectomy with isthmusectomy. Comparison of the first 10 TATE approaches to a control group of 10 consecutive open approaches by the senior author's group. RESULTS: All 24 TATE patients were successful without the need to convert to an open procedure. The TATE approach had longer operative times than the open group (142 vs 105), but these operative times decreased as the number of procedures increased (first five TATE = 170, last five TATE = 114, n = 24, average = 114). No patients had peri- or postoperative complications. CONCLUSIONS: The TATE approach to the thyroid gland is safe and effective. Operative time is longer but decreases with experience. The TATE approach is one option to treat young patients with unilateral benign thyroid disease who are seeking to avoid visible scars and limit morbidity.

Transaxillary totally endoscopic robot-assisted ansa cervicalis to recurrent laryngeal nerve reinnervation for repair of unilateral vocal fold paralysis.

Pediatric unilateral vocal-fold paralysis represents a source of significant morbidity, for which treatment options are quite limited. Conventional management strategies suitable for adults are not appropriate for the developing larynx. In this study, we report the first experience with minimally invasive laryngeal reinnervation. While open techniques for pediatric recurrent laryngeal nerve reinnervation have been performed, these require large, visible incisions, which limit the appeal of this technique. The transaxillary endoscopic approach to the neck significantly reduces pain and recovery time from cervical surgery. In this study, we report the feasibility of transaxillary totally endoscopic robot-assisted laryngeal reinnervation for unilateral vocal-fold paralysis. Operative time was less than 3 hours, and patients were discharged the day of surgery. No postoperative narcotics were required. Initial results are favorable.

A virtual reality environment for patient data visualization and endoscopic surgical planning.

Visualizing patient data in a three-dimensional (3D) representation can be an effective surgical planning tool.As medical imaging technologies improve with faster and higher resolution scans, the use of virtual reality for interacting with medical images adds another level of realism to a 3D representation. The software framework presented in this paper is designed to load and display any DICOM/PACS-compatible 3D image data for visualization and interaction in an immersive virtual environment. In "examiner" mode, the surgeon can interact with a 3D virtual model of the patient by using an intuitive set of controls designed to allow slicing, coloring,and windowing of the image to show different tissue densities and enhance important structures. In the simulated"endoscopic camera" mode, the surgeon can see through the point of view of a virtual endoscopic camera to navigate inside the patient. These tools allow the surgeon to perform virtual endoscopy on any suitable structure.The software is highly scalable, as it can be used on a single desktop computer to a cluster of computers in an immersive multiprojection virtual environment. By wearing a pair of stereo glasses, a surgeon becomes immersed within the model itself, thus providing a sense of realism, as if the surgeon is "inside" the patient.

A collaborative interaction and visualization multi-modal environment for surgical planning.

The proliferation of virtual reality visualization and interaction technologies has changed the way medical image data is analyzed and processed. This paper presents a multi-modal environment that combines a virtual reality application with a desktop application for collaborative surgical planning. Both visualization applications can function independently but can also be synced over a network connection for collaborative work. Any changes to either application is immediately synced and updated to the other. This is an efficient collaboration tool that allows multiple teams of doctors with only an internet connection to visualize and interact with the same patient data simultaneously. With this multi-modal environment framework, one team working in the VR environment and another team from a remote location working on a desktop machine can both collaborate in the examination and discussion for procedures such as diagnosis, surgical planning, teaching and tele-mentoring.

A framework for interactive visualization of digital medical images.

The visualization of medical images obtained from scanning techniques such as computed tomography and magnetic resonance imaging is a well-researched field. However, advanced tools and methods to manipulate these data for surgical planning and other tasks have not seen widespread use among medical professionals. Radiologists have begun using more advanced visualization packages on desktop computer systems, but most physicians continue to work with basic two-dimensional grayscale images or not work directly with the data at all. In addition, new display technologies that are in use in other fields have yet to be fully applied in medicine. It is our estimation that usability is the key aspect in keeping this new technology from being more widely used by the medical community at large. Therefore, we have a software and hardware framework that not only make use of advanced visualization techniques, but also feature powerful, yet simple-to-use, interfaces. A virtual reality system was created to display volume-rendered medical models in three dimensions. It was designed to run in many configurations, from a large cluster of machines powering a multiwalled display down to a single desktop computer. An augmented reality system was also created for, literally, hands-on interaction when viewing models of medical data. Last, a desktop application was designed to provide a simple visualization tool, which can be run on nearly any computer at a user's disposal. This research is directed toward improving the capabilities of medical professionals in the tasks of preoperative planning, surgical training, diagnostic assistance, and patient education.

A framework for interactive examination of automatic segmented tumors in a virtual environment.

An immersive virtual environment for viewing and interacting with three-dimensional representations of medical image data is presented. Using a newly developed automatic segmentation method, a segmented object (e.g., tumor or organ) can also be viewed in the context of the original patient data. Real time interaction is established using joystick movements and button presses on a wireless gamepad. Several open-source platforms have been utilized, such as DCMTK for processing of DICOM formatted data, Coin3D for scenegraph management, SimVoleon for volume rendering, and VRJuggler to handle the immersive visualization. The application allows the user to manipulate representations with features such as fast pseudo-coloring to highlight details of the patient data, windowing to select a range of tissue densities for display, and multiple clipping planes to allow the user to slice into the patient.

Results of teenaged bariatric patients performed in an adult program.

BACKGROUND: Morbid obesity is a growing epidemic among adolescents. Bariatric surgery has proven to be the only long-term effective method in treating morbidly obese adults for over a decade. The laparoscopic approach has become a popular option. This study tested the hypothesis that laparoscopic Roux-en-Y gastric bypass is a feasible option in teenaged patients with good results through an adult bariatric program. METHODS: All patients under the age of 20 at the time of surgery were included in this study. Each patient had undergone a laparoscopic Roux-en-Y gastric bypass. Charts were reviewed for preoperative evaluation, operative time, complications, and length of hospital stay. Percentage of excess body weight lost (%EBWL) was calculated at the follow-up. RESULTS: Of the 202 patients who underwent a laparoscopic gastric bypass procedure at our institution, 5 (2%) were teenagers. The mean age was 18 years (range, 17-19). The mean height was 69 inches (range, 61-75). Average weight was 323 lbs (range, 227-394). The mean preoperative body mass index was 48 kg/m2 (range, 44-56). All patients had medical and psychological clearance prior to surgery. Mean operative time was 150 minutes (range, 130-172). There were no complications in this subset of patients. All 5 patients were discharged on postoperative day 2. Follow-up ranged from 17.8 to 44.8 months. The mean %EBWL was 77% (range, 58%-88%). CONCLUSIONS: The laparoscopic gastric bypass procedure is technically feasible in teenaged patients, with excellent results even when performed in an adult bariatric program. Long-term data will be needed to determine its role in the treatment of morbidly obese adolescents.

Perioperative hypnosis reduces hospitalization in patients undergoing the Nuss procedure for pectus excavatum.

PURPOSE: To assess whether perioperative hypnosis can reduce the length of hospitalization and alter the need for postoperative analgesics in patients undergoing the Nuss procedure. MATERIALS AND METHODS: Ten consecutive patients (age range, 12-18 years) underwent the Nuss procedure with the same operative technique. For pain management they were divided into two sequential groups: the 5 patients in the nonhypnosis group were managed with an epidural catheter, and analgesia was supplemented with intravenous or oral narcotics as requested. These patients all required Foley catheters for bladder drainage while the epidural was in place. The second group of 5 patients was prepared by teaching them self-hypnosis for postoperative pain management in one or two brief sessions. Postoperative self-hypnosis was prescribed and encouraged. These patients were allowed patient controlled analgesia and were supplemented with intravenous or oral narcotics as requested. Four of the patients in this group required a straight catheterization of the bladder the evening of surgery. Data collected included hospitalization and analgesia requirements as well as other unusual findings. RESULTS: The patients in the hypnosis group spend an average of 2.8 days in the hospital compared with 4.6 days in the nonhypnosis group (p < 0.01). There was also a trend toward less parenteral narcotic use. Postoperative discomfort was better controlled with oral analgesics in the hypnosis group. There were no adverse effects from the hypnosis. CONCLUSION: In this small study, perioperative hypnosis was associated with a reduced hospital stay in patients undergoing the Nuss procedure for pectus excavatum.

Children from ethnic minorities have benefited equally as other children from contemporary therapy for rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study Group.

PURPOSE: To define the clinical characteristics of rhabdomyosarcoma (RMS) occurring in children from ethnic minorities and determine whether these children have benefited equally from advances in therapy. PATIENTS AND METHODS: This was a retrospective cohort analysis of children treated on the Intergroup Rhabdomyosarcoma Study Group protocols between 1984 and 1997. The clinical features and outcomes of 336 African-American children and 286 children from other ethnic minorities were compared with those of white children (n = 1,721). RESULTS: African-American, other ethnic group, and white children enjoyed similar 5-year failure-free survivals (FFS) of 61%, 61%, and 66%, respectively, P =.15. Compared with white children, nonwhite patients more often had (1) invasive, T2 tumors (P =.03); (2) stage 2 or 3 tumors (P =.003); (3) large tumors (more than 5 cm, P <.006); and/or (4) tumors with positive regional nodes (ie, N1, P =.002). Using Cox proportional hazards analysis, seven patient risk categories were defined with significant differences in outcome. This model was then used to search for other factors associated with FFS after adjusting for these risk categories. Only T stage and age remained associated with FFS (P =.001 and P <.001, respectively). After adjusting for T stage, risk category, and age, we explored the relationship of ethnic group to FFS and found that, compared with whites, the relative risk of failure was 1.14 for African-American patients and 1.2 for other ethnic minority patients, values that are not significantly different. CONCLUSION: Patients from ethnic minority groups more often have larger, invasive tumors with positive lymph nodes. Nevertheless, they have benefited as equally as white children from the dramatic progress in therapy of RMS.

One-stitch laparoscopic gastric bypass technique for adolescents.

Morbid obesity is increasingly recognized in children and adolescents. The National Institute of Health Consensus Conference has concluded that bariatric surgery is the only consistent effective method for achieving long-term weight loss. Advantages of the laparoscopic approach, which include decreased hospital stay and morbidity, have been demonstrated in randomized controlled studies. Herein, we describe our technique of laparoscopic Roux-en-Y gastric bypass.

Novel uses of surgical robotics in head and neck surgery.

PURPOSE: To demonstrate the utility of robotically assisted approaches in head and neck surgery. MATERIALS AND METHODS: Two teenage patients, one with a solitary thyroid nodule who was scheduled for a right thyroid lobectomy and the other with intractable seizures who was scheduled for placement of a vagal nerve stimulator were offered the option of a robotically assisted technique using a transaxillary endoscopic approach. RESULTS: Both procedures were completed successfully using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, California). A 12 mm telescope and 5 mm instruments were used. There was sufficient mobility of the robotic arms despite the small working space. There were no complications, minimal pain in the axillary incisions, and patient satisfaction was high. Operative times were 4.5 and 4.2 hours, respectively. CONCLUSION: Transaxillary, endoscopic, robotically assisted approaches to the head and neck are feasible. The addition of robotics improves surgical dexterity in a difficult-to-reach anatomic region. Patient satisfaction appears high because of the avoidance of a cervical incision.

Evaluating mental workload of two-dimensional and three-dimensional visualization for anatomical structure localization.

Visualization of medical data in three-dimensional (3D) or two-dimensional (2D) views is a complex area of research. In many fields 3D views are used to understand the shape of an object, and 2D views are used to understand spatial relationships. It is unclear how 2D/3D views play a role in the medical field. Using 3D views can potentially decrease the learning curve experienced with traditional 2D views by providing a whole representation of the patient's anatomy. However, there are challenges with 3D views compared with 2D. This current study expands on a previous study to evaluate the mental workload associated with both 2D and 3D views. Twenty-five first-year medical students were asked to localize three anatomical structures--gallbladder, celiac trunk, and superior mesenteric artery--in either 2D or 3D environments. Accuracy and time were taken as the objective measures for mental workload. The NASA Task Load Index (NASA-TLX) was used as a subjective measure for mental workload. Results showed that participants viewing in 3D had higher localization accuracy and a lower subjective measure of mental workload, specifically, the mental demand component of the NASA-TLX. Results from this study may prove useful for designing curricula in anatomy education and improving training procedures for surgeons.