Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

Development and validation of a tool for non-technical skills evaluation in robotic surgery-the ICARS system.

BACKGROUND: Non-technical skills (NTS) are being increasingly recognised as vital for safe surgical practice. Numerous NTS rating systems have been developed to support effective training and assessment. Yet despite the additional challenges posed by robotic surgery, no NTS rating systems have been developed for this unique surgical environment. This study reports the development and validation of the first NTS behavioural rating system for robotic surgery. METHODS: A comprehensive index of all relevant NTS behaviours in robotic surgery was developed through observation of robotic theatre and interviews with robotic surgeons. Using a Delphi methodology, a panel of 16 expert surgeons was consulted to identify behaviours important to NTS assessment. These behaviours were organised into an appropriate assessment template. Experts were consulted on the feasibility, applicability and educational impact of ICARS. An observational trial was used to validate ICARS. 73 novice, intermediate and expert robotic surgeons completed a urethrovesical anastomosis within a simulated operating room. NTS were tested using four scripted scenarios of increasing difficulty. Performances were video recorded. Robotic and NTS experts assessed the videos post hoc using ICARS and the standard behavioural rating system, NOn-Technical Skills for Surgeons (NOTSS). RESULTS: 28 key non-technical behaviours were identified by the expert panel. The finalised behavioural rating system was organised into four principle domains and seven categories. Expert opinion strongly supported its implementation. ICARS was found to be equivalent to NOTSS on Bland-Altman analysis and accurately differentiated between novice, intermediate and expert participants, p = 0.01. Moderate agreement was found between raters, Krippendorff's alpha = 0.4. The internal structure of ICARS was shown to be consistent and reliable (median Cronbach alpha = 0.92, range 0.85-0.94). CONCLUSION: ICARS is the first NTS behavioural rating system developed for robotic surgery. Initial validation has shown it to be an effective and reliable tool. Implementation of ICARS will supported structured training and assessment of NTS within the robotic surgical curriculum.

Clarifying the PSA grey zone: The management of patients with a borderline PSA.

INTRODUCTION: Prostate specific antigen is a marker for prostate cancer and a key diagnostic tool, yet when to refer patients with a borderline PSA is currently unclear. This review describes how to assess a patient with borderline PSA and provides an algorithm for management. METHODS: Current literature on reference values, factors affecting PSA, indications for referral, non-invasive investigations and the role of MRI were reviewed. Medline and EMBASE were searched using MeSH terms. RESULTS: The literature suggests that a PSA of over 1.5 ng/mL should be used as a cut-off to consider further testing for all age groups. There is strong evidence to show that adjuncts are useful when interpreting PSA results, most notably percentage free PSA and proPSA. Considerable weighting should also be given to the ERSPC risk calculator when deciding when to refer. Multi-parametric MRI is valuable in closely examining suspicious lesions to reduce the number of negative biopsies. MRI fusion biopsy (TRUS, transrectal ultrasonography or transperineal) should be considered over standard TRUS biopsy to detect more clinically significant disease. CONCLUSIONS: Management of borderline PSA is not straightforward. A cut-off of 1.5 ng/mL should be used in conjunction with digital rectal exam, risk calculation and PSA adjuncts. Imaging and biopsy should utilise mpMRI to achieve improved diagnosis of clinically significant prostate cancer, with fewer unnecessary investigations.

Deep Learning for Automated Image Segmentation of the Middle Ear: A Scoping Review.

OBJECTIVE: Convolutional neural networks (CNNs) have revolutionized medical image segmentation in recent years. This scoping review aimed to carry out a comprehensive review of the literature describing automated image segmentation of the middle ear using CNNs from computed tomography (CT) scans. DATA SOURCES: A comprehensive literature search, generated jointly with a medical librarian, was performed on Medline, Embase, Scopus, Web of Science, and Cochrane, using Medical Subject Heading terms and keywords. Databases were searched from inception to July 2023. Reference lists of included papers were also screened. REVIEW METHODS: Ten studies were included for analysis, which contained a total of 866 scans which were used in model training/testing. Thirteen different architectures were described to perform automated segmentation. The best Dice similarity coefficient (DSC) for the entire ossicular chain was 0.87 using ResNet. The highest DSC for any structure was the incus using 3D-V-Net at 0.93. The most difficult structure to segment was the stapes, with the highest DSC of 0.84 using 3D-V-Net. CONCLUSIONS: Numerous architectures have demonstrated good performance in segmenting the middle ear using CNNs. To overcome some of the difficulties in segmenting the stapes, we recommend the development of an architecture trained on cone beam CTs to provide improved spatial resolution to assist with delineating the smallest ossicle. IMPLICATIONS FOR PRACTICE: This has clinical applications for preoperative planning, diagnosis, and simulation.

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data.

OBJECTIVE: Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk. METHODS: Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed. RESULTS: Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited. CONCLUSION: Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Necrotising fasciitis of the posterior neck crossing the midline: A case report.

INTRODUCTION AND IMPORTANCE: Craniofacial necrotising fasciitis is a complex condition, with high mortality given its propensity to descend via the deep neck spaces into the chest and mediastinum. Management requires optimal antimicrobial therapy with associated aggressive surgical debridement. PRESENTATION OF CASE: A 64-year-old man presented to ENT with a posterior neck swelling. Despite incision and drainage of the swelling following a trial of antimicrobial therapy, it increased in size, with areas of overlying necrosis demonstrated. Based on radiological and clinical findings, a diagnosis of necrotising fasciitis was made. He was taken to theatre for debridement. Intra-operatively, carotid sheath suppuration was noted, after tissue retraction resulted in copious bleeding from the anterior wound bed, requiring vigorous resuscitation and clamping of underlying structures to achieve haemostasis. Senior ENT and vascular surgery involvement was quickly sought to achieve haemostasis, however bleeding from the wound bed was difficult to control. This was due to the significant watershed area at the posterior neck which would not have been amenable to selective vessel ligation. After multiple cardiac arrests, a team decision was taken to discontinue resuscitation. CLINICAL DISCUSSION: Operating in this area of anatomical complexity required input from a number of different specialty teams. Although input from infectious diseases, microbiology, plastic surgery and tissue viability was commendable, there was room for optimising this further. Early patient referral to a tertiary centre where on-site input was available from maxillofacial surgery and plastic surgery would have been beneficial; a set-up commonly seen in regional trauma networks. CONCLUSION: This case demonstrates the intricacies surrounding a rare occurrence of necrotising fasciitis of the neck crossing the midline. Multi-disciplinary team involvement is imperative and should be encouraged at an early stage.

The multi-disciplinary team - Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's "lead clinician", and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.

Oligometastatic renal cell carcinoma in the palatine tonsil: successful resection using trans-oral robotic surgery.

A man in his mid 70s was referred to head and neck outpatients with bulky tissue in the left tonsillar fossa. He had previously been treated for oligometastatic renal clear cell carcinoma (diagnosed over 15 years prior to disease recurrence) by tonsillectomy and adjuvant radiotherapy (years from primary treatment), followed by trans-oral laser surgery to his oropharyngeal recurrence 3 years later. Examination under anaesthetic and biopsy confirmed further recurrence of disease in the left tonsillar fossa, with parapharyngeal extension, which has not been previously reported in the literature. After discussion in the head and neck and urology multi-disciplinary teams meeting, the patient was offered trans-oral robotic-assisted surgery (TORS) for local control and prevention of progression of a fungating oropharyngeal mass. TORS partial pharyngectomy and left buccal artery myomucosal flap reconstruction were successfully carried out, with preservation of some swallow function.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review.

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO2, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Colonic stenting for malignant large bowel obstruction is safe and effective: a single-surgeon experience.

INTRODUCTION: Self-expanding metal stents (SEMS) can be used as a bridge to surgery (BTS) or for palliation in the treatment of malignant large bowel obstruction. This case series evaluates the short-term outcomes of SEMS and success rates over time. METHODS: A total of 75 consecutive patients who underwent colonic stenting for malignant colonic obstruction over a period of six years were included. This time period was subdivided into two equal parts for analysis. The procedure was carried out by a single surgeon from a tertiary institution in Singapore. RESULTS: Technical success was reported in 93.3% of cases and clinical success in 81.3% of cases, with better success rates in the second half of the study (89.2% vs. 73.7%; p < 0.05). There were seven cases of inadequate decompression and two cases of colonic perforation. The median duration from stent insertion to surgery was ten days, and the median postoperative length of stay was six days. CONCLUSION: SEMS are a safe and effective way of relieving malignant large bowel obstruction, including those that are proximal. The improvement in success over time reflects the importance of having an experienced endoscopist carry out the procedure to ensure optimum success rates.