MIEO: a micro-invasive endoscopic operation port system for transluminal interventions-an acute and survival porcine study.

BACKGROUND: A reliable and sterile access through the intestinal wall to ease flexible endoscopic transluminal interventions is still appealing but lacks a suitable port system. METHODS: In a granted industry cooperation, we developed the MIEO-Port, a flexible three components overtube system that provides a temporary hermetic sealing of the intestinal wall to allow endoscopic disinfection and manipulation to gain access to the abdominal cavity. The port features an innovative head part which allows for coupling the port to the intestinal wall by vacuum suction and for controlled jetting the isolated intestinal surface with a disinfectant. The device was tested in vivo in 6 pigs for acute and long-term usability. All animal tests were approved by the local ethics committee. RESULTS: In the acute experiment, the port system supported sealed endoscopic mucosa resection and transluminal cholecystectomy. In the survival study on 5 animals, the MIEO-Port proved its reliability after transcolonic peritoneoscopy. In one animal, a port dislocation occurred after extensive retroperitoneal preparation, one animal revealed bacterial contamination at necropsy; however, all animals showed a favourable course over ten days and offered no signs of peritonitis or abscedation during post-mortem examination. DISCUSSION: To the best of our knowledge, the MIEO-Port system is the first device to provide a reliable and sterile flexible access to the peritoneal cavity that can be used throughout the entire gastrointestinal tract regardless of the access route and which combines hermetic sealing with local sterilization. Further studies are warranted.

Esophageal bougination: a novel ex vivo endoscopic training model correlated with clinical data.

BACKGROUND: Esophageal bougination is a worldwide standard endoscopic procedure. Clinical methods and recommendations are based on clinical experiences only. Mechanical properties have never been described. Aim of the study was to establish a realistic ex vivo training model. Therefore, detailed assessment of relevant mechanical features of esophageal bougination should be evaluated ex vivo and in patient setting and correlated against. PATIENTS AND METHODS: A three-step concept was used to evaluate mechanical properties at stenosis level. First, insertion forces were evaluated in an ex vivo linear single stenosis model during steady mechanical insertion. Second, adding friction and properties of the pharynx and upper esophagus, the model was integrated in an artificial endoscopic training model (ELITE training model). Third, in vivo measurements were taken to correlate ex vivo data with parameters of a realistic patient setting. RESULTS: With the presented setup, we were able to assess insertion force and pressure levels in an artificial stricture using different sizes of commercially available standard bougies. In all models, there was a relevant increase in insertion force with higher stricture pressure levels. Insertion force levels in the ELITE model show higher levels compared to the linear stenosis model. Having regard to the maximum forces in patients, there is also a constant increase in mean insertion force according to higher bougie sizes, but lower forces were measured as in the ELITE model. DISCUSSION: The applied models are suitable to appraise mechanical properties of esophageal bougination in an ex vivo model and patient setting. Forces could be constituted reliable, significant increase was documented according to stenosis level and results were comparable to patient data. This was comparable to patient data. Further clinical evaluation in different kinds of stenosis is necessary.

[Long-term HR-Manometry of the Esophagus: first findings in clinical use]. / Langzeit-HR-Manometrie der Speiseröhre: Erste Beobachtungen aus dem klinischen Einsatz.

Diagnosis of oesophageal motility disorders has been well established for many years now, although circadian gastrointestinal motility is still purely understood. So far, high-resolution manometry (HRM) is only available for short-term measurement in clinical practice to evaluate simultaneous pressure conditions throughout the esophagus. Thus, only a very limited period of time can be investigated. There is evidence that disorders in esophageal motility can cause severe discomfort and symptoms even though they only tend to occur spontaneously. When performing short-term-measurements, these often cannot be detected. Therefore, one can assume that long-term analysis of the esophageal function will provide valuable new insights, which will contribute to more effective medicamenteous and operative treatment in esophageal motility disorders. At our gastrointestinal functional diagnostic laboratory, it has been possible to perform high-resolution manometry over the period of 24 hours since June 2014. We used a manometric probe consisting of 36 pressure sensors which are connected to a mobile recording device for ambulatory measurement. This article describes our experiences in clinical use when performing long-term high-resolution manometry and discusses usability and relevance of the results in the context of the underlying esophageal motility disorder.

Comparative evaluation of HD 2D/3D laparoscopic monitors and benchmarking to a theoretically ideal 3D pseudodisplay: even well-experienced laparoscopists perform better with 3D.

BACKGROUND: Though theoretically superior to standard 2D visualization, 3D video systems have not yet achieved a breakthrough in laparoscopy. The latest 3D monitors, including autostereoscopic displays and high-definition (HD) resolution, are designed to overcome the existing limitations. METHODS: We performed a randomized study on 48 individuals with different experience levels in laparoscopy. Three different 3D displays (glasses-based 3D monitor, autostereoscopic display, and a mirror-based theoretically ideal 3D display) were compared to a 2D HD display by assessing multiple performance and mental workload parameters and rating the subjects during a laparoscopic suturing task. Electromagnetic tracking provided information on the instruments' pathlength, movement velocity, and economy. The usability, the perception of visual discomfort, and the quality of image transmission of each monitor were subjectively rated. RESULTS: Almost all performance parameters were superior with the conventional glasses-based 3D display compared to the 2D display and the autostereoscopic display, but were often significantly exceeded by the mirror-based 3D display. Subjects performed a task faster and with greater precision when visualization was achieved with the 3D and the mirror-based display. Instrument pathlength was shortened by improved depth perception. Workload parameters (NASA TLX) did not show significant differences. Test persons complained of impaired vision while using the autostereoscopic monitor. The 3D and 2D displays were rated user-friendly and applicable in daily work. Experienced and inexperienced laparoscopists profited equally from using a 3D display, with an improvement in task performance about 20%. CONCLUSION: Novel 3D displays improve laparoscopic interventions as a result of faster performance and higher precision without causing a higher mental workload. Therefore, they have the potential to significantly impact the further development of minimally invasive surgery. However, as shown by the custom-built 3D mirror display, this effect can be improved, thus stimulating further research.

EndoResect study: endoscopic full-thickness resection of gastric subepithelial tumors.

BACKGROUND AND STUDY AIMS: Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation. New techniques such as use of the over-the-scope clip (OTSC) may enable secure endoscopic closure of perforations. We aimed to evaluate the feasibility of endoscopic resection of small gastric SETs using a grasp-and-snare technique followed by OTSC closure of the gastric wall if necessary. PATIENTS AND METHODS: In this prospective study 20 consecutive patients who presented with gastric SETs ≤ 3 cm were enrolled. Endoscopic resection was performed using a double-channel endoscope, a tissue anchor and a monofilament snare. If perforation occurred, the aim was to achieve complete closure with a tissue twin grasper and the OTSC. Procedures were performed under laparoscopic control using a 5-mm optic, which was introduced via a single 5-mm trocar through the umbilicus. All patients were followed up for 3 months after the procedure. RESULTS: In 6 /20 patients a pure endoscopic approach was impossible and a switch to laparoscopic wedge resection was necessary (large tumor size in 2 /6 patients; mainly extraluminal growth in 4 /6 patients). Solely endoscopic resection was successfully performed in the remaining 14 patients. Amongst these, laparoscopic control was impossible in two cases. Perforation occurred in 6 /14 patients but gastric closure with the OTSC was performed successfully in all these cases. No complications occurred and follow-up was unremarkable. CONCLUSION: Endoscopic snare resection enables safe treatment of small gastric SETs (diameter ≤ 3 cm) and seems faster and easier to perform than other endoscopic resection techniques, such as endoscopic submucosal dissection (ESD) or submucosal tunneling. Perforations occurring after full-thickness resection can be adequately managed by OTSC closure. Solely endoscopic resection without laparoscopic control seems possible in selected patients with tumors known to have purely intraluminal growth.

NOTES in Europe: summary of the working group reports of the 2012 EURO-NOTES meeting.

The sixth EURO-NOTES workshop (4 - 6 October 2012, Prague, Czech Republic) focused on enabling intensive scientific dialogue and interaction between surgeons, gastroenterologists, and engineers/industry representatives and discussion of the state of the practice and development of natural orifice transluminal endoscopic surgery (NOTES) in Europe. In accordance with previous meetings, five working groups were formed. In 2012, emphasis was put on specific indications for NOTES and interventional endoscopy. Each group was assigned an important indication related to ongoing research in NOTES and interventional endoscopy: cholecystectomy and appendectomy, therapy of colorectal diseases, therapy of adenocarcinoma and neoplasia in the upper gastrointestinal tract, treating obesity, and new therapeutic approaches for achalasia. This review summarizes consensus statements of the working groups.

Impact of iterative reconstruction on CNR and SNR in dynamic myocardial perfusion imaging in an animal model.

OBJECTIVES: To evaluate a new iterative reconstruction (IR) algorithm for radiation dose, image quality (IQ), signal-to-noise-ratio (SNR), and contrast-to-noise-ratio (CNR) in multidetector computed tomography (MDCT) dynamic myocardial perfusion imaging (MPI). METHODS: ECG-gated 256-slice MDCT dynamic MPI was performed in six pigs after subtotal balloon occlusion of one artery. Two 100 kVp protocols were compared: high dose (HD): 150 mAs; low dose (LD): 100 mAs. HD images were reconstructed with filtered back projection (FBP), LD images with FBP and different strengths of IR (L1, L4, and L7). IQ (5-point scale), SNR, and CNR (ischemic vs. normal myocardium) values derived from the HD (FBP) images and the different LD images were compared. RESULTS: Mean SNR values for myocardium were 16.3, 11.3, 13.1, 17.1, and 28.9 for the HD, LD (FBP), LD (L1), LD (L4), and LD (L7) reconstructions, respectively. Mean CNR values were 8.9, 6.3, 7.8, 9.3, and 12.8. IQ was scored as 4.6, 3.3, 4.4, 4.7, and 3.4, respectively. A significant loss of IQ was observed for the LD (L7) images compared to the HD (FBP) images (P < 0.05). CONCLUSION: Appropriate levels of iterative reconstruction can improve SNR and CNR, facilitating radiation dose savings in CT-MPI without influencing diagnostic quality. KEY POINTS: Iterative reconstruction (IR) can reduce radiation dose in myocardial perfusion CT. Our study also demonstrated improvements in image quality (noise, SNR, and CNR). Dynamic CT-MPI could help determine the hemodynamic significance of coronary artery disease. With dynamic CT MPI, myocardial blood flow can be determined quantitatively.

[Diagnosis of oesophageal reflux by PH, impedance, and bilirubin measurement: recommendations of the German Society of Neurogastroenterology and of the working group for neurogastroenterology of the German Society for Digestive and Metabolic Diseases]. / Ösophageale Refluxdiagnostik - pH-Metrie, Impedanzmessung, Bilirubin-Messung: Empfehlungen der Deutschen Gesellschaft für Neurogastroenterologie und Motilität und der Arbeitsgruppe Neurogastroenterologie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten.

The current recommendations on indications, technical performance, and interpretation of diagnostic techniques for oesophageal reflux update the German recommandations about 24 hour pH measurement of 2003. The recommendations encompass conventional pH measurement, wireless pH measurement, pH and impedance measurements, and bilirubin measurement (duodenogastro-oesophageal reflux).

[Image-based supportive measures for future application in surgery]. / Bildbasierte Unterstützungsmethoden für die zukünftige Anwendung in der Chirurgie.

BACKGROUND: The development of assistive technologies will become of increasing importance in the coming years and not only in surgery. The comprehensive perception of the actual situation is the basis of every autonomous action. Different sensor systems can be used for this purpose, of which video-based systems have a special potential. METHOD: Based on the available literature and on own research projects, central aspects of image-based support systems for surgery are presented. In this context, not only the potential but also the limitations of the methods are explained. RESULTS: An established application is the phase detection of surgical interventions, for which surgical videos are analyzed using neural networks. Through a time-based and transformative analysis the results of the prediction could only recently be significantly improved. Robotic camera guidance systems will also use image data to autonomously navigate laparoscopes in the near future. The reliability of the systems needs to be adapted to the high requirements in surgery by means of additional information. A comparable multimodal approach has already been implemented for navigation and localization during laparoscopic procedures. For this purpose, video data are analyzed using various methods and these data are fused with other sensor modalities. DISCUSSION: Image-based supportive methods are already available for various tasks and will become an important aspect for the surgery of the future; however, in order to be able to be reliably implemented for autonomous functions, they must be embedded in multimodal approaches in the future in order to provide the necessary security.

Surgical reporting for laparoscopic cholecystectomy based on phase annotation by a convolutional neural network (CNN) and the phenomenon of phase flickering: a proof of concept.

PURPOSE: Surgical documentation is an important yet time-consuming necessity in clinical routine. Beside its core function to transmit information about a surgery to other medical professionals, the surgical report has gained even more significance in terms of information extraction for scientific, administrative and judicial application. A possible basis for computer aided reporting is phase detection by convolutional neural networks (CNN). In this article we propose a workflow to generate operative notes based on the output of the TeCNO CNN. METHODS: Video recordings of 15 cholecystectomies were used for inference. The annotation of TeCNO was compared to that of an expert surgeon (HE) and the algorithm based annotation of a scientist (HA). The CNN output then was used to identify aberrance from standard course as basis for the final report. Moreover, we assessed the phenomenon of 'phase flickering' as clusters of incorrectly labeled frames and evaluated its usability. RESULTS: The accordance of the HE and CNN was 79.7% and that of HA and CNN 87.0%. 'Phase flickering' indicated an aberrant course with AUCs of 0.91 and 0.89 in ROC analysis regarding number and extend of concerned frames. Finally, we created operative notes based on a standard text, deviation alerts, and manual completion by the surgeon. CONCLUSION: Computer-aided documentation is a noteworthy use case for phase recognition in standardized surgery. The analysis of phase flickering in a CNN's annotation has the potential of retrieving more information about the course of a particular procedure to complement an automated report.

Randomized controlled trial of ultrasonic dissection versus standard surgical technique in open left hemicolectomy or total gastrectomy.

BACKGROUND: Ultrasonic dissection devices have been designed for use in open surgery but it is not certain how they compare with standard surgical techniques. METHODS: This was a multicentre randomized controlled trial comparing ultrasonic dissection with the traditional surgical technique for haemostasis and dissection during left hemicolectomy and total gastrectomy. The primary endpoint was duration of operation; secondary endpoints were blood loss and other intraoperative parameters, and patient outcomes. Performance of the two techniques was rated by surgeons and assistants on a ten-point Likert scale. RESULTS: The analysis included 100 patients in the ultrasonic and 101 in the conventional dissection group. Patient demographics, and clinical and tumour-related parameters were similar in the two groups. There was no significant difference in duration of operation (mean 170 and 178 min in ultrasonic and conventional groups respectively; P = 0·405). Nor were there significant differences in intraoperative blood loss (median 350 and 400 ml respectively; P = 0·882), other intraoperative parameters, oncological or functional outcome. The ultrasonic dissector device was rated one point higher than conventional techniques by the surgeons. CONCLUSION: Use of the ultrasonic dissector in open total gastrectomy and hemicolectomy had no impact on the overall operating time or other endpoints studied. Surgeons preferred the ultrasonic device for dissection.

Natural-orifice transluminal endoscopic surgery: low-pressure pneumoperitoneum is sufficient and is associated with an improved cardiopulmonary response (PressurePig Study).

BACKGROUND AND AIMS: The aim of this randomized trial in the acute porcine model was to compare the quality of transgastric peritoneoscopy with the use of low-pressure versus standard-pressure pneumoperitoneum and to evaluate the respective associated cardiopulmonary changes. METHODS: For transgastric peritoneoscopy, carbon dioxide was insufflated via the endoscope for a constant intraperitoneal pressure of 6 mmHg or 12 mmHg in 9 pigs each. The quality of transgastric peritoneoscopy was rated on a visual analog scale (0 mm, min.; 100 mm, max.) by the endoscopist, who was blinded to the intraperitoneal pressure. The cardiac index and global end-diastolic volume index (GEDVI, reflecting preload) were measured every 3 minutes by transpulmonary thermodilution. The following were also recorded: heart rate, mean arterial pressure (MAP), systemic vascular resistance index (SVRI, reflecting afterload), peak inspiratory pressure (PIP), pH, PCO (2), and PO (2). RESULTS: The quality of transgastric peritoneoscopy with the use of low-pressure pneumoperitoneum was not inferior to that obtained using standard-pressure pneumoperitoneum (87.0 mm vs. 87.3 mm; P<0.05). In both groups we observed a statistically significant rise in MAP and SVRI. The increase in SVRI was less pronounced during low-pressure peritoneum ( P=0.042), indicating a reduced stress response in comparison to standard-pressure peritoneum. There were no relevant differences between the groups in relation to cardiac index, GEDVI, and heart rate. An intra-abdominal pressure of 6 mmHg also led to better oxygenation ( P=0.031 for difference in PO (2) between the two groups) due to lower peak inspiratory pressure ( P<0.001 for difference). There were only slight differences between the groups with regard to pH and PCO (2). CONCLUSIONS: Pneumoperitoneum of 12-16 mmHg is used for standard laparoscopy. For NOTES, low-pressure pneumoperitoneum is sufficient and is associated with an improved cardiopulmonary response compared to standard-pressure pneumoperitoneum.

Training of a standardized natural orifice transluminal endoscopic surgery cholecystectomy using an ex vivo training unit.

BACKGROUND AND STUDY AIMS: The endoscopic-laparoscopic interdisciplinary training entity (ELITE) is one of the first training models for the training of natural orifice transluminal endoscopic surgery (NOTES) and conventional laparoscopic and endoscopic skills. The current study was designed to assess whether the effect of surgical simulation with an ex vivo training unit is relevant to surgical practice in the operating room and who, in particular, might benefit from this training. PATIENTS AND METHODS: A group of 30 participants (gastroenterologists, laparoscopists, and novices) performed a standardized NOTES cholecystectomy via a trans-sigmoidal approach. Fifteen participants performed the cholecystectomy following training with ELITE and 15 participants performed the procedures without previous training. The parameters studied were task times, quality and safety of the surgical procedure, and subjective evaluation of the ELITE trainer as a teaching model. RESULTS: During the training courses all participants showed a significant learning curve, with a total time needed on the first pass of 32 minutes vs. 18 minutes for the fourth pass ( P < 0.001). For the cholecystectomy in the pig model, participants with prior training needed less time to complete the procedure than participants without training. In the group without training, more complications/difficulties occurred than in the group with prior training (16 vs. 8). The video analyses by two independent NOTES experts showed an inter-rater validity of 1.0. Subjective evaluation showed that participants considered ELITE to be a suitable and recommendable simulator for NOTES. CONCLUSIONS: The ELITE model is suitable for training in the NOTES cholecystectomy procedure. This type of simulator training leads to fewer intraoperative complications.

Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010.

The fourth Euro-NOTES workshop took place in September 2010 and focused on enabling intensive scientific dialogue and interaction between participants to discuss the state of the practice and development of natural-orifice transluminal endoscopic surgery (NOTES) in Europe. Five working groups were formed, consisting of participants with varying scientific and medical backgrounds. Each group was assigned to an important topic: the correct strategy for dealing with bacterial contamination and related complications, the question of the ideal entry point and secure closure, interdisciplinary collaboration and indications, robotics and platforms, and matters related to training and education. This review summarizes consensus statements of the working groups to give an overview of what has been achieved so far and what might be relevant for research related to NOTES in the near future.

Safe sigmoid access for natural orifice transluminal endoscopic surgery (NOTES).

One of the main challenges in transluminal surgery is sterile and safe access. For many interventions, a transanal approach would be ideal but it is considered too risky because of contamination and the danger of secondary leakage. A new safe and sterile transanal access was developed, combining four basic principles: (i) the creation of a decontaminating hydroperitoneum, (ii) the use of an overtube, (iii) defining the entry point with ultrasound and (iv) dedicated closure technique. Applicability and reliability was first proven in extensive animal experiments. Feasibility of the concept in humans was subsequently demonstrated in cadavers.

NOTES for the cardia: antireflux therapy via transluminal access.

BACKGROUND AND STUDY AIMS: The current standard for surgical antireflux therapy is laparoscopic Nissen fundoplication, but natural orifice transluminal endoscopic surgery (NOTES) enables even less invasive access to the peritoneal cavity. We therefore aimed to evaluate a NOTES approach to antireflux therapy. PATIENTS AND METHODS: An animal study including 24 pigs (16 nonsurvival and eight survival). After the peritoneal cavity had been accessed via the rectosigmoid, the gastroesophageal junction (GEJ) was laid open using conventional endoscopic instruments. Thereafter, a transcutaneously introduced hook was used for tunneling and lifting of the distal esophagus. Finally, an antireflux ring was placed around the cardia. Animals were observed over 10 days in the survival series. Correct application of the prosthesis, adverse events as a result of the procedure, and bacterial contamination were evaluated by autopsy. RESULTS: The esophagogastric junction was strengthened by applying the ring prosthesis in 22 of 24 animals. Four bleeding episodes were observed, three of which were handled endoscopically. Correct placement of the prosthesis was accomplished in 21 of 22 animals. In the survival series, 1 pig died after transhiatal herniation of the stomach, and 1 pig suffered from peritonitis due to intraoperative contamination. In 7 of the 8 survival animals, no bacterial growth was noted by smear culture. The intervention had to be performed as a hybrid NOTES procedure in all cases. CONCLUSION: Exposure of the GEJ and placement of an antireflux prosthesis via a hybrid NOTES procedure is feasible, despite some complications. This approach may be considered as a basis for optimization and further development of pure NOTES antireflux procedures.

Natural orifice transluminal endoscopic surgery: cardiopulmonary safety of transesophageal mediastinoscopy.

BACKGROUND AND STUDY AIMS: Physiological reactions during natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy may lead to cardiorespiratory depression. The aim of the current study was to assess cardiopulmonary changes during transesophageal mediastinoscopy in an acute porcine model. METHODS: Transesophageal mediastinoscopy was performed under general anesthesia in eight female pigs with a bodyweight of 39 +/- 6 kg. Mediastinal access was achieved via a submucosal tunnel. The cardiac index and global end-diastolic volume index (reflecting preload) were measured every 3 minutes by transpulmonary thermodilution. The following parameters were also recorded: mediastinal pressure, heart rate, mean arterial pressure, systemic vascular resistance index (SVRI; reflecting afterload), peak inspiratory pressure, pH, pCO (2), and pO (2). RESULTS: In three animals, small tears in the parietal pleura resulted in tension pneumothoraces. The associated cardioplumonary deterioration was fatal in one pig. The other two pigs recovered after decompression with a chest tube. In the remaining five animals there were only mild hemodynamic and respiratory changes during mediastinoscopy. There was a significant ( P = 0.005) but minor transient fall in cardiac index, which correlated with a small rise in SVRI (r = - 0.857, P < 0.001). In the pigs with uncomplicated mediastinoscopy, on-demand insufflation via the endoscope resulted in median mediastinal pressures of 4.5 mm Hg (range 2.3 - 10.2 mm Hg). Overall, mediastinal and thoracic structures could be identified without difficulty via the transesophageal approach. CONCLUSIONS: NOTES mediastinoscopy carries a substantial risk of inadvertent development of a pneumothorax. Otherwise, it leads to negligible hemodynamic and pulmonary changes. In conclusion, close monitoring for the presence of a pneumothorax during NOTES mediastinoscopy appears to be mandatory.

[Efficiency, risks, and advantages of using robotic support systems in interventional medicine]. / Leistungsfähigkeit, Risiken und Vorteile des Einsatzes der Robotik in medizinisch-operativen Disziplinen.

During the past decade, robotic systems were evaluated for the first time in practically all surgical disciplines. With only a few exceptions (radical prostatectomy), mechatronic systems did not achieve a breakthrough in any field of application. Second generation robotic devices with better integration of complementary technologies (preoperative therapy planning, intraoperative diagnostic work-up, navigation, etc.) and augmented functionality are now ready to be introduced into clinical practice. It is hoped that the specific advantages of robotics will result in increased use compared to previous systems. Robotics is a key technology if new surgical strategies ("scarless surgery") are to succeed.

[Artificial intelligence in general and visceral surgery]. / Künstliche Intelligenz in der Allgemein- und Viszeralchirurgie.

Artificial intelligence procedures will find special fields of application also in general and visceral surgery. These will not only be limited to intraoperative surgical applications but also extend to perioperative processes, education and training as well as to future scientific developments. Major impulses are to be expected in decision support systems, cognitive collaborative interventional environments and in evidence-based knowledge acquisition models; however, the implementation into the daily practice not only requires profound insights into the field of informatics and computer science but also a comprehensive knowledge of the surgical domain. Accordingly, the future implementation of artificial intelligence in surgery requires a new culture of collaboration between surgeons and researchers/computer scientists.

[Digitalization in surgery : What surgeons currently think and know about it-results of an online survey]. / Digitalisierung in der Chirurgie : Was Chirurgen darüber denken und was sie wissen ­ Ergebnisse einer Onlineumfrage.

BACKGROUND: The digitalization process is currently on everyone's lips and sweeping changes in the field of public health and especially in surgery are to be expected within the next few years. Besides general issues, such as electronic health records and medical information systems, artificial intelligence, robotics and model-based surgery will decisively impact on the daily routine. In order to provide the necessary knowledge base, to point out related risks and chances and also to define fields of action for surgery, the German Society of Surgery commissioned a position paper on digitalization. A first appraisal in form of an online survey is the subject of this article. METHODS: This article is based on an online survey of the members of the German Society of Surgery and selected members of other related societies. The survey asked for the members' personal assessment concerning different aspects of the digitalization process and the respective state of knowledge as well as the impact on the field of surgery. RESULTS: A total of 296 members contributed to this survey. According to their assessment, digitalization in surgery is currently associated with terms such as electronic health records and medical information systems but they also assume a relevant influence on their own activities and on the fields of interventional medicine and surgery. A relevant need for improvement of the current state of knowledge was highlighted, not only for general aspects of digitalization but also for surgically relevant issues in particular. The vast majority of interviewed members saw digitalization more as a chance for improvement than as a risk factor. CONCLUSION: According to the views of interviewed members of the German Society of Surgery the process of digital transformation will significantly impact the field of surgery. All those involved should feel responsible to contribute to and guide this process in order to maintain the surgically inherent requirements and to protect patient safety. The position paper on digitalization can serve as a basis and should define concrete recommendations for action. In the sense of an academic approach the new possibilities should be critically evaluated with respect to suitability and should be exclusively confined to applications that are beneficial to ourselves and to our patients.